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Patel N, Bandyopadhyay D, Agarwal G, Chakraborty S, Kumar A, Hajra A, Amgai B, Krittanawong C, Martin L, Abbott JD, Mamas MA, Naidu SS. Outcomes of rotational atherectomy followed by cutting balloon versus plain balloon before drug-eluting stent implantation for calcified coronary lesions: A meta-analysis. Catheter Cardiovasc Interv 2022; 99:1741-1749. [PMID: 35366389 DOI: 10.1002/ccd.30159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/11/2022] [Accepted: 03/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study is to compare outcomes of rotational atherectomy and cutting balloon (RACB) versus rotational atherectomy and plain balloon (RAPB) before drug-eluting stent (DES) implantation in calcified coronary lesions. METHODS Randomized controlled trials (RCT) and observational studies comparing RACB with RAPB were identified through a systematic search of published literature across multiple databases. Random effect meta-analysis was performed to compare the outcome between the two groups. RESULTS Four studies were included in the meta-analysis (three observational and one RCT) involving a total of 315 patients. 166 patients had RACB, and 149 patients had RAPB before DES placement with a median follow-up of 11.5 months. Compared with patients who had RAPB there was no difference in MACE (composite of death, myocardial infarction, and target vessel revascularization) (odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.25-2.18], slow flow/no reflow (OR: 0.71; 95% CI: 0.23-2.16), all-cause mortality (OR: 2.02; 95% CI: 0.28-14.60), and device success rate (OR: 1.79; 95% CI: 0.28-11.18) in the RACB approach. There was a benefit towards less target lesion revascularization in the RACB group; however, this outcome was reported in two studies (OR: 0.29; 95% CI: 0.08-0.99). On meta-regression there was no association between age, sex, diabetes, or lesion location with MACE and all-cause mortality. The studies were homogenous across all outcomes. CONCLUSION RACB, as compared with RAPB, had a similar risk of MACE, all-cause mortality, device success, and complication, but a lower risk of target lesion revascularization.
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Affiliation(s)
- Neelkumar Patel
- Department of Cardiology, University of Kansas, Lawrence, Kansas, USA
| | - Dhrubajyoti Bandyopadhyay
- Department of Cardiology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Gaurav Agarwal
- Jersey City Medical Center, Jersey City, New Jersey, USA
| | | | - Ashish Kumar
- Crozer-Chester Medical Center, Philadelphia, Pennsylvania, USA
| | - Adrija Hajra
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Chayakrit Krittanawong
- Department of Cardiology, The Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA
| | - Lily Martin
- Levy Library, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Dawn Abbott
- Department of Cardiology, Lifespan Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mamas A Mamas
- Department of Cardiology, Keele Cardiovascular Research Group, Keele University, Keele, UK
| | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
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Impact of chronic total occlusion lesions on clinical outcomes in patients receiving rotational atherectomy: results from the ROCK registry. Heart Vessels 2021; 36:1617-1625. [PMID: 33837813 DOI: 10.1007/s00380-021-01849-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
The aim of this study was to investigate the impact of chronic total occlusion (CTO) on clinical outcomes in patients with calcified coronary lesions receiving rotational atherectomy (RA). This multi-center registry enrolled consecutive patients with calcified coronary artery disease who underwent RA during percutaneous coronary intervention (PCI) from 9 tertiary centers in Korea between January 2010 and October 2019. The primary outcome was target-vessel failure (TVF) which included the composite of cardiac death, target-vessel myocardial infarction (TVMI), and target-vessel revascularization (TVR). A total of 583 lesions were enrolled in this registry and classified as CTO (n = 42 lesions, 7.2%) and non-CTO (n = 541 lesions, 92.8%). The CTO group consisted of younger patients who were more likely to have a history of previous percutaneous coronary intervention or coronary artery bypass graft surgery. The incidence of the primary outcome was 14.1% and 16.7% for the non-CTO group and CTO group, respectively. The primary outcomes observed in the two groups were not significantly different (log-rank p = 0.736). The 18-month clinical outcomes of the CTO group were comparable to those of the non-CTO group in multivariate analysis. About 7% of patients requiring RA have CTO lesions and these patients experience similar clinical outcomes compared with those having non-CTO lesions. Use of RA for CTO lesions was safe despite higher procedural complexity.
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Percutaneous Left Main Coronary Intervention: A Review of Plaque Modification in Left Main Percutaneous Coronary Intervention. J Clin Med 2018; 7:jcm7070180. [PMID: 30041422 PMCID: PMC6068647 DOI: 10.3390/jcm7070180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 12/01/2022] Open
Abstract
Left main coronary artery (LMCA) stenosis has long been recognized as a marker of increased morbidity and mortality. Current treatment algorithms for LMCA stenosis consider both percutaneous coronary intervention (PCI) with drug eluting stents (DES) and coronary bypass surgery, each with advantages based on individual patient characteristics. Since the LMCA is the largest artery in the coronary tree, plaque volume and calcification is greater than other coronary segments and often extends to the distal bifurcation segment. In LMCA bifurcation lesions, larger minimal stent area is strongly associated with better outcome in the DES era. Plaque modification strategies such as rotational, orbital, or laser atherectomy are effective mechanisms to reduce plaque volume and alter compliance, facilitating stent delivery and stent expansion. We present a case of a calcified, medina class 1,1,1 LMCA lesion where intravascular ultrasound (IVUS) and orbital atherectomy were employed for optimal results. In this context, we review the evidence of plaque modification devices and the rationale for their use in unprotected left main PCI.
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Sotomi Y, Shlofmitz RA, Colombo A, Serruys PW, Onuma Y. Patient Selection and Procedural Considerations for Coronary Orbital Atherectomy System. Interv Cardiol 2016; 11:33-38. [PMID: 29588702 PMCID: PMC5808671 DOI: 10.15420/icr.2015:19:2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/10/2016] [Indexed: 12/14/2022] Open
Abstract
Despite advances in technology, percutaneous coronary intervention (PCI) of severely calcified coronary lesions remains challenging. Rotational atherectomy is one of the current therapeutic options to manage calcified lesions, but has a limited role in facilitating the dilation or stenting of lesions that cannot be crossed or expanded with other PCI techniques due to unfavourable clinical outcome in long-term follow-up. However the results of orbital atherectomy presented in the ORBIT I and ORBIT II trials were encouraging. In addition to these encouraging data, necessity for sufficient lesion preparation before implantation of bioresorbable scaffolds lead to resurgence in the use of atherectomy. This article summarises currently available publications on orbital atherectomy (Cardiovascular Systems Inc.) and compares them with rotational atherectomy.
