Rotational atherectomy and its technical secrets: use of floppy or ES guidewire

Rotational atherectomy (RA) remains a very useful tool in the management of severe coronary calcification. However, many of its technical aspects rely more on operator experience than on solid evidence. Among the variables involved during the procedure, the type of guidewire used (Rotawire floppy or extra-support) and the ablation speed may play an important role.

Kawamura et al. conducted an experimental study evaluating the interaction between ablation speed and the type of RotaWire on the direction and pattern of plaque modification. The study was performed using an in vitro model with the HEARTROID simulator and pre- and post-procedural OCT analysis in 20 calcified lesions of the left anterior descending artery in the model. Two types of guidewires—floppy and extra-support—were compared at speeds of 140,000 and 190,000 rpm.

Simulation results showed that the combination of the extra-support guidewire with high speed resulted in the smallest discrepancy between the expected position and the actual direction of ablation (wire bias), indicating a more controlled behavior. In contrast, with the floppy guidewire, high speed was associated with greater discrepancy between the expected and the observed ablation compared with low speed.

When evaluating the ablated area, a tendency toward greater debulking at lower speed was observed with the floppy guidewire, although without statistically significant differences. Conversely, with the extra-support guidewire, higher speed was associated with a larger ablated area and greater depth compared with lower speed, suggesting that the effect of speed largely depends on the level of guidewire support.

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Another variable evaluated was the position of the guiding catheter. Changes were observed in the guidewire orbit and in the direction of ablation depending on the catheter position within the artery, whether more superficial or deeper (deep intubation), with a more precise behavior when the catheter was positioned deeper.

Conclusions

The main limitation of the study is its experimental nature and the absence of clinical events. Nevertheless, understanding the behavior of the equipment is important, and based on these findings it can be suggested that in rotational atherectomy the combination of an extra-support guidewire and high-speed ablation at 190,000 rpm demonstrated the most predictable and controlled effect.

Original Title: Difference Between Low‐Speed and High‐Speed Rotational Atherectomy Using Two Types of Guidewires.

Reference: Kawamura A, Okayama K, Nohara H, Nakano T, Sakata Y. Difference Between Low-Speed and High-Speed Rotational Atherectomy Using Two Types of Guidewires. Catheter Cardiovasc Interv. 2026 Feb 9. doi: 10.1002/ccd.70514. Epub ahead of print. PMID: 41662389.