Chapters Transcript Video Rotarex™ Rotational Excisional Atherectomy System Duration: 14:19 minutes This 59 year old male patient has diabetes and arterial hypertension. He arrived in our department with rest pain, and he has dry gangrene on his first toe. He has arterial hypertension diabetes. He doesn't smoke. He doesn't use alcohol. He's a previous smoker from long ago. On this right side, a femoral pulse is present and distal is absent. He has an ABI of 0.3. He had a previous angioplasty attempted about a week ago from antigra with no success. There was a small perforation, two small perforations, and then he had his amputation indicated, and then he was referred to our department. We did the ultrasound. We could see that the common femoral artery is opened, and we have an occlusion close to the edductor canal right in the transition of the superficial femoral to the P1 segment. The artery is occluded. This is the common femoral. Then we have the superficial femoral, and then we have nothing in terms of the anterior tibule, no fibular, and we have a proximal to mid refilling. Here you have the occlusion, and here we have a monophasic flow in the posterior tibule from the mid. To the distal portion, it travels right into the distal part of the proximal portion, and we also, as we can see here in the screen, we also tried a little bit. We see the occlusion right in the abductor canal. The scenario started about 4 months ago with rest pain. So we see nothing here and then we have through the inferior medial genicular the refilling of the posterior tibule which has another segment. Of the posterior tibile which has another segment, but But really we cannot see much because the inflow is really bad. The occlusion is severe. And and this patient has, as we can see, a very low flow only through a posterior tibule that comes until the ankle. So we try to come a little bit from above. We faced some difficulties. It wasn't good for us. We didn't want to perforate, so we planned to come from below. Uh, coming from, from uh. We plan to come from low. See, we are in OK. Yeah. So we do have some issues regarding compression here. But but we are in. So now I'm moving with the guide wire below and let's go for the thrombectomy and see what happens. The guide wire is now in. I Automato. We'll focus here in the medial plantar artery. So we take the guide wire now and we go for the rotorex activity. So let's open the rotorex. So we do have a chamber here that is connected to a pistol, and this is the hemostatic valve that we have. What we do is that we fill the device from inside with saline solution from the tip. With the selling solution. From the tip The tip rotates together with the inner part of the engine. Doctor Wellington is filling the distal tube with saline solution, so everything here is washed out. And uh after that and we also have a collecting bag. It's important that this collecting bag remains vertical. and as you can as you can see. Doctor Wellington is by me. He's holding the tube, the outer tube, and kinking it a little bit. We can start the device and see that the blood is coming, and as the blood is coming, we know that the device is working properly. We can. We have a hemostatic valve, and he's holding the wire so that we can work slowly and steadily. Steadily, slowly. There is no need to rush. Uh Even though this is a webinar, uh, And we have some time. There we need to finish somehow, but we need to give time to the device to work properly. So from time to time we have to check whether there is blood and material coming up. Doctor Wellington keeps telling me that we do have material coming up, and he's working with the table so that we can keep taking material out while keeping the device centralized. Out And keep the device centralized. If you notice, I'm moving back and forth, back and forth in order to be able to let the device do the work. Let the device work. Very clearly and we are done in the first segment. The sound changed a little bit, probably because we are on a smoother region. How, how often do you flush the device outside the patient? So depending on the amount of the material and which rotorex I'm using, we can clean it more often or take a little bit out. We can clean it more often. The point is, up to now, Doctor Wellington is not stressing it to me. Whenever it's starting not to aspirate very well, he would be hitting my hand here to tell me that there is no material coming there. If he's not doing that, then I'm OK. I mean, he knows how to use this device better than me, so if he thinks it's not working here, he would already have told me. But one thing that is important here, normally what I do is that I rarely use a filter for this kind of procedure. Now we are in one vessel run off. I wouldn't even have the possibility of using a filter if I wanted to. I have no place to put the filter. There is very bad flow, apparently also in the foot, so even the posterior tibule is very huge and big. I didn't see very good flow because of the proximal occlusion, long occlusion. So what I have now here is a work channel, but I didn't clean everything. So if I want to have a look at the segment that I just cleaned now to see if I want to make 2 passes, 3 passes, 4 passes, if I'm gentle with the contrast injection, I will not allow anything to embolize because there is still a distal occlusion. So it works like a natural filter for me. So I keep a little bit of occlusion to protect me, to prevent me from embolizing. So as I'm doing this, I take advantage of taking the device out, and I clean it. So this is just what I will do now. Doctor Wellington will take out the device. Do you, do you run it while removing it? I used to do it. Yes, this is also another advantage. We can take it out while aspirating, and this is also a good advantage. I could have done it in this moment. I didn't do it, but I could have done it, and it's also more efficient, I would say. It is also adequate. I have the impression that the Vice went down very, very easily. We only had some small change in the sound and in perspective as I passed the abductor's canal, so I think that was the main problem, but let's see, I have no idea. The main point is that do not take the wire out of the device. So here we have saline solution. Doctor Wellington keeps the device straight vertical, and we dip the tip into the saline solution and look in the chamber where it becomes clean or not. Professor, can you please remember us if you are using a 6 French rotas or 8 French rota. We are using a 6 French rotorX. Thank you very much. So let me see how far we've gone here. Let's see what's going on. So, see, see. Excellent. We were able with one small, let's say first pass while we were talking while we were discussing, explaining. We were able to clean this material that was here for about 12 weeks, 13 weeks. So this is something. I mean, I don't know what will happen at the end because now we'll move a little bit forward, and I want to know aspirate the P2, P3, and proximal TPE segment. I don't know what will go on, but let's see what will happen. Let's see, let's see what will happen. Bruno, I totally agree with you. I think this is a very nice indication for this kind of device and probably the best indication because this is not a chronic occlusion with heavy calcifications. This is something probably very fragmentable, a mix of fresh and And let's say chronic thrombus and as we can see, the result is very nice, at least at this part uh and uh uh instead of, you know, just crossing the lesion and, and doing angioplasty and uh with the risk of distal embolization and, and everything, I mean, it's, it's very nice. So I'm moving forward a little bit to introduce so that I can gain some length here. Um, I Oh, So I can see here. I don't know if you guys can see that P2 is occluded, so I am right in the middle portion of it. It's occluded, so I opened up to this level here. Below this level is closed, so I will start from here. The same thing. Doctor Wellington will kink the outer tube and will hold the wire to avoid distal imbalization. I will start working. Can you see the contrast? The blood is coming. Then I'm moving down. Slowly, steadily, gently, there is no need to rush. I don't think I would have any option available in the market that could make this job faster. So let the device work because if we do it too fast. Sorry, we'll need to do 234 passes. So if you do it correctly, you do just one or two passes and it's OK, but you need to be a little bit patient for it to work properly. So here, here, as you can see we are not working any more in the P3 segment. We are probably in the proximal posterior tibule, so I will refrain a little bit so I don't go too much further down. And I'll watch out what's going on here and see how much I could take out from this material. But I think from the perspective of the proximal thrombectomy that we did in that segment up to the P3, the demonstration was quite good. Unfortunately for time issues we need to take probably another hour here, and this would be too long for the live case. Published December 20, 2024 Created by