Recently, Dr. Alfonso Ielasi, an interventional cardiologist from Sant'Ambrogio Cardio-Thoracic Center in Milan, Italy, published one of his “Rotatripsy” cases in Cardiovascular Revascularization Medicine: "Rota-tripsy": A successful combined approach for the treatment of a long and heavily calcified coronary lesion.
We had the privilege of corresponding with Dr. Alfonso Ielasi to learn more about his publication as well as getting his thoughts on challenging calcium, a “Rotatripsy” algorithm, and his advice for physicians new to IVL:
Question: You noted in the paper’s discussion about the limitations of current technologies in addressing medial and circumferential calcium – why do you think IVL is well suited to address these challenging types of calcium?
Dr. Ielasi: “ELCA (laser atherectomy catheters) may generate, in case of simultaneous contrast dye injection, a perpendicular (to the blood flow) photomechanical action that may crack both superficial and deeper calcium. However, this tool is cost consuming and it is not available in every cath lab (at least in Italy/EU). Rotational (RA) and orbital atherectomy -OA- (not available in EU) are more standard in the cath labs (compared to ELCA). Due to their mechanical action they may exert an intimal calcium ablation facilitating the delivery of intracoronary devices but not always induce lesion expansion due to the presence of circumferential, thick and deep calcium (as in our case). This happens because the RA/OA ablation could be (from a mechanical point of view) not "deep" enough, leading to suboptimal NC balloon expansion. In those cases the operator may need a second larger RA burr/OA catheter (to perform something like a tangential "peeling" of the calcium) or use shockwave inducing a perpendicular pressure waves propagation (easier to be used and probably associated with less complications compared to ELCA, RA, OA) that may theoretically break superficial and deeper calcium favouring lesion expansion by NC balloon inflation.”
Question: What’s the most important thing to know for those who have never used the “Rotatripsy” approach for calcified lesions?
Dr. Ielasi: “Shockwave could (theoretically) be used complementarily to RA in straight, long and heavily calcified lesions or bailout in every calcified lesion resulting unexpandable by NC balloons following an appropriately sized RA burr ablation (in this case it is up to the operator to start with RA). In long lesions, RA may favor an initial "improvement" of the vessel pavement facilitating the advancement of IVL. The latter (balloon diameter chosen to be enough adherent to the unexpanded lesion) may favour final lesion expansion in an otherwise difficult to be reached lesion (we know that the current SW balloon is relatively bulkier compared to other balloons).”
Question: In which cases do you proactively use a “Rotatripsy” approach vs proceeding directly with Intravascular Lithotripsy?
Dr. Ielasi: “I would consider IVL as a first line strategy in every calcified lesion (unexpandable or not fully expandable by NC balloon) with length less than 24 mm, located in a straight, mid-proximal coronary segment (I consider a very good target every calcified left main/ostial LCx lesion).”
Question: You’ve had the chance to get very familiar with IVL based on your publications and presentations at conferences, what advice would you give to those who are just starting out using the technology?
Dr. Ielasi: “Shockwave is relatively more "user friendly" compared to RA/OA/ELCA and it results more natural to be used by the operator. I personally, would use it as a first line strategy in cases of lesions with the abovementioned features. On the other hand, I would discourage its use as a first line strategy in the context of long, heavily calcified lesions, tight and calcified lesions, distal lesions or tortuose vessels due to the higher profile compared to other devices that could be associated with a delivery failure at the target site.”
Hope you enjoyed his perspective – for more on this topic you might be interested a recent video filmed with Prof. Javier Escaned and the winning “Rotatripsy” case from the TopShock case competition at PCR19 from Dr. Alfonso Jurado-Román.
Important Safety Information - Coronary
Caution: In the United States, Shockwave C2 Coronary IVL catheters are investigational devices, limited by United States law to investigational use. DISRUPT CAD III Study
Shockwave C2 Coronary IVL catheters are commercially available in certain countries outside the U.S. Please contact your local Shockwave representative for specific country availability. The Shockwave C2 Coronary IVL catheters are indicated for lithotripsy-enhanced, low-pressure balloon dilatation of calcified, stenotic de novo coronary arteries prior to stenting. For the full IFU containing important safety information please visit: https://shockwavemedical.com/clinicians/international/coronary/shockwave-c2/