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Affiliation(s)
- Yohei Sotomi
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Patrick W Serruys
- International Centre for Circulatory Health, NHLI, Imperial College London, London, UK
| | - Yoshinobu Onuma
- ThoraxCenter, Erasmus Medical Center, Rotterdam, The Netherlands
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Édes IF, Ruzsa Z, Szabó G, Nardai S, Becker D, Benke K, Szilveszter B, Merkely B. Clinical predictors of mortality following rotational atherectomy and stent implantation in high-risk patients: A single center experience. Catheter Cardiovasc Interv 2015; 86:634-41. [PMID: 26032270 PMCID: PMC5033034 DOI: 10.1002/ccd.25945] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 02/26/2015] [Accepted: 03/14/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Our aim was to assess the procedural success and determine the clinical predictors of postprocedure mortality, following rotational atherectomy (RA) and stenting in high-risk patients. BACKGROUND RA is mainly used to facilitate stenting in complex lesions. Outcomes involving RA and stenting have been investigated, yet high-risk patients have not been adequately described. METHODS Data of 218 consecutive patients who underwent RA were evaluated in a prospective register. Primary endpoints were the angiographic success and long-term mortality. Secondary endpoints were procedural success, consumption of the angioplasty equipment, and periprocedural major adverse cardiac events. The impact of the relevant angiographic and clinical characteristics on long-term mortality was analyzed using uni- and multivariate Cox regression analysis. RESULTS Mean age of the patients was 70 ± 8.2 years, diabetes was present in 44%, and chronic renal failure in 29%. Prior myocardial infarction and three-vessel disease amounted to 42.2% and 32.6%, respectively. Altogether, 52.8% of patients underwent RA after a failed, non-RA intervention attempt, and 30.7% of cases presented as acute coronary syndromes. Angiographic success was 100%, and all patients received stents after RA. Periprocedural major adverse cardiac events occurred in five (2.3%) patients. Postprocedural death was investigated, with a mean follow-up of 36 months. Mortality amounted to 37.2%. Multivariate analysis revealed that left ventricular ejection fraction < 50%, glomerular filtration rate < 60 ml/min, cardiogenic shock, and diabetes were the only independent mortality predictors. CONCLUSIONS We have found that RA and stenting is feasible and viable in an elderly high-risk population, with exceptional procedural success and acceptable long-term results.
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Affiliation(s)
- István F. Édes
- Semmelweis University Heart and Vascular CenterVárosmajor street 681122BudapestHungary
| | - Zoltán Ruzsa
- Semmelweis University Heart and Vascular CenterVárosmajor street 681122BudapestHungary
| | - György Szabó
- György Gottsegen National Institute of CardiologyHaller steet 291096BudapestHungary
| | - Sándor Nardai
- Semmelweis University Heart and Vascular CenterVárosmajor street 681122BudapestHungary
| | - Dávid Becker
- Semmelweis University Heart and Vascular CenterVárosmajor street 681122BudapestHungary
| | - Kálmán Benke
- Semmelweis University Heart and Vascular CenterVárosmajor street 681122BudapestHungary
| | - Bálint Szilveszter
- Semmelweis University Heart and Vascular CenterVárosmajor street 681122BudapestHungary
| | - Béla Merkely
- Semmelweis University Heart and Vascular CenterVárosmajor street 681122BudapestHungary
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Colombo A, Panoulas VF. After 3 Decades, at Long Last, a New Device to Deal With Calcific Lesions. JACC Cardiovasc Interv 2014; 7:519-20. [DOI: 10.1016/j.jcin.2014.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
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Bhatt P, Parikh P, Patel A, Chag M, Chandarana A, Parikh R, Parikh K. Orbital atherectomy system in treating calcified coronary lesions: 3-Year follow-up in first human use study (ORBIT I trial). CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:204-8. [PMID: 24746600 DOI: 10.1016/j.carrev.2014.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 03/11/2014] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE The ORBIT I trial evaluated the safety and performance of an orbital atherectomy system (OAS) in treating de novo calcified coronary lesions. Severely calcified coronary arteries pose ongoing treatment challenges. Stent placement in calcified lesions can result in stent under expansion, malapposition and procedural complications. OAS treatment may be recommended to facilitate coronary stent implantation in these difficult lesions. MATERIALS/METHODS Fifty patients with de novo calcified coronary lesions were enrolled in the ORBIT I trial. Patients were treated with the OAS followed by stent placement. Our institution treated 33/50 patients and continued follow-up for 3 years. RESULTS Average age was 54.4 years and 90.9% were males. Mean lesion length was 15.9mm. The average number of OAS devices used per patient was 1.3. Procedural success was achieved in 97% of patients. Angiographic complications were observed in five patients (two minor dissections, one major dissection and two perforations). The cumulative major adverse cardiac event (MACE) rate was 6.1% in-hospital, 9.1% at 30 days, 12.1% at 6 months, 15.2% at 2 years, and 18.2% at 3years. The MACE rate included two in-hospital non Q-wave myocardial infarctions (MI), one additional non Q-wave MI at 30 days leading to target lesion revascularization (TLR), and three cardiac deaths. CONCLUSIONS The ORBIT I trial suggests that OAS treatment may offer an effective method to modify calcified coronary lesion compliance to facilitate optimal stent placement in these difficult-to-treat patients with acceptable levels of safety up to 3 years post-index procedure.
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Affiliation(s)
- Parloop Bhatt
- Care Institute of Medical Sciences (CIMS), Ahmedabad 380060, Gujarat, India.
| | - Parth Parikh
- Care Institute of Medical Sciences (CIMS), Ahmedabad 380060, Gujarat, India.
| | - Apurva Patel
- Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Milan Chag
- Care Institute of Medical Sciences (CIMS), Ahmedabad 380060, Gujarat, India.
| | - Anish Chandarana
- Care Institute of Medical Sciences (CIMS), Ahmedabad 380060, Gujarat, India.
| | - Roosha Parikh
- Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Keyur Parikh
- Care Institute of Medical Sciences (CIMS), Ahmedabad 380060, Gujarat, India.
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Cohen MG, Ghatak A, Kleiman NS, Naidu SS, Massaro JM, Kirtane AJ, Moses J, Magnus Ohman E, Džavík V, Palacios IF, Heldman AW, Popma JJ, O'Neill WW. Optimizing rotational atherectomy in high-risk percutaneous coronary interventions: Insights from the PROTECT ΙΙ study. Catheter Cardiovasc Interv 2013; 83:1057-64. [DOI: 10.1002/ccd.25277] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 08/12/2013] [Accepted: 10/23/2013] [Indexed: 12/31/2022]
Affiliation(s)
| | - Abhijit Ghatak
- University of Miami Miller School of Medicine; Miami Florida
| | - Neal S. Kleiman
- Methodist DeBakey Heart and Vascular Institute; Houston Texas
| | | | | | - Ajay J. Kirtane
- Columbia University Medical Center/New York-Presbyterian Hospital; New York New York
| | - Jeffrey Moses
- Columbia University Medical Center/New York-Presbyterian Hospital; New York New York
| | | | - Vladimír Džavík
- Peter Munk Cardiac Centre; University Health Network; Toronto ON Canada
| | - Igor F. Palacios
- Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Alan W. Heldman
- University of Miami Miller School of Medicine; Miami Florida
| | - Jeffrey J. Popma
- Beth Israel Medical Deaconess Harvard Medical School; Boston Massachusetts
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Parikh K, Chandra P, Choksi N, Khanna P, Chambers J. Safety and feasibility of orbital atherectomy for the treatment of calcified coronary lesions. Catheter Cardiovasc Interv 2013; 81:1134-9. [DOI: 10.1002/ccd.24700] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 10/01/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Keyur Parikh
- Care Institute of Medical Science; The Heart Care Clinic; Ahmedabad; India
| | - Praveen Chandra
- Care Institute of Medical Science; The Heart Care Clinic; Ahmedabad; India
| | - Nishit Choksi
- Care Institute of Medical Science; The Heart Care Clinic; Ahmedabad; India
| | - Puneet Khanna
- Care Institute of Medical Science; The Heart Care Clinic; Ahmedabad; India
| | - Jeffrey Chambers
- Care Institute of Medical Science; The Heart Care Clinic; Ahmedabad; India
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2012; 79:453-95. [PMID: 22328235 DOI: 10.1002/ccd.23438] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary. J Am Coll Cardiol 2011. [DOI: 10.1016/j.jacc.2011.08.006] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:2574-609. [PMID: 22064598 DOI: 10.1161/cir.0b013e31823a5596] [Citation(s) in RCA: 381] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44-122. [PMID: 22070834 DOI: 10.1016/j.jacc.2011.08.007] [Citation(s) in RCA: 1724] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:e574-651. [PMID: 22064601 DOI: 10.1161/cir.0b013e31823ba622] [Citation(s) in RCA: 902] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Catheter Cardiovasc Interv 2011; 82:E266-355. [DOI: 10.1002/ccd.23390] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kandzari DE, Zankar AA, Teirstein PS, Brilakis ES, Banerjee S, Price MJ, Stinis CT, Hudson PA, Dahle TG, Eng M, Brown R, Ferguson A, Addo TA, Popma JJ. Clinical outcomes following predilation with a novel 1.25-mm diameter angioplasty catheter. Catheter Cardiovasc Interv 2010; 77:510-4. [DOI: 10.1002/ccd.22734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 07/07/2010] [Indexed: 11/06/2022]
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Garg S, Schultz C, Sarno G, Serruys P. How should I treat a tortuous calcified right coronary artery? EUROINTERVENTION 2010. [DOI: 10.4244/eijv6i1a23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Tran T, Brown M, Lasala J. An evidence-based approach to the use of rotational and directional coronary atherectomy in the era of drug-eluting stents: when does it make sense? Catheter Cardiovasc Interv 2009; 72:650-62. [PMID: 18942126 DOI: 10.1002/ccd.21676] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Advances in percutaneous interventions have profoundly changed the way we manage patients with coronary and peripheral arterial disease. Though the use of stents, particularly drug-eluting stents, is the preferred method for revascularization because of ease of use and lower restenosis rates, there are many short comings. Ostial and bifurcation lesions as well as heavily calcified and tortuous arteries remain problematic. Mechanical debulking with rotational and direct coronary atherectomy may be beneficial in these situations. In this review, we present the general concepts of mechanical debulking and attempt to summarize the available data on its use in the setting of drug-eluting stents. In addition, we will discuss its special role in the management of peripheral arterial disease.
