Rotational atherectomy for the management of undilatable in-stent restenosis with single or multiple stent layers

Comparison of long-term outcome in patients with in-stent restenosis treated with intravascular lithotripsy or with modified balloon angioplasty

BACKGROUND

Modified balloon angioplasty (MB) using a cutting-/scoring balloon or intravascular lithotripsy (IVL) is used in patients with in-stent restenosis (ISR). However, IVL is an off-label use in this setting. The aim of this subgroup analysis of an all-comers registry was to compare IVL to MB angioplasty in patients with ISR.

METHODS

The subgroup (n = 117) included all patients with an ISR treated by MB or IVL between 2019 and 2021. Primary endpoint was strategy success (< 20% residual stenosis). The secondary endpoint was cardiac death, acute myocardial infarction (AMI) and target lesion failure/revascularization (TVR). Quantitative coronary angiography was performed in all patients.

RESULTS

A total of n = 36 patients were treated by IVL and n = 81 patients by MB. No significant differences in baseline characteristics were observed between the groups. The primary endpoint was reached in 99 patients (84.6%). Patients in the IVL group had less residual stenosis (2.8% vs. 21.0%; p = 0.012). Multivariate regression analysis revealed that IVL had a significant positive effect on reaching the primary end point (Estimate 2.857; standard error (SE) 1.166; p = 0.014). During the follow-up period (450 days) there were no significant differences in rates of cardiac death (IVL n = 2 (1.7%) vs. MB n = 3 (2.6%); p = 0.643), AMI (IVL n = 2 (1.7%) vs. MB n = 4 (3.4%); p = 0.999) and TVR (IVL n = 5 (4.3%) vs. MB n = 14 (12%); p = 0.851).

CONCLUSION

IVL results in a significantly lower rate of residual stenosis than MB in patients with ISR. During the long-term follow-up, no differences in rates of cardiac death, AMI or TVR were observed.

Intracoronary imaging-guided rotational atherectomy combined with intravascular lithotripsy in the treatment of severe coronary artery calcification-A case report

Background

Severe coronary artery calcification increases the difficulty of percutaneous coronary intervention procedures and impairs stent expansion. Herein, we report a case of a patient who was successfully treated with rotational atherectomy using a stepped burr strategy combined with intravascular lithotripsy for plaque modification under intracoronary imaging.

Case summary

A 65 year-old woman presented to our hospital with recurrent chest pain evolving for 1 year. Coronary angiography showed approximately 80% stenosis of the proximal mid-left anterior descending artery. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) revealed a 360° annular calcification. The calcification was rotablated with 1.5 and 1.75 burrs, and the lesion was undilatable with a 3.0 mm non-compliant balloon at 14 atm. Subsequently, the intravascular lithotripsy was reset for the modification of the calcified lesion. A shockwave balloon measuring 3.0 mm × 12 mm was delivered, and 40 pulses were performed at 6 atm. Intravascular imaging modalities (IVUS and OCT) revealed a circumferential calcified plaque with deep fractures. After post-balloon expansion followed by drug-eluting stent placement with a final stent expansion of 84%, there were no intraoperative complications and no major adverse cardiovascular events within 90 days postoperatively.

Conclusion

A combination of rotational atherectomy and intravascular lithotripsy may be an effective and complementary strategy for the treatment of severely calcified lesions that cannot be resolved using a single procedure. However, more clinical studies are required to clarify this finding.

Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics: update 2023

The Task Force on Rotational Atherectomy of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed the expert consensus document to summarize the techniques and evidences regarding rotational atherectomy (RA) in 2020. Because the revascularization strategy to severely calcified lesions is the hottest topic in contemporary percutaneous coronary intervention (PCI), many evidences related to RA have been published since 2020. Latest advancements have been incorporated in this updated expert consensus document.

Coronary lithotripsy for the treatment of underexpanded stents: the international & multicentre CRUNCH registry

BACKGROUND

Stent underexpansion increases the risk of cardiac adverse events. At present, there are limited options to treat refractory stent underexpansion. In this context, the intravascular lithotripsy (IVL) system might be a safe and effective strategy.

AIMS

We aimed to evaluate the safety and efficacy of IVL in addressing resistant stent underexpansion due to heavy underlying calcification.

METHODS

This was an international multicentre registry including patients receiving IVL therapy to treat stent underexpansion from December 2017 to August 2020. Angiographic and intracoronary imaging data were collected. The efficacy endpoint was device success (technical success with a final percentage diameter stenosis <50%). The safety endpoint was in-hospital major adverse cardiac events (MACE).

RESULTS

Seventy patients were included, the mean age was 73±9.2 years and 76% were male. The median time from stent implantation to IVL therapy was 49 days (0-2,537). Adjuvant treatment with non-compliant balloon dilatations pre- and post-IVL was performed in 72.3% and 76.8% of patients, respectively, and additional stenting was performed in 22.4%. Device success was 92.3%. Minimum lumen diameter increased from 1.49±0.73 mm to 2.41±0.67 mm (p<0.001) and stent expansion increased by 124.93±138.19% (p=0.016). No IVL-related procedural complications or MACE were observed. The use of bailout IVL therapy directly after stenting and the presence of ostial underexpanded lesions negatively predicted lumen diameter gain.

CONCLUSIONS

Coronary lithotripsy is safe and effective in increasing lumen and stent dimensions in underexpanded stents secondary to heavily calcified lesions.