Intervencionismo coronario en lesiones severamente calcificadas mediante aterectomía rotacional y stent liberador de paclitaxel: resultados tras un año de seguimiento

Contemporary percutaneous management of coronary calcification: current status and future directions

Severe coronary artery calcification is one of the greatest challenges in attaining success in percutaneous coronary intervention, limiting acute and long-term results. In many cases, plaque preparation is a critical prerequisite for delivery of devices across calcific stenoses and also to achieve adequate luminal dimensions. Recent advances in intracoronary imaging and adjunctive technologies now allow the operator to select the most appropriate strategy in each individual case. In this review, we will revisit the distinct advantages of a complete assessment of coronary artery calcification with imaging and application of appropriate and contemporary plaque modification technologies in achieving durable results in this complex lesion subset.

Long-Term Clinical Outcome of Early Generation Versus New-Generation Drug-Eluting Stents in 481 Patients Undergoing Rotational Atherectomy: A Retrospective Analysis

INTRODUCTION

New-generation drug-eluting stents (NG-DES) are superior to early generation DES (EG-DES) in the majority of lesion and patient subsets, but comparative data in patients with severely calcified coronary lesions are lacking. This study aims to compare clinical outcomes of EG-DES and NG-DES in patients undergoing rotational atherectomy (RA) in calcified lesions.

METHODS

Data of 268 patients (288 lesions) treated with EG-DES and 213 patients (225 lesions) receiving NG-DES after RA were retrospectively analyzed from a single-center registry. All major adverse cardiac events (MACE) were assessed at 2 years.

RESULTS

Compared to the EG-DES group, patients with NG-DES more commonly had diabetes mellitus (31.9% vs. 40.9%; p = 0.04), left main lesions (7.6% vs. 17.3%; p < 0.001) and chronic total occlusions (3.5% vs. 8.5%; p = 0.016), and had a higher total stent length (30.5, IQR 20-40 mm, vs. 38, IQR 22-53 mm, p < 0.001). The Kaplan-Meier estimated rate of cardiovascular events at 2 years showed a lower incidence of death (13.5% vs. 8.2%, log-rank p = 0.13; adjusted HR after Cox regression analysis 0.49; 95% CI 0.26-0.92; p = 0.03) and a lower MACE rate (31.1% vs. 21.1%, log-rank p = 0.04; adjusted HR 0.65; 95% CI 0.42-0.98; p = 0.04) in the NG-DES group.

CONCLUSIONS

Although RA is performed in more complex patients and lesions in the NG-DES era, use of NG-DES is associated with lower rates of death and MACE at 2 years as compared to EG-DES.

Very Long-Term Follow-Up After Coronary Rotational Atherectomy: A Single-Center Experience

We assessed the very long-term follow-up of a large cohort of unselected patients treated with coronary rotational atherectomy (RA). All 143 patients who underwent RA at our institution from 2000 to 2013 and with complete baseline and follow-up information were analyzed in a retrospective manner. Major adverse cardiac events (MACE) were defined as the composite of target vessel revascularization (TVR), acute myocardial infarction, and all-cause mortality. The mean follow-up was 8.2 years. The 10-year cumulative incidence of MACE for all patients was 57.9% (standard error [SE]: 5.0%). When comparing patients who received a drug-eluting stent (DES; n = 68) versus patients who did not (balloon only, bare-metal stent, or none of the aforementioned; n = 75), the RA + DES demonstrated very long-term MACE of 49.2% (SE: 7.5%) versus 62.7% (SE: 6.1%), P = .160 with TVR as the most discriminating factor, 10.7% (SE: 4.0%) versus 29.2% (SE: 6.0%), P = .016. Our results point to RA having reasonable long-term clinical results, especially in combined treatment with DES. To date, our study has the longest follow-up after RA.

Rotational atherectomy: Technical update

Percutaneous coronary intervention is currently the most common form of revascularization for symptomatic coronary artery disease. In elderly, diabetic and renal patients, there is an increased prevalence of calcified coronary disease. Rotational atherectomy (RA) can be useful in the treatment of these lesions. Plaque removal was initially proposed as an alternative to balloon angioplasty, hence RA required high-velocity protocols with large-sized burrs (over 2.0 mm). With a high incidence of acute complications and disappointing restenosis rates, the use of RA dwindled. However, the advent of drug-eluting stents, which significantly decreased the rate of restenosis, led to the repositioning of RA as an adjunctive technique in the preparation of densely calcified lesions, improving stent delivery and expansion. In recent years, a better understanding of the mechanism of action of RA has changed it from a plaque debulking to a compliance modifying technique. As a result, RA has become less aggressive, using smaller size burrs and lower rotational speeds. This conservative approach has improved immediate results, with increased safety and better long-term outcomes. In this review paper, the technique of RA is explained in the light of current knowledge.

Evaluation of the Diamondback 360 Coronary Orbital Atherectomy System for treating de novo, severely calcified lesions

Coronary lesions with severe (or heavy) calcification are classified as complex lesions and are known to carry lower success rates and higher complication rates following percutaneous coronary intervention. The Diamondback 360(®) Coronary Orbital Atherectomy System is the first and only device approved for use in the USA as a treatment for severely calcified coronary lesions to facilitate stent delivery and optimal deployment. Availability of this device provides a safe and effective option for physicians to improve treatment outcomes in this patient population with severely calcified coronary lesions.