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Affiliation(s)
- Trung Tran
- Division of Cardiology, Washington University Medical School, St. Louis, Missouri 63110-1093, USA
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Hyogo M, Inoue N, Nakamura R, Tokura T, Matsuo A, Inoue K, Tanaka T, Fujita H. Usefulness of conquest guidewire for retrieval of an entrapped rotablator burr. Catheter Cardiovasc Interv 2006; 63:469-72. [PMID: 15558759 DOI: 10.1002/ccd.20232] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We experienced an entrapped rotablator burr that could not be retrieved even by deep seating of the guiding catheter. We successfully retrieved the burr by balloon inflation after the tapered tip of a Conquest wire managed to penetrate the quite hard plaque and pass through the outer lumen of the burr.
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Affiliation(s)
- Masayuki Hyogo
- Department of Cardiology, Kyoto Second Red Cross Hospital, 355-5 Haruobi, Kamanza-dori Marutamachi-agaru, Kamigyo, Kyoto, Japan.
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Bittl JA. Reducing the Risk of Emergency Bypass Surgery for Failed Percutaneous Coronary Interventions**Editorials published in the Journal of American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology. J Am Coll Cardiol 2005; 46:2010-2. [PMID: 16325033 DOI: 10.1016/j.jacc.2005.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Bittl JA, Chew DP, Topol EJ, Kong DF, Califf RM. Meta-Analysis of randomized trials of percutaneous transluminal coronary angioplasty versus atherectomy, cutting balloon atherotomy, or laser angioplasty. J Am Coll Cardiol 2004; 43:936-42. [PMID: 15028347 DOI: 10.1016/j.jacc.2003.10.039] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2003] [Accepted: 10/09/2003] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We conducted a systematic overview (meta-analysis) of randomized trials of balloon angioplasty versus coronary atherectomy, laser angioplasty, or cutting balloon atherotomy to evaluate the effects of plaque modification during percutaneous coronary intervention. BACKGROUND Several mechanical approaches have been developed that ablate or section atheromatous plaque during percutaneous coronary interventions to optimize acute results, minimize intimal injury, and reduce complications and restenosis. METHODS Sixteen trials (9,222 patients) constitute the randomized controlled experience with atherectomy, laser, or atherotomy versus balloon angioplasty with or without coronary stenting. Each trial tested the hypothesis that ablative therapy would result in better clinical or angiographic results than balloon dilation alone. RESULTS Short-term death rates (<31 days) were not improved by the use of ablative procedures (0.3% vs. 0.4%, odds ratio [OR] 0.94 [95% confidence interval 0.46 to 1.92]), but periprocedural myocardial infarctions (4.4% vs. 2.5%, OR 1.83 [95% CI 1.43 to 2.34]) and major adverse cardiac events (5.1% vs. 3.3%, OR 1.54 [95% CI 1.25 to 1.89]) were increased. Angiographic restenosis rates (6,958 patients) were not improved with the ablative devices (38.9% vs. 37.4%, OR 1.06 [95% CI 0.97 to 1.17]). No reduction in revascularization rates (25.2% vs. 24.5%, OR 1.04 [95% CI 0.94 to 1.14]) or cumulative adverse cardiac events rates up to one year after treatment were seen with ablative devices (27.8% vs. 26.1%, OR 1.09 [95% CI 0.99 to 1.20]). CONCLUSIONS The combined experience from randomized trials suggests that ablative devices failed to achieve predefined clinical and angiographic outcomes. This meta-analysis does not support the hypothesis that routine ablation or sectioning of atheromatous tissue is beneficial during percutaneous coronary interventions.
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Affiliation(s)
- John A Bittl
- Ocala Heart Institute, Munroe Regional Medical Center, 1511 SW 1st Avenue, Ocala, Florida 34474, USA.
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Rubartelli P, Niccoli L, Alberti A, Giachero C, Ettori F, Missiroli B, Bernardi G, Maiello L, Reimers B, Cernigliaro C, Sardella G, Bramucci E. Coronary rotational atherectomy in current practice: Acute and mid-term results in high- and low-volume centers. Catheter Cardiovasc Interv 2004; 61:463-71. [PMID: 15065139 DOI: 10.1002/ccd.20004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We conducted a prospective observational study to evaluate the indications, technique, in-hospital and 9-month results of consecutive patients treated with rotational atherectomy (RA) in 12 centers during 1 year, as well as their relationship with volume of RA activity. The study included 345 lesions in 289 patients treated (4.4% +/- 2.6% of procedures at the participating centers). The lesions were mostly calcified (63%) and type B2 or C (74%). Procedural success was obtained in 94% of patients, with a major adverse cardiac event (MACE) rate of 4.5%. At 9 months, MACE occurred in 17.3%. Multivariate analysis identified multivessel disease and slow flow as negative predictors of procedural success, whereas balloon pressure <or= 6 atm and hypercholesterolemia were associated with decreased MACE at 9 months. Center RA volume was not associated with in-hospital or 9-month outcome. We conclude that RA, even when used sporadically in selected complex lesions, can provide good immediate and mid-term results.
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Abstract
Despite the increasing use of percutaneous transluminal coronary angioplasty and intracoronary stent placement for the treatment of obstructive coronary artery disease, a large subset of coronary lesions cannot be adequately treated with balloon angioplasty and/or intracoronary stenting alone. Such lesions are often heavily calcified or fibrotic and undilatable with the present balloon technology and attempts to treat them with balloon angioplasty or intracoronary stent placement often lead to vessel dissection or incomplete stent deployment with resultant adverse outcomes. Rotational atherectomy remains a useful niche device for the percutaneous treatment of such complex lesions, usually as an adjunct to subsequent balloon angioplasty and/or intracoronary stent placement. In contrast to balloon angioplasty or stent placement that widen the coronary lumen by displacing atherosclerotic plaque, rotational atherectomy removes plaque by ablating the atherosclerotic material, which is dispersed into the distal coronary circulation. Other lesion subtypes amenable to treatment with this modality include ostial and branch-ostial lesions, chronic total occlusions, and in-stent restenosis. This review discusses the technique and principles of rotational atherectomy, the various treatment strategies for its use (including adjunctive pharmacotherapy), the lesion-specific applications for this device, and the complications unique to this modality. Recommendations are also made for its use in the current interventional era.
