Rotational and directional coronary atherectomy

Treatment of calcified coronary artery lesions

Heavily calcified coronary plaques represent a complex lesion subset and a challenge to the interventional cardiologist, as they are often resistant to simple plaque modification with conventional balloon angioplasty. Inadequate plaque modification can lead to stent underdeployment, which itself predisposes to in-stent restenosis and stent thrombosis. Over the years, a number of mechanical devices ranging from modified angioplasty balloons to atherectomy devices have become available in order to tackle such lesions. Here we review these devices concentrating on the evidence behind their use.

Long-term outcomes of rotational atherectomy in coronary bifurcation lesions

The aim of the present study was to determine the long-term outcomes of bifurcation lesions following a rotational atherectomy (ROTA). In this retrospective study, patients that had undergone a ROTA of the bifurcation coronary lesions in Juntendo University Hospital (Tokyo, Japan) were enrolled between January 2007 and December 2009, and received follow-up for a median duration of 48 months (range, 12-84 months). A total of 337 patients were enrolled. Each patient was treated with an average of 1.2±0.4 ROTA burrs (mean size, 2.9±0.3 mm). Baseline lesion length, reference diameter, minimal lumen diameter (MLD) and percentage of diameter stenosis (%DS) prior to the procedure were comparable between the DM and non-DM patients. Furthermore, MLD, %DS and acute gain following the procedure were similar between the two groups. At follow-up, DM patients exhibited a significantly decreased MLD (1.97±0.92 vs. 2.26±0.73 mm; P=0.0038), increased %DS (27.9±21.3 vs. 20.2±13.3%; P=0.022) and late loss (0.70±0.45 vs. 0.42±0.36 mm; P=0.0047) compared with the non-DM patients. Follow-up examinations (mean duration, 52.2±19.4 months) revealed that the DM patients experienced significantly higher rates of target lesion revascularization (TLR) [28 (15.7%) vs. 8 (5.0%); P=0.0011], target lesion (TL) restenosis [46 (25.8%) vs. 20 (12.6%); P=0.0019] and major adverse cardiac events (MACE) [36 (20.2%) vs. 19 (12.0%), P=0.039] compared with the non-DM patients. Although the usage of ROTA and drug-eluting stent evidently improved long-term outcomes in patients with bifurcation lesions, DM remained an independent risk factor for TLR, TL restenosis and MACE. Therefore, the management of DM in bifurcation lesions treated with ROTA requires increased investigation in future clinical practice.

Directional atherectomy before stenting versus stenting alone in percutaneous coronary interventions: A meta-analysis

Plaque debulking before stenting is still controversial. We performed a meta-analysis of 12 randomized and non-randomized trials comparing directional coronary atherectomy (DCA) before stenting versus stenting alone. Angiographic end points were acute gain, late loss and angiographic restenosis rate. Clinical end points were early major adverse cardiac events [MACEs: death, Q-wave myocardial infarction (MI), non-Q-wave MI], late MACEs (death, Q-wave MI) and target lesion revascularization (TLR). Data are expressed as odds ratio (OR) with 95% confidence intervals (CI) or weighted mean difference (WMD) with 95% CI, as appropriate. A total of 1216 patients undergoing DCA before stent and 1484 patients undergoing stent alone have been included. DCA before stent was associated to a better acute gain compared to stenting alone (WMD 0.23, [0.18-0.28]; p<0.0001), to a striking reduction of angiographic restenosis rate (OR of 0.67, [0.54-0.84], p=0.0003) and to a significantly lower rate of late TLR (OR 0.73 [0.59-0.91], p=0.006). Late loss did not differ between the two groups (WMD 0.00 [-0.08 and 0.08], p=0.98). We found a higher rate of early MACEs for the combined approach (OR 1.87 [1.16-3.02], p=0.01), with similar prevalence of late MACEs (OR 0.83 [0.65-1.06], p=0.13). In conclusion, this meta-analysis demonstrates that DCA before stenting is superior to stenting alone with regard to acute angiographic results and TLR with a similar prevalence of late MACEs. The higher prevalence of early MACEs with DCA before stenting, however, is disturbing and probably related to distal embolization.

Catheter-induced vasospasm of both the right external iliac and right coronary arteries during coronary angiography

Catheter-induced vasospasm is well appreciated during diagnostic coronary angiography and angioplasty, but has rarely been described in peripheral arteries. We present an unusual case of concomitant catheter-induced vasospasm of the right external iliac and right coronary arteries. This case illustrates the potential challenges in diagnosing catheter-induced vasospasm from fixed obstructive atherosclerotic lesions in peripheral vessels.

Direct stent implantation without predilatation through 5 French guiding catheter following transfemoral coronary angiogram: a feasibility study

Direct stenting (DS) is accepted as reducing procedural cost and duration and 5 Fr guiding catheters as lowering peripheral vascular complications. We aimed to evaluate the feasibility and safety of both strategies. We retrospectively studied 150 consecutive patients treated with DS strategy using a 5 Fr femoral approach. A need for 6 Fr devices or balloon predilatation defined 5 Fr DS failure. Procedural success was defined as good angiographic result (residual stenosis < 30% and TIMI flow 3) without ischemic complications. A total of 161 out of 174 lesions were elected as suitable for DS. The success rate of 5 Fr DS was 87.6% (141/161 lesions). The procedural success rate was 92% (138/150 patients). The angiographic success rate was 96.3% (155/161 lesions). Other complications were six non-Q-wave MI and one repeat angioplasty for acute in-stent thrombosis. Only one major peripheral vascular complication occurred. Direct stenting through 5 Fr guiding catheters in selected lesions is safe and effective with a low incidence of peripheral arterial complications.