Combined percutaneous coronary atherectomy and coronary angioplasty: experience in 19 consecutive patients

"Rescue" directional coronary atherectomy after unsuccessful percutaneous transluminal coronary angioplasty

OBJECTIVE

To evaluate the outcome in patients who underwent directional coronary atherectomy after unsuccessful balloon angioplasty.

DESIGN

We conducted a retrospective computerized data bank search of patients in whom unsuccessful balloon angioplasty and subsequent "rescue" coronary atherectomy had been performed at the Mayo Clinic between Nov. 1, 1988, and May 1, 1993.

MATERIAL AND METHODS

Among the 336 patients who underwent directional coronary atherectomy during the study period, in 16 the procedure was a rescue attempt. The mean age of these 16 study patients was 67 years. The following vessels were treated: left anterior descending coronary artery, six patients; right coronary artery, six; circumflex artery, two; and saphenous vein graft, two. Coronary angioplasty had failed because of dissection in eight patients, elastic recoil without evident dissection in seven, and recurrent thrombus without evident dissection in one.

RESULTS

After coronary atherectomy, the mean stenosis was 41% (in comparison with 90% before coronary angioplasty and 71% after coronary angioplasty). Both angiographic success (20% or more decrease in stenosis after tissue removal and a final stenosis of less than 50%) and clinical success (angiographic success without in-hospital Q-wave myocardial infarction, bypass operation, or death) were achieved in 10 patients. Adventitia was obtained in two patients, both of whom underwent atherectomy for elastic recoil. In six patients, a stenosis of more than 50% remained after atherectomy; one patient suffered a Q-wave myocardial infarction, and one underwent emergent coronary artery bypass grafting. No deaths occurred in the study group. During follow-up (mean, 22 +/- 19 months), one patient suffered a non-Q-wave myocardial infarction, and two others underwent elective coronary artery bypass grafting. Eleven patients were asymptomatic at last contact. Repeated angiography, done in five patients a mean of 3.4 +/- 3.1 months after the procedure, showed restenosis in three.

CONCLUSION

Rescue directional coronary atherectomy seems to be safe and effective in achieving angiographic and clinical successes in carefully selected patients after unsuccessful coronary angioplasty.

Early experience of directional coronary atherectomy: clinical results, complications and histopathological findings

OBJECTIVE

To report the early experience, clinical results and histopathologic findings of Directional Coronary Atherectomy from a UK centre experienced in coronary angioplasty.

DESIGN

Prospective study of the first 45 Directional Coronary Atherectomy (DCA) procedures using the Simpson coronary atherectomy device.

RESULTS

Forty-five procedures were performed in 33 male and 5 female patients (mean age, 55.1 years). Directional Coronary Atherectomy was performed to 50 lesions (39 de novo, 11 restenosis; 44 left anterior descending, 3 right, 2 circumflex coronary arteries and 1 saphenous vein graft). Clinical and primary angiographic success was achieved in 43 of 45 cases (95.5%) and in 47 of 50 lesions (94%) after DCA alone. Before DCA the mean diameter stenosis was 88.7% (range, 50-100%) but following DCA (and percutaneous coronary angioplasty (PTCA) if necessary) the mean diameter stenosis was 3.5% (range, 0-15%; P < 0.001). Complications included occlusive dissection requiring coronary artery bypass surgery in two patients; abrupt closure of right coronary artery in one patient successfully reopened by PTCA and thrombolysis, complicated by excessive blood loss; reversible coronary artery spasm due to minor nose-cone trauma in four patients and temporary side branch loss in one patient. There were no coronary artery perforations, guide catheter complications, peripheral vascular trauma or deaths. On average 5.6 specimens (range, 1-18) were removed per case. Histology showed fibrous intimal plaque in 98%, media in 39% and adventitia in 7%. Neo-intimal hyperplasia was found in all restenosis lesions but also in 30% of de novo lesions.

CONCLUSIONS

This small initial series indicates that directional coronary atherectomy is an effective and safe procedure for the treatment of obstructive coronary artery disease in carefully selected patients. With care, a high success rate can be achieved even during a learning phase. The technique is particularly effective for morphologically complex lesions that are unfavourable for PTCA. The procedure is unlike PTCA and requires additional training if pitfalls are to be avoided, high success rates achieved and complication rates kept low.

Multicenter clinical experience with rescue atherectomy for failed angioplasty

Directional coronary atherectomy (DCA) has been proposed as a "rescue" technique for failed or suboptimal percutaneous transluminal coronary angioplasty (PTCA) in an attempt to avoid myocardial infarction or emergency coronary artery bypass grafting. In this report we review the utilization and outcome of rescue atherectomy from the clinical experience of The Cleveland Clinic Foundation and Medical College of Virginia from November 1988 through January 1993, and from the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) database. This analysis includes 100 patients with 103 treated lesions from 44 patients at the Cleveland Clinic, 36 patients from the Medical College of Virginia, and 20 patients from the CAVEAT database. The etiology of failed PTCA was primarily from dissection in 52 lesions (50.5%), "recoil" in 43 lesions (41.8%), and recurrent thrombosis in 8 lesions (7.8%). Complete vessel closure was present in 23 lesions (22.3%). The vessels treated included 51.5% left anterior descending, 24.3% right coronary, and 16.5% circumflex coronary arteries. The average reference vessel diameter in the group was 3.10 +/- 0.06 mm (SEM), with an average stenosis of 78.9 +/- 1.2% before PTCA, 55.8 +/- 2.4% after PTCA, and 24.1 +/- 2.2% after rescue DCA. DCA was successful (Thrombosis in Myocardial Infarction [TIMI] grade 3 flow with > 20% stenosis reduction without death, Q-wave myocardial infarction, or coronary artery bypass grafting) in 94 of 103 lesions (91.3%). Complications included 1 patient with perforation (1%), 2 deaths within 24 hours (2.0%), and 6 patients requiring coronary artery bypass grafting (6%).(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of major ischemic complications after coronary dissection following angioplasty