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Affiliation(s)
- Erdal Cavusoglu
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA
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Whitbourn RJ, Sethi R, Pomerantsev EV, Fitzgerald PJ. High-speed rotational atherectomy and coronary stenting: QCA and QCU analysis. Catheter Cardiovasc Interv 2003; 60:167-71. [PMID: 14517919 DOI: 10.1002/ccd.10639] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
To evaluate the acute effect of pretreatment with high-speed rotational atherectomy (HSRA) on stent deployment (rotastenting), we studied 33 patients with rotastenting of 40 segments, 34 patients with 40 coronary segments treated with Palmaz-Schatz stenting alone, and 34 patients with 40 segments treated with HSRA. The HSRA- and stent-alone patient groups were selected retrospectively by matching the quantitative coronary angiography (QCA) reference diameter (D ref). QCA revealed similar baseline percent of stenosis (85.3% +/- 12.4%), minimal luminal diameter (MLD), and D ref. The percent area expansion was calculated as a ratio between the minimal intrastent area and the reference area measured by intracoronary ultrasound. The rotastent group was characterized by more frequent calcification compared to HSRA and stent groups (67.5% vs. 20% and 12.5%; P < 0.01). Lesion length determined by QCA was longer both in the HSRA and the rotastent groups vs. the stent-alone group (21.1 +/- 12.3 and 20.9 +/- 4.3 vs. 17.0 +/- 7.7 mm; P < 0.05). In this small study, there was no difference demonstrated between final MLD in the rotastent and stent-alone groups. However, a smaller MLD was achieved in the HSRA group (3.0 +/- 0.7 vs. 3.1 +/- 0.5 vs. 2.5 +/- 0.7 mm, respectively; P < 0.01). The degree of stent expansion was higher in the rotastent group compared to the stent-alone group (91.9% +/- 4.4% vs. 79.7% +/- 3.4%; P < 0.03) and the % residual area of plaque was less for the rotastent group than for the stent-alone group (12.1% +/- 13.2% vs. 21.1% +/- 17.5%; P = 0.03). These data suggest that antecedent HSRA atheroma debulking using HSRA results in improved intravascular stent expansion and reduction in residual plaque, facilitating optimal stent deployment.
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Affiliation(s)
- Robert J Whitbourn
- Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, Australia.
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25
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Pedersen WR, Goldenberg IF, Johnson RK, Mooney MR. Successful rotational atherectomy in the setting of extensive coronary dissection: a case of failed balloon angioplasty in a nondilatable calcified lesion complicated by balloon rupture and extensive dissection. Catheter Cardiovasc Interv 2003; 59:329-32. [PMID: 12822151 DOI: 10.1002/ccd.10552] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We describe a case of rotational atherectomy (RA) used in the setting of extensive coronary dissection. Unsuccessful predilitation of a heavily calcified proximal LAD stenosis resulted in balloon rupture, which produced occlusive dissection extending into the mid LAD. Limited options for this patient required that we perform RA to permit stent delivery and deployment and avoid anterior myocardial infarction. A brief discussion of reasons for balloon angioplasty failure and the potential role for subsequent RA is given. Predictors for coronary perforation when performing RA are reviewed. Our rationale and strategy to avoid the increased risk of perforation with RA in this contraindicated setting of extensive dissection is given.
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MESH Headings
- Aged
- Angioplasty, Balloon, Coronary/adverse effects
- Angioplasty, Balloon, Coronary/instrumentation
- Angioplasty, Balloon, Coronary/methods
- Atherectomy, Coronary/methods
- Calcinosis/diagnostic imaging
- Calcinosis/therapy
- Coronary Angiography/methods
- Coronary Restenosis/diagnostic imaging
- Coronary Restenosis/etiology
- Coronary Restenosis/therapy
- Coronary Stenosis/diagnostic imaging
- Coronary Stenosis/therapy
- Coronary Vessels/injuries
- Equipment Failure
- Female
- Follow-Up Studies
- Humans
- Risk Assessment
- Rupture, Spontaneous/diagnostic imaging
- Rupture, Spontaneous/etiology
- Rupture, Spontaneous/surgery
- Severity of Illness Index
- Treatment Outcome
- Vascular Patency
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Affiliation(s)
- Wesley R Pedersen
- Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
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Ischinger TA, Solar RJ, Hitzke E. Improved outcome with novel device for low-pressure PTCA in de novo and in-stent lesions. CARDIOVASCULAR RADIATION MEDICINE 2003; 4:2-6. [PMID: 12892765 DOI: 10.1016/s1522-1865(03)00118-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Complex lesion morphology requiring the use of high pressure to effect lumen expansion and in-stent restenosis (ISR) remain two indications that challenge conventional PTCA balloons. We report on a new PTCA device that is designed to provide precise, low-pressure dilatation of both de novo and in-stent lesions. METHODS The FX miniRAIL catheter (FX) has an integral wire positioned external to a dilating balloon and a short, 12-mm guidewire lumen distal to the balloon. The balloon inflates against the guidewire and the external wire to prevent slippage and to introduce high focal longitudinal stresses at low inflation pressures. In this initial study, the FX was used in 37 lesions (25 de novo, 12 in-stent; vessel reference diameter=2.73+/-0.49 mm) in 30 patients. A stepwise inflation protocol and QCA were used to determine the balloon pressure at which the stenosis was resolved (stenosis resolution pressure, SRP). RESULTS All lesions (100%) were easily reached, crossed and dilated without complication. The SRP was 4.5+/-2.9 atm, and no balloon slippage was observed. Residual stenosis after FX was 26.39+/-13.29%. Minor dissections (Types A and B) were observed in eight lesions (21.6%). Target lesion revascularization (TLR) and target vessel revascularization (TVR) at follow-up (8.1+/-1.5 months) were 8.3% and 12.5%, respectively. CONCLUSION The design of the FX is versatile and appears to provide for a safe, effective and improved low-pressure PTCA technique in de novo and in-stent lesions.
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Moreno R, García E, Pérez de Isla L, Acosta J, Abeytua M, Soriano J, López-Sendón JL. [In-hospital major complications associated with rotational atherectomy: experience with 800 patients at a single center]. Rev Esp Cardiol 2001; 54:460-8. [PMID: 11282051 DOI: 10.1016/s0300-8932(01)76334-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Rotational atherectomy is usually performed in patients with angiographically determined high risk coronary lesions. The aim of this study was to evaluate the rate of major adverse cardiac events (death, Q-wave infarction or new revascularization) after rotational atherectomy, as well as to identify the clinical characteristics associated with this incidence. PATIENTS AND METHODS The study population included 800 patients treated with rotational atherectomy from 1993 to 1999: 512 (64%), for de novo lesions, and 288 (36%) for restenosis. Balloon dilation and coronary stenting was performed in 95% and 34% of patients, respectively. RESULTS During hospitalization, 17 patients (2.1%) died, 16 (2%) had a Q-wave infarction, 30 (3.8%) a non-Q infarction, and new revascularization was performed in 28 (3.5%). The incidence of major adverse cardiac events was 6.5% (n = 52), this incidence being higher in the presence of diabetes (8.9 vs. 4.4%; p = 0.01), unstable angina or acute/recent myocardial infarction (7.6 vs. 3.3%; p = 0.02), multivessel disease (8.6 vs. 3.3%; p < 0.01), treated vessel other than right coronary (7.0 vs. 1.7%; p = 0.01), procedure in > 1 vessel (10.7 vs. 4.7%; p < 0.01), angiographic failure (62.5 vs. 5.5%; p < 0.001), and de novo lesions (8.4 vs. 2.5%; p < 0.01), with diabetes and treatment of de novo lesions being independent predictors of major adverse cardiac events. However, age, previous infarction, and left ventricular dysfunction, were not associated with the rate of events. CONCLUSION Some simple variables are associated with a higher incidence of major adverse cardiac events after rotational atherectomy. Advanced age, previous infarction and left ventricular dysfunction, however, do not necessarily imply a poorer prognosis in these patients.
