ABSTRACT
When selecting the first burr, the diameter is usually 75-85% of the arterial diameter below the stenosis. With the guidewire positioned, this burr is slowly advanced along the wire to about 1 cm above the stenosis (because the burr advances spontaneously when rotation begins). The rotational speed should not be allowed to dip below 2000-5000 rpm, and ablation sequences must be short (15-30 seconds) to reduce heat accumulation and ensure appropriate downstream dispersion of the particles produced. The total rotation time depends on the lesion (15-450 seconds in our experience), but a note of caution is warranted. Inasmuch as the total ablation time has a major influence on hemolysis, spasm frequency, and distal embolism, rotation time must be strictly limited. Once the lesion has been cleared with the Rotablator, the burr is withdrawn, and angiography is used to evaluate the results. If the remaining stenosis is > 50%, a larger burr is used. If < 20% luminal narrowing remains, the procedure is stopped. Residual stenoses between 20 and 50% are always treated by adjunctive balloon dilatation. As a rule the results of Rotablator therapy in the femoral segment are always insufficient, whereas in the distal arteries the outcome is almost always adequate. If a complementary dilatation is necessary, the balloon chosen is equal in diameter to the size of the nondiseased artery, and the inflation pressure must remain below 4-5 atmospheres. This low pressure is sufficient to remove the residual stenosis while avoiding a dissection. A completion angiogram documents the final results at the treatment site(s) as well as the distal run-off.
