The previously discussed procedures are useful when the arteries are supple and can be stretched by an angioplasty (PTCA) ballon or a stent. However some heavily calcified coronary arteries resist the passage of a PTCA or stent catheter. In such cases additional tools are required to create a passage way through the calcified blockage. This is achieved by "burring" through it with a football shaped burr.
The procedure is known as Rotational Atherectomy and since it is performed "percutanously" or through the skin and is used to work in the lumen or channel of the artery, it is also known as Percutaneous Transluminal Rotational Coronary Aterectomy or PTCRA. The lay public may refer to it as a "Roto Rooter" (TM) approach as it helps clear blockages ina pipe. PTCRA is peormed in the cath lab by first placing a guiding catheter through a needle hole in the groin, similar to the technique that is used in balloon angioplasty. The tip of the guiding catheter is then placed in the opening of the coronary artery. Using x-ray giudance and small puffs of dye a special thin guide wire is placed within the catheter and the flexible tip if the wire is guided past the blockage. Following this, the PTCRA catheter is passed over the guide wire close to the calcified blockage. It consists of football shaped metal burr, the front half of which is coted with diamond dust and the rear half is connected to a coil covered wire that sits within its own sheath, A motor rapidly rotates the atherectomy burr as it is gently advanced across the blockage by the cardiologist. This is demonstrated in the animation below. A slow "pecking" back and forth movement is used as the burr widens the channel of the calcified artery by "shaving off" the hard surface and "softens" the inner lining so that it may allow the delivery of a PTCA balloon usually followed by a stent.
The PTCRA procedure. It is usually performed using the groin approach. In many cases a temporary pacemaker is used as a precaution because some patients develop temprary slowing of the heart whie the burr is being used.
The procedure generally takes 1-3 hours and is relatively safe in experienced hands. The after care is similar to that provided after a stenting procedure.