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Affiliation(s)
- R Moreno
- Servicio de Cardiología, Hospital Gregorio Marañón, Madrid
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Jahnke T, Link J, Müller-Hülsbeck S, Grimm J, Heller M, Brossman J. Treatment of infrapopliteal occlusive disease by high-speed rotational atherectomy: initial and mid-term results. J Vasc Interv Radiol 2001; 12:221-6. [PMID: 11265887 DOI: 10.1016/s1051-0443(07)61829-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To assess the effectiveness and patency rates of high-speed rotational atherectomy (HSRA) for the treatment of infrapopliteal arterial occlusive disease. MATERIAL AND METHODS During an 18-month period, a total of 19 infrapopliteal lesions in 15 consecutive patients were treated primarily by HSRA with use of the Rotablator device. Patients were followed up with documentation of clinical symptoms, standardized treadmill exercise, and Doppler sonography at 1, 3, and 6 months. Control angiography was performed 6 months after primary treatment. RESULTS HSRA was initially successful in 14 of 15 patients, yielding an initial technical success rate of 94%. Percutaneous treatment induced an improvement of the ankle-brachial index (ABI) from 0.6 +/- 0.09 to 0.86 +/- 0.2 after intervention (P < .0001). Doppler analysis showed a mean ABI of 0.85 +/- 0.2 (P < .001) at 1 month, 0.72 +/- 0.2 (P = .012) at 3 months, and 0.7 +/- 0.2 (P = .08) at 6 months after initial therapy. Although six patients were lost to follow-up at various times, control angiography at 6 months was carried out in nine of 15 patients, allowing direct assessment of 12 of 19 treated lesions. Among six high-grade restenoses and five total occlusions in the treated vascular segments, only one arterial lumen (of 12) remained patent without presenting a hemodynamically relevant restenosis. These results led to termination of the study. CONCLUSION Although HSRA for the treatment of infrapopliteal occlusive disease yields a very high initial technical success rate, mid-term results are extremely poor. Therefore, HSRA cannot be recommended for primary treatment of this type of lesion.
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Affiliation(s)
- T Jahnke
- Klinik für Diagnostiche Radiologie, Christian-Albrechts-Universität zu Kiel, Uniklinik Regensburg, Germany
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Cohen BM, Blum MA, Weber VJ, Kammona H, Phillips A, Daniels S, Mirabella D, Santiago D, Banas JS. Rotational Atherectomy in Octogenarians: Results and Follow Up. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2000; 9:73-75. [PMID: 11416541 DOI: 10.1111/j.1076-7460.2000.80011.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We examined our first 390 rotational atherectomy procedures to determine success and complications rates of patients aged 80 or greater (Group I, N equals 35) as compared to those younger (Group II, N equals 355). Procedural success was achieved in 32/35 (91%) of Group I and 42/355 (96%) of Group II patients (p equals NS). Coronary artery bypass graft surgery was required in 2/35 (5.7%) of Group I and 7/355 (2%) of Group II patients. No deaths, Q wave infarctions, or perforations occurred in the elderly patients and only one of each was observed in the younger group. During clinical follow up (26 months, 3-50), 4/25 patients (16%) in the octogenarian group died. Two of the deaths were cardiac (including the only crossover to surgery). One patient who sustained a late non Q myocardial infarction was asymptomatic. Of the remaining 20 patients the anginal class was 0-II in 19 and III in one. Rotational atherectomy can achieve excellent short and long term outcomes in selected octogenarians. (c)2000 by CVRR, Inc.
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Affiliation(s)
- Barry M. Cohen
- Department of Cardiovascular Medicine, Morristown Memorial Hospital, Morristown, NJ, and the Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ
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Erbel R, Heusch G. Coronary microembolization--its role in acute coronary syndromes and interventions. Herz 1999; 24:558-75. [PMID: 10609163 DOI: 10.1007/bf03044228] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The diagnosis coronary artery disease is classically based on patient's symptoms and morphology, as analyzed by angiography. The importance of risk factors for the development of coronary atherosclerosis and disturbance of coronary vasomotion is clearly established. However, microembolization of the coronary circulation has also to be taken into account. Microembolization may occur as a single or as multiple, repetitive events, and it may induce inflammatory responses. Spontaneous microembolization may occur, when the fibrous cap of an atheroma or fibroatheroma (Stary i.v. and Va) ruptures and the lipid pool with or without additional thrombus formation is washed out of the atheroma into the microcirculation. Such events with progressive thrombus formation are known as cyclic flow variations. Plaque rupture occurs more frequently than previously assumed, i.e. in 9% of patients without known heart disease suffering a traffic accident and in 22% of patients with hypertension and diabetes. Also, in patients dying from sudden death microembolization is frequently found. Patients with stable and unstable angina show not only signs of coronary plaque rupture and thrombus formation, but also microemboli and microinfarcts, the only difference between those with stable and unstable angina being the number of events. Appreciation of microembolization may help to better understand the pathogenesis of ischemic cardiomyopathy, diabetic cardiomyopathy and acute coronary syndromes, in particular in patients with normal coronary angiograms, but plaque rupture detected by intravascular ultrasound. Also, the benefit from glycoprotein IIb/IIIa receptor antagonist is better understood, when not only the prevention of thrombus formation in the epicardial atherosclerotic plaque, but also that of microemboli is taken into account. Microembolization also occurs during PTCA, inducing elevations of troponin T and I and elevations of the ST segment in the EKG. Elevated baseline coronary blood flow velocity, as a potential consequence of reactive hyperemia in myocardium surrounding areas of microembolization, is more frequent in patients with high frequency rotablation than in patients with stenting and in patients with PTCA. The hypothesis of iafrogenic microembolization during coronary interventions is now supported by the use of aspiration and filtration devices, where particles with a size of up to 700 microns have been retrieved. In the experiment, microembolization is characterized by perfusion-contraction mismatch, as the proportionate reduction of flow and function seen with an epicardial stenosis is lost and replaced by contractile dysfunction in the absence of reduced flow. The analysis of the coronary microcirculation, in addition to that of the morphology and function of epicardial coronary arteries, and in particular appreciation of the concept of microembolization will further improve the understanding of the pathophysiology and clinical symptoms of coronary artery disease.
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Affiliation(s)
- R Erbel
- Department of Cardiology, University Essen, Germany.
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Abstract
Several well-designed, randomized trials and registries have recently been completed in patients undergoing percutaneous coronary intervention (PCI) for the treatment of symptomatic coronary artery disease. These studies have further clarified the value of newer pharmacologic and mechanical approaches to patients with atherosclerotic disease and have resulted in improved clinical outcomes in patients undergoing PCI. As a result, many of the older paradigms of lesion-specific device selection have been revised to include the intricate balance of devices and drugs, tailored to the specific clinical presentation and lesion morphology in patients undergoing PCI. This article reviews several recent clinical trials and discusses their impact on early and late outcomes in patients undergoing PCI for symptomatic coronary artery disease.