Coronary dissection is a major cause of abrupt arterial closure after coronary angioplasty but may also be associated with no discernible event. Deciding which dissections should receive further treatment is often a dilemma if the artery remains patent. This case-control study examined predictors of major ischemic complications after coronary dissections. Fifty-eight patients with coronary dissections, but a patent artery at the completion of the angioplasty procedure, subsequently had in-hospital abrupt arterial closure, acute myocardial infarction, emergency coronary bypass surgery, or died; they were matched to 58 control subjects with dissection but no event. Analysis of each angiogram was performed with the examiner unaware of patient's history. Baseline angiographic and clinical characteristics of cases and controls were similar except for an excess of current smokers among the cases (31 vs 16%; p = 0.048). Residual luminal diameter at the dissection site was 1.2 +/- 0.6 mm (cases) versus 1.6 +/- 0.6 mm (controls; p = 0.001) with relative stenosis of 59 +/- 21% vs 43 +/- 21%, respectively (p = 0.0001). Dissections among cases were longer than among controls (11 +/- 7 mm vs 7 +/- 4 mm; p = 0.001). No significant difference was found in dissection morphology using 2 classification schemes or in final Thrombolysis in Myocardial Infarction study flow grade. Transient occlusion during the procedure, however, occurred in 47% of cases versus 5% of controls (p = 0.0001). Transient occlusion, residual percent stenosis > or = 70%, and dissections > or = 6 mm were independently predictive of major ischemic events.

Autoperfusion balloon catheter for complicated coronary angioplasty: a prospective study with retrospective controls

Prolonged angioplasty balloon inflation with an autoperfusion balloon for failed conventional coronary angioplasty, was compared with emergency surgery for this condition. Restenosis was assessed 6 weeks after successful intervention with the autoperfusion balloon. Forty consecutive patients with persistent acute occlusion and/or severe intimal dissection during conventional angioplasty, were treated with the autoperfusion balloon. They were candidates for emergency surgery if it failed. Total inflation time was significantly longer (p < 0.001) with the autoperfusion balloon (27.5; 10-180 min) than with the standard balloon (10; 1-20 min) (median; range). The number of inflations was significantly lower (p < 0.001) with the autoperfusion balloon (2; 1-5 times) than with the standard balloon (5; 2-14 times) (median; range). Two patients died, one before surgery could be performed. The autoperfusion balloon was successful in 26 patients (65%). After 6 weeks, 16 (62%) were asymptomatic without anti-anginal medication, 24 underwent repeat angiography, 10 (42%) had restenosis, 7 (27%) underwent elective bypass surgery. Emergency surgery remained necessary in 13 patients (33%), 9 received arterial grafts. In 31 retrospective controls, who had undergone immediate surgery for the same indication, only venous grafts could be used. Thus, prolonged autoperfusion balloon inflation was successful in 65% of the cases of failed, conventional angioplasty. The angiographic restenosis rate after 6 weeks was 42%. If emergency surgery remained necessary, the autoperfusion balloon facilitated the use of arterial bypass grafts.

Relation of deep arterial resection and coronary artery aneurysms after directional coronary atherectomy

OBJECTIVES

The aims of this study were to document the frequency of coronary artery aneurysm formation in patients undergoing directional coronary atherectomy and to determine the relation of such aneurysms to the depth of arterial resection.

BACKGROUND

Deep arterial injury is relatively frequent with the use of directional coronary atherectomy, but the potential for subsequent coronary artery aneurysm formation is unknown.

METHODS

Results in a consecutive series of 64 successfully treated patients (a total of 69 lesions; mean angiographic follow-up at 5 months) treated with directional coronary atherectomy were retrospectively analyzed with use of quantitative angiographic and histologic data.

RESULTS

Coronary aneurysms (ratio of dilated vessel segment to the adjacent reference segment > 1.2:1) occurred in seven patients (10%). The only significant clinical correlate of aneurysm formation was a relatively shorter duration of angina. There were no significant preprocedural angiographic predictors of aneurysms, although 6 (86%) of the 7 aneurysmal lesions arose from restenosis lesions compared with 30 (48%) of 62 lesions with no subsequent aneurysm development (p = 0.06). Histopathologic examination of 414 specimens from 68 treated lesions showed no significant difference in the occurrence of subintimal resection (media +/- adventitia) between those with and without subsequent aneurysm (29% vs. 22%). Media alone was found in 14% of specimens from lesions that later became aneurysmal versus 15% of those that did not; adventitial resection was found in 14% and 7% of specimens, respectively (p = 0.08), with relatively more adventitia per specimen from those with aneurysm (55% vs. 30% without aneurysm, p = 0.08).

CONCLUSIONS

Aneurysms occur relatively frequently after directional coronary atherectomy. Although there was no statistically significant correlation with the depth of arterial resection, the evidence from this study suggests that the role of adventitial resection in the occurrence of late aneurysm development should be explored further.