Safety and Workflow Using Rotational Atherectomy in Non-Surgical Centres—The SWAN Study - 27/12/25

Doi : 10.1016/j.hlc.2025.08.008

Samantha L. Saunders, MD ^a,^b, Ganeev Malhotra, MBBS ^c, Kelsey Gardiner, MD ^d, Michael Tierney, MD ^e, Adam Perkovic, MD ^a, Eunice Chuah, MBBS ^a, Eleanor Redwood, MBBS ^a, William Meere, MBBS ^a, Dominic Cooper, MD ^e, Angus Higgins, MD ^d, Patrick Sutton, MD ^e, Adam Bland, MBBS ^a, Philopatir Mikhail, MBBS ^a, Gregory Starmer, MBBS ^f, Andrew Boyle, PhD ^b,^g, Astin Lee, MBBS ^e,^h, Ritin Fernandez, PhD ⁱ, Peter Stewart, MBBS ^j, Roberto Spina, MBBS ^a, Thomas J. Ford, PhD ^a,^b,^k,^l,^⁎

^a Cardiology Department, Gosford Hospital, Gosford, NSW, Australia

^b School of Medicine and Public Health, The University of Newcastle, NSW, Australia

^c St George’s University Hospitals NHS Foundation Trust, London, UK

^d Cardiology Department, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, NSW, Australia

^e Cardiology Department, The Wollongong Hospital, Wollongong, NSW, Australia

^f Cardiology Department, Cairns Hospital, Cairns, Qld, Australia

^g Hunter Medical Research Institute, New Lambton Heights, NSW, Australia

^h School of Medicine, Faculty of Science, Medicine and Health, The University of Wollongong, Wollongong, NSW, Australia

ⁱ School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia

^j Cardiology Department, Royal Brisbane and Women’s Hospital, Brisbane, Qld, Australia

^k Cardiology Department, Gosford Private Hospital, Gosford, NSW, Australia

^l Lake Macquarie Private Hospital, Gateshead, NSW, Australia

^∗ Correpsonding author at: Gosford Hospital, 75 Holden St., Gosford, NSW 2250, Australia 75 Holden St. Gosford NSW 2250 Australia

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Saturday 27 December 2025

Abstract

Background

Historically, high-risk percutaneous coronary intervention (PCI) procedures such as rotational atherectomy (RA) required on-site surgical backup. However, advancements in PCI techniques, coupled with the geographic realities of Australia’s dispersed population, warrant a reassessment of RA in the context of contemporary clinical practice.

Aim

We aimed to establish the safety and outcomes after RA at non-surgical centres.

Method

Consecutive RA PCI cases from September 2012 to February 2024 at seven Australian hospitals without on-site cardiac surgery were analysed. Primary outcomes were referrals for emergency cardiac surgery (bailout) and 30-day mortality.

Results

A total of 943 patients (1,010 lesions) were included, with a mean age of 74.4±9.6 years. A total of 72.6% were male and the average body mass index was 28.7±7.1 kg/m ² . Common comorbidities included diabetes (35.1%), a history of smoking (48.7%), and acute coronary syndrome or emergency presentation (32.9%). Off-site surgical bailout was necessary for four patients (0.4%) (temporary pacing wire-related right ventricular perforation with tamponade [n=2]; burr entrapment not retrievable percutaneously [n=2]). Major coronary perforations occurred in 0.8% (n=8; Ellis III). Minor perforations occurred in 2.3% (n=22). Tamponade occurred in eight (0.8%) patients. Burr entrapment occurred in six (0.6%) patients. A total of 32 patients (3.4%) died within 30 days of the procedure; 13 cases (1.4%) were PCI-related, but only eight of these (0.8%) were directly attributable to RA (significant ischaemia, e.g., no/slow reflow [n=4]; perforation with tamponade unable to be temporised percutaneously [n=2]; burr entrapment [n=1]; extensive coronary dissection [n=1]). Female sex and acute coronary syndrome presentation were predictors of poorer outcome.

Conclusions

RA can be safely conducted without on-site surgical backup, including in regional Australian areas. In geographically dispersed populations, regional access to RA-assisted PCI is critical. Immediate percutaneous management remains the mainstay of management of rare but potentially severe complications such as tamponade, perforations, and burr entrapment.

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Keywords : Rotational atherectomy, Burr entrapment, No/slow-reflow phenomenon, Coronary perforation