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Affiliation(s)
- J J Popma
- Department of Internal Medicine (Cardiology Division) of the Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Bersin RM, Cedarholm JC, Kowalchuk GJ, Fitzgerald PJ. Long-term clinical follow-up of patients treated with the coronary rotablator: a single-center experience. Catheter Cardiovasc Interv 1999; 46:399-405. [PMID: 10216003 DOI: 10.1002/(sici)1522-726x(199904)46:4<399::aid-ccd3>3.0.co;2-n] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The acute angiographic and long-term clinical outcomes of a consecutive series of patients treated with the coronary rotablator at a single center are described. The patient population was a high-risk population, with significant instances of unstable angina or acute myocardial infarctions (MI) on presentation (75.5%), three-vessel coronary artery disease (27.5%), congestive heart failure (23.8%), and diabetes (39%). The coronary anatomy was also complex, with 79.3% of lesions treated being National Heart Lung and Blood Institute (NHLBI) class B or C. The maximum burr:artery ratio averaged 0.79+/-0.11. The maximum balloon:artery ratio averaged 1.19+/-0.17. Acute procedural success was 90%. The reference vessel diameter was 2.72 mm +/-0.54 mm. The average minimum luminal diameter (MLD) preprocedure was 0.87+/-0.31 mm. The average MLD postprocedure was 2.01+/-0.54 mm. The acute gain averaged 1.14+/-0.51 mm. Urgent coronary artery bypass grafting was required in 1% of patients. Subendocardial infarctions occurred in 8.5% of patients, and abrupt closure postprocedure while in hospital occurred in 1% of patients. Reinterventions or coronary artery bypass grafting (CABG) in hospital occurred in only 3.5% of patients; 96% of patients were available for a long-term clinical follow-up. Repeat coronary interventions for target lesion revascularizations were required in 17.4% of patients, coronary artery bypass grafting for target lesion revascularization was necessary in 9.5% of patients, and the combined target lesion revascularization rate was 25.3% at 1 year. Subsequent Q-wave myocardial infarctions or cardiac death occurred in 5.7% of patients at 1 year. Event-free survival was 75.1% at 6 months and 69.9% at 1 year. The strongest predictor of subsequent target lesion revascularization was lesion length (P=0.034) and not the postprocedure MLD (P=0.41). Most major adverse clinical events occurred within the first 4 months and greater than 90% of all major adverse clinical events occurred within the first 6 months. The coronary rotablator was able to achieve a high degree of clinical success in a high-risk patient population with complex anatomy. Most major adverse clinical events occurred early (<6 months) and were comprised principally of target lesion revascularizations. The overall target lesion revascularization rates and combined major adverse clinical event rates are favorable, given the complex anatomy and the high proportion of diabetics, females, and multivessel disease patients treated in this series.
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Affiliation(s)
- R M Bersin
- The Sanger Clinic, Carolinas Heart Institute, Carolinas Medical Center, Charlotte, North Carolina 28203, USA.
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Henneke KH, Regar E, König A, Werner F, Klauss V, Metz J, Theisen K, Mudra H. Impact of target lesion calcification on coronary stent expansion after rotational atherectomy. Am Heart J 1999; 137:93-9. [PMID: 9878940 DOI: 10.1016/s0002-8703(99)70463-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Calcified lesions carry the risk of suboptimal stent expansion. The purpose of this study was to investigate the impact of target lesion calcification on intracoronary ultrasound (ICUS) guided stent expansion after rotational atherectomy. METHODS Stent expansion was assessed by ICUS in 39 patients with the aid of the proximal stent/proximal reference lumen, the minimal stent/mean reference lumen, and the minimal stent/minor reference lumen ratios as well as the symmetry index. Thirty-nine stent implantations in uncalcified lesions served for comparison. RESULTS Relative stent expansion ranged between 76.3% +/- 6.7% and 98.4% +/- 16.4%. Categorization according to an ICUS-derived arc of superficial lesion calcium of <180 degrees (average 102 +/- 74 degrees) or >180 degrees (average 248 +/- 71 degrees) revealed decreased stent symmetry in calcified lesions >180 degrees compared with the control group (P <.05). Despite a trend toward less expansion with increasing calcium load, no significant differences of the lumen area ratios between the study groups was present. CONCLUSION Rotational atherectomy before ICUS-guided stent implantation enables adequate stent expansion even in significant superficial target lesion calcification.
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Affiliation(s)
- K H Henneke
- Ludwig-Maximilians-Universität München, Germany
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Levin TN, Holloway S, Feldman T. Acute and late clinical outcome after rotational atherectomy for complex coronary disease. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 45:122-30. [PMID: 9786388 DOI: 10.1002/(sici)1097-0304(199810)45:2<122::aid-ccd5>3.0.co;2-e] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Rotational atherectomy is effective acutely in treating complex coronary disease, but less is known about its long-term clinical outcome. We examined the acute results and late clinical outcome in 178 patients undergoing treatment with this device. Rotational atherectomy was used to treat 240 lesions in 178 individual patients. Nineteen percent had multilesion or staged multivessel procedures, and 71% had AHA-ACC Type B2/C lesions. The procedure was completed successfully in 94% of patients. Major complications occurred in 6% (death 1%, Q-MI 2.8%, and emergency bypass surgery 2.2%). Clinical follow-up was available for 167 (94%) patients at 13+/-6 months. Thirty-five percent required additional catheterization because of recurrent symptoms or an abnormal stress test. Clinical restenosis was confirmed in 18%, and an additional 2.2% of patients had progression of disease in previously untreated segments. At the end of 1 year, 14% had undergone repeat target vessel revascularization. Cumulatively at follow-up, approximately 80% had avoided an acute major complication and repeat revascularization for restenosis. Rotational atherectomy provides excellent acute and good late clinical results. At 1 year follow-up, the likelihood of developing clinical restenosis or significant progression of disease was 1 in 5, and patients had a 1 in 7 chance of requiring revascularization because of restenosis. These findings are encouraging and indicate that rotational atherectomy can be performed safely and with a high degree of acute and late clinical success in complex coronary disease characterized by multivessel or multilesion involvement and a predominance of B2 and C lesions.
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Affiliation(s)
- T N Levin
- University of Chicago Hospital, Hans Hecht Hemodynamics Laboratory, Pritzker School of Medicine, IL 60637, USA
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Abstract
Rotational atherectomy (Rotablation) represents one of the alternative devices to treat complex coronary artery stenoses. Rather than increasing luminal diameter by arterial stretching and plaque fracture as with balloon angioplasty, rotablation debulks atherosclerotic plaque with an abrasive diamond coated burr. The basic physical principle is differential cutting. It allows the advancing burr to selectively cut inelastic material while elastic tissue deflects away from the burr. 95% of the particles generated by the Rotablator are less than 5 microns. They are removed by the body's reticuloendothelial system. There are different strategies to perform a rotablation, regarding the number of burrs used and the final burr-to-artery ratio. An adjunctive PTCA is recommended without proof by randomized studies so far. The best indication for the Rotablator is the undilatable lesion. Lesion modification (debulking) as a method of improving vessel compliance seems to be also usefull in diffusely diseased and calcified vessels, as well as in aorto-ostial and angulated stenoses. The instent restenoses is a new indication. Randomized studies will have to proof if there is an advantage for rotablation compared to PTCA. Restenosis rates appear comparable to balloon angioplasty.
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Affiliation(s)
- T Dill
- Abteilung für Kardiologie, Universitätskrankenhaus Eppendorf, Hamburg
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37
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Affiliation(s)
- P L Whitlow
- Department of Cardiology, Cleveland Clinic Foundation, OH 44195, USA.
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Bertrand OF, Bonan R, Bilodeau L, Tanguay JF, Tardif JC, Rodés J, Joyal M, Crépeau J, Côté G. Management of resistant coronary lesions by the cutting balloon catheter: initial experience. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 41:179-84. [PMID: 9184293 DOI: 10.1002/(sici)1097-0304(199706)41:2<179::aid-ccd16>3.0.co;2-l] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Resistant coronary lesions remain a challenge for modern angioplasty. Classical approaches include high-pressure inflations, prolonged inflations, or balloon oversizing. More recently, new technologies like rotablator, atherectomy, or laser have been proposed as adjunct to balloon angioplasty for the treatment of these specific lesions. However, all these technologies remain more difficult to handle, costly, and they do not offer long-term benefit over conventional methods. Therefore, a simple device such as the cutting balloon catheter which has been developed from a standard over the wire balloon catheter, may prove to be useful in resistant coronary lesions. We present our single center experience using the new cutting balloon catheter in six resistant lesions.
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INOUE TERUO, HOSHI KAZUHIRO, MIZOGUCHI KEIICHI, SHIMIZU MINORU, SAKAI YOSHIHIKO, MOROOKA SHIGENORI. Cutting Balloon Angioplasty for a Restenosis Lesion at the Distal Anastomosis of a Saphenous Vein Graft. J Interv Cardiol 1997. [DOI: 10.1111/j.1540-8183.1997.tb00019.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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BARBIERI ENRICO, ZANOLLA FACCLUISA, ZARDINI PIERO. Economic and Ethical Issues Regarding Therapeutic Procedures in Interventional Cardiology: State of the Art in Italy. J Interv Cardiol 1997. [DOI: 10.1111/j.1540-8183.1997.tb00010.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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41
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Affiliation(s)
- M K Hong
- Washington Cardiology Center, Washington, DC, USA
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Dussaillant GR, Mintz GS, Pichard AD, Kent KM, Satler LF, Popma JJ, Bucher TA, Griffin J, Leon MB. Mechanisms and immediate and long-term results of adjunct directional coronary atherectomy after rotational atherectomy. J Am Coll Cardiol 1996; 27:1390-7. [PMID: 8626949 DOI: 10.1016/0735-1097(96)00026-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The purpose of this study was to confirm the mechanisms and the immediate and long-term results of rotational atherectomy and adjunct directional coronary atherectomy. BACKGROUND Rotational atherectomy is best suited for treating calcific stenoses, but the ability of rotational atherectomy alone to optimize lumen dimensions in large vessels is limited; this is only partly improved by adjunct balloon angioplasty. METHODS We treated 165 lesions in 163 patients by use of rotational atherectomy and adjunct directional coronary atherectomy. Quantitative angiography and intravascular ultrasound were used for lesion analysis. A matched comparison with 208 lesions treated with rotational atherectomy and adjunct coronary angioplasty was performed. Patients were then followed up for at least 9 months, and target-lesion revascularization was assessed. RESULTS In the 61 lesions imaged sequentially, lumen area increased from 1.7 +/- 0.8 (mean +/- 1 SD) to 3.9 +/- 1.1 mm(2) after rotational atherectomy, owing to a decrease in plaque plus media area from 16.8 +/- 5.0 to 15.2 +/- 5.2 mm(2) (both p < 0.0001). After adjunct directional coronary atherectomy, lumen area increased even more to 6.7 +/- 2.0 mm(2) (vs. 5.1 +/- 1.4 mm(2) after adjunct coronary angioplasty, p < 0.0001) as a result of both vessel expansion (18.8 +/ 5.3 to 20.8 +/- 5.7 mm(2)) and additional plaque removal (to 14.1 +/- 5.0 mm(2), all p < 0.0001). The total arcs of calcium decreased from 207 +/- 107 degrees to 166 +/- 93 degrees after rotational atherectomy and to 145 +/- 87 degrees after directional coronary atherectomy. Overall, procedural success was 96%, and final diameter stenosis was 15 +/- 17%. Target-lesion revascularization was 23%. The only independent predictor of target-lesion revascularization was a larger overall atherectomy index (84% vs. 59%, p = 0.048). CONCLUSIONS There is a synergistic relationship between rotational atherectomy and directional coronary atherectomy in the treatment of calcific lesions. The immediate results show a high procedural success--lumen dimensions were larger and late target-lesion revascularization was lower in lesions treated with rotational atherectomy and directional coronary atherectomy than in those treated with rotational atherectomy and adjunct balloon angioplasty.
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Affiliation(s)
- G R Dussaillant
- Intravascular Ultrasound Imaging and Cardiac Catheterization Laboratories, The Washington Hospital Center, Washington, D.C. USA
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von Birgelen C, Umans VA, Di Mario C, Keane D, Gil R, Prati F, de Feyter P, Serruys PW. Mechanism of high-speed rotational atherectomy and adjunctive balloon angioplasty revisited by quantitative coronary angiography: edge detection versus videodensitometry. Am Heart J 1995; 130:405-12. [PMID: 7661053 DOI: 10.1016/0002-8703(95)90344-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
High-speed rotational coronary atherectomy (RA) is primarily used to treat complex lesions. Quantitative angiographic analysis of such complex lesions by edge detection is often unsuitable, whereas videodensitometry, measuring vessel dimensions independently of the target stenosis contours, may offer potential advantages. To gain insight into the operative mechanism of RA and to study the agreement between the two quantitative angiographic methods in measuring the minimal luminal cross-sectional area, the edge detection and videodensitometry techniques were applied to coronary angiograms of 21 lesions in 19 patients with symptoms who underwent successful RA and balloon angioplasty (BA). Obstruction diameter as determined by edge detection increased from 1.00 +/- 0.31 mm before intervention to 1.35 +/- 0.29 mm after RA (p < 0.001) and further increased to 1.74 +/- 0.33 mm after adjunctive BA (p > 0.001). The mean between-method difference (edge detection minus videodensitometry) was 0.34 mm2 before intervention, 0.13 mm2 after RA, and 0.09 mm2 after adjunctive BA (not significant). The standard deviation of the differences decreased from +/- 0.87 mm2 before intervention to +/- 0.80 mm2 after RA (not significant) and increased after BA significantly to +/- 1.21 mm2 (p < 0.05). Thus edge detection and videodensitometry provided equivalent immediate angiographic results after RA and adjunctive BA. The good agreement after RA may reflect the operative mechanism of RA, which by ablation of noncompliant plaque material yields a circular symmetric lumen with smooth surface. The increased dispersion of the between-method differences observed after adjunctive BA presumably results from dissections, plaque ruptures, and loss of luminal smoothness after balloon dilatation.
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MESH Headings
- Absorptiometry, Photon/instrumentation
- Absorptiometry, Photon/methods
- Absorptiometry, Photon/statistics & numerical data
- Aged
- Analysis of Variance
- Angioplasty, Balloon, Coronary
- Atherectomy, Coronary
- Calcinosis/diagnostic imaging
- Calcinosis/therapy
- Combined Modality Therapy
- Coronary Angiography/instrumentation
- Coronary Angiography/methods
- Coronary Angiography/statistics & numerical data
- Coronary Disease/diagnostic imaging
- Coronary Disease/therapy
- Evaluation Studies as Topic
- Female
- Humans
- Male
- Middle Aged
- Radiographic Image Interpretation, Computer-Assisted/instrumentation
- Radiographic Image Interpretation, Computer-Assisted/methods
- Radiography, Interventional/instrumentation
- Radiography, Interventional/methods
- Radiography, Interventional/statistics & numerical data
- Video Recording/instrumentation
- Video Recording/methods
- Video Recording/statistics & numerical data
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Affiliation(s)
- C von Birgelen
- Thoraxcenter, Erasmus University Rotterdam, The Netherlands
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Cardenas JR, Strumpf RK, Heuser RR. Rotational atherectomy in restenotic lesions at the distal saphenous vein graft anastomosis. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1995; 36:53-7; discussion 58. [PMID: 7489594 DOI: 10.1002/ccd.1810360113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Restenotic lesions at distal saphenous vein graft (SVG) anastomoses have been notoriously difficult to treat with standard angioplasty techniques. We explored the potential of rotational atherectomy in three patients with nonthrombotic, focal restenoses at the SVG touch down. The Rotablator safely and successfully recanalized the lesions, allowing further treatment with dilation or stenting or both. Rotational atherectomy may warrant investigation as a treatment for nonthrombotic restenotic SVG lesions.
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Affiliation(s)
- J R Cardenas
- Department of Cardiology, Arizona Heart Institute and Foundation, Phoenix 85006, USA
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MacIsaac AI, Bass TA, Buchbinder M, Cowley MJ, Leon MB, Warth DC, Whitlow PL. High speed rotational atherectomy: outcome in calcified and noncalcified coronary artery lesions. J Am Coll Cardiol 1995; 26:731-6. [PMID: 7642867 DOI: 10.1016/0735-1097(95)00206-j] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study sought to determine the success and complication rates of high speed rotational coronary atherectomy in calcified and noncalcified lesions. BACKGROUND Percutaneous transluminal coronary angioplasty and directional coronary atherectomy of calcified lesions are associated with reduced procedural success and increased complications. Rotational atherectomy using the Rotablator catheter abrades noncompliant plaque and may improve outcome in calcified lesions. METHODS Data from the completed Multicenter Rotablator Registry of 2,161 rotational atherectomy procedures in single lesions were analyzed to determine the relative efficacy of rotational atherectomy for 1,078 calcified and 1,083 noncalcified lesions. The power of the study was 0.86 to detect a significant difference in outcome, if the true success rates in the noncalcified and calcified lesions were 96% and 93%, respectively. RESULTS Patients with calcified lesions were older (mean [+/- SD] age 66.2 +/- 10.3 vs. 60.5 +/- 11.0 years, p = 0.0001) than those with noncalcified lesions. Calcified lesions were more frequently new (75% vs. 64%, p = 0.0001), angulated (27% vs. 22%, p = 0.02), eccentric (75% vs. 64%, p = 0.0001) and long (32% vs. 27%, > 10 mm in length, p = 0.01). They were also more often complex (57% vs. 46%, p = 0.001) and located in the left anterior descending coronary artery (51% vs. 44%, p = 0.001). Adjunctive coronary angioplasty was used in 82.9% of calcified and 66.9% of noncalcified lesions. Procedural success, defined as < 50% residual stenosis without major complications, was achieved in 94.3% of calcified and 95.2% of noncalcified lesions (p = 0.32). Major complication rates were 4.1% in calcified and 3.1% in noncalcified lesions (p = 0.24). Non-Q wave myocardial infarction was documented in 10.0% of calcified and 7.7% of noncalcified lesions (p = 0.054). Mean postprocedural residual stenosis was 21.6 +/- 13.9% in calcified and 23.3 +/- 15% in noncalcified lesions (p = 0.39). CONCLUSIONS In this review of data from a large multicenter registry, the success rate of rotational atherectomy was not reduced by calcification despite the more frequent complex nature of the calcified lesions. The Rotablator catheter is likely to be the device of choice for percutaneous intervention in calcified lesions, but definitive conclusions await the results of randomized trials.
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Affiliation(s)
- A I MacIsaac
- Department of Cardiology, Cleveland Clinic Foundation, Ohio 44106, USA
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Rozenman Y, Lotan C, Weiss AT, Gotsman MS. Emergency rotational ablation of a calcified left main coronary artery stenosis in a patient with ischemic induced cardiogenic shock. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1995; 36:63-6. [PMID: 7489596 DOI: 10.1002/ccd.1810360117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
High-speed rotational ablation is ideal in the treatment of chronic calcified atherosclerotic lesions. This report describes an elderly woman with a prior history of coronary artery bypass surgery, who developed cardiogenic shock secondary to occlusion of a saphenous vein graft to the obtuse marginal branch of the circumflex coronary artery. Her left main coronary artery was heavily calcified and almost completely occluded. She was treated successfully by high-speed rotational ablation of her left main stenosis.
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Affiliation(s)
- Y Rozenman
- Department of Cardiology, Hadassah University Hospital, Jerusalem, Israel
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47
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Brown RI, Penn IM, Viera FM. Case report: A new guidewire for coronary rotational ablation. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1995; 35:59-63. [PMID: 7614543 DOI: 10.1002/ccd.1810350112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We report three cases using a new guidewire designed for coronary rotational ablation. The tips are .014 in diameter and available in different degrees of flexibility. The improved torquability of these guidewires may improve the success rate of coronary rotablation in select cases.
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Affiliation(s)
- R I Brown
- Department of Cardiology, Royal Columbia Hospital, New Westminster, B.C., Canada
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Safian RD. Lesion specific approach to coronary intervention. J Interv Cardiol 1995; 8:143-80. [PMID: 10155226 DOI: 10.1111/j.1540-8183.1995.tb00528.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- R D Safian
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan 48073, USA
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Abstract
The authors studied the magnetic resonance (MR) imaging appearance of excised human arteries and correlated these findings with those from histologic sections obtained in corresponding planes. Imaging was performed with a 1.5-T clinical imager modified with an additional gradient insert capable of a 30 mT/m gradient. High-resolution images of arteries obtained at autopsy indicated that the medial and adventitial layers could be distinguished and that T2-weighted sequences offered superior contrast. Intimal thickening could be detected at a relatively early stage as a long T2 rim on the luminal surface of the artery. Atherosclerotic plaque was found to have MR properties similar to those of intimal thickening, although necrotic regions within plaque had low signal intensity. Fat suppression sequences did not significantly alter the appearance of atherosclerotic plaque. Calcified plaque produced effects ranging from slight signal loss to signal void. MR imaging findings correlated reliably with the tissue types indicated by histologic analysis.
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Affiliation(s)
- A J Martin
- Department of Medical Biophysics, Sunnybrook Health Science Centre, Toronto, Canada
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50
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Moscucci M, Mansour KA, Kent KC, Kuntz RE, Senerchia C, Baim DS, Carrozza JP. Peripheral vascular complications of directional coronary atherectomy and stenting: predictors, management, and outcome. Am J Cardiol 1994; 74:448-53. [PMID: 8059724 DOI: 10.1016/0002-9149(94)90901-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The hospital course of 688 patients consecutively treated with directional coronary atherectomy (375 procedures) or Palmaz-Schatz stenting (376 procedures) was evaluated to identify incidence, predictors, and outcome of major vascular complications. Major vascular complications (defined as surgical repair, major hematoma, or bleeding with a > 10-point hematocrit decrease requiring transfusion alone, or nonsurgically managed arteriovenous fistula, pseudoaneurysm, retroperitoneal hematoma or femoral neuropathy) occurred in 11.7% of procedures, and were more common after stenting than after directional coronary atherectomy (16.8% vs 6.7%, p < 0.001). In particular, surgical repair was required after 10.1% of stenting procedures, versus 5.1% of directional coronary atherectomies (p < 0.02). Multivariable analysis identified age > 70 years, coronary stenting, female gender, multiple procedures during the index hospitalization, and a low nadir platelet count as independent predictors of major vascular complications (all p < 0.03). In the stent subgroup, excessive anticoagulation, nadir platelet count, hypertension, and sheath removal protocol (other than a same-day, activated clotting time-guided protocol) were all independent predictors of vascular complications. Thus, the overall risk of vascular complications with new device procedures (stenting, directional atherectomy) is greater than that traditionally seen with balloon angioplasty alone, and is determined by patient-related factors, procedure type, and management parameters.
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Affiliation(s)
- M Moscucci
- Charles A. Dana Research Institute, Boston, Massachusetts
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