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PubMed2000

Left main coronary artery rotational atherectomy and stenting.

BACKGROUND: Coronary artery bypass surgery is a difficult option in patients who are not candidates for bypass surgery and high-risk patients with critical left main coronary artery (LMCA) disease. We report outcomes and short-term follow-up of patients who had LMCA rotational atherectomy and/or stenting, assess the role of these interventions in protected and unprotected significant LMCA stenosis, and review the literature. METHODS: We reviewed the cases of seven men with critical LMCA stenosis for whom coronary artery bypass surgery was considered a high risk. Five patients had rotational atherectomy, one had coronary artery stenting, and one had both. RESULTS: In all cases, angiographic success was achieved, and symptoms were relieved. Six patients were discharged from the hospital in 3 to 6 days. One patient who had cardiogenic shock, respiratory failure, and acute renal failure before the procedure died of arrhythmia 4 days afterward. Another patient had elective coronary artery bypass graft surgery 3 weeks later for recurrent angina. Cardiac catheterization was repeated in 1 month for chest pain in three patients at 4 to 7 months follow-up, and none had progression of residual stenosis in the LMCA. CONCLUSIONS: Our study suggests that LMCA rotational atherectomy and stenting are safe and effective revascularization procedures in high-risk patients and patients who are not candidates for bypass surgery.

Aged↗

PubMed2001

Acute outcome with the flexicut directional coronary atherectomy catheter for the treatment of coronary in-stent restenosis.

In-stent restenosis (ISR) is a growing problem that is without a practical, efficacious treatment strategy. The purpose of this study was to determine the acute outcome of 17 patients with coronary ISR who were treated with the new 8 French (Fr), guide-catheter compatible Flexicut directional atherectomy catheter (Guidant Corporation, Santa Clara, California). Failure to deliver the device occurred in 2/17 ISR lesions. The remaining 15 ISR lesions were successfully debulked (e.g., minimum lumen diameter pre-procedure: 0.30 +/- 0.16 mm; post-atherectomy plus adjuvant therapy: 2.16 +/- 0.57 mm). Of note, the reference vessel diameter was only 2.62 +/- 0.63 mm. In 11/15 tissue specimens, macroscopic or microscopic particles consistent with stent material were found. There was an absence of acute closure or elevations of creatinine phosphokinase levels. Apart from 1 patient who developed recurrent restenosis, all other patients demonstrated either clinical improvement or lack of restenosis during early clinical follow-up (mean, 5 months). We conclude that use of the Flexicut catheter provides satisfactory debulking and early clinical outcomes in patients with ISR. Long-term follow-up of these and additional patients will be helpful in determining the efficacy of the Flexicut atherectomy catheter for the treatment of ISR.

Aged↗

PubMed1992

[Directional coronary atherectomy. The initial experience].

Four male patients, 38 to 59 years old (mean 49 +/- 2.5), with angina and the angiographic features has been the classical indications for the method, underwent directional coronary atherectomy. Vessels treated were, respectively, left anterior descending artery (LAD), right coronary artery (RCA), saphenous vein graft (SVG) to LAD and SVG to left marginal branch. Reductions to 50% or less of the internal diameter was considered a satisfactory result. Early success was obtained in all four patients. Obstructions of 75 to 95% (mean of 83 +/- 7.5%) were reduced to 0-25% (mean 12 +/- 5%) after atherectomy. Only one patient died suddenly five days after de procedure. So, directional coronary atherectomy may represent a reliable and safe method for special situations.

Adult↗

PubMed1994

Commentary: coronary interventions--overview of a 16-year odyssey based on pathoanatomy: angioplasty, atherectomy, and calcifectomy.

The last 16 years have seen the development of a variety of coronary interventional procedures based on pathoanatomy. New terms have been introduced, such as atherectomy for excision of atheroma. Coronary calcification occurs in the intima and is an important marker of significant coronary artery disease. Echocardiography of the coronary arteries can detect atheroma and calcification. Ultrafast computed tomography can quantify extent of coronary calcium. New devices, such as the rotablator, can specifically treat calcified lesions, and a lesion-specific approach is now possible. The removal of atheroma is called atherectomy. The removal of calcium is called calcifectomy. New procedures spawn new terms. Atherectomy and calcifectomy complement each other, and enable us to be specific about the pathoanatomy and the matched interventional device used. This article is an overview of the evolution of lesion-specific devices and the terminologies pertaining to their use.

Angioplasty, Balloon, Coronary↗

PubMed1993

Directional atherectomy for long lesions: improved results.

The percutaneous treatment of complex stenoses, specifically long lesions, has improved substantially during the past decade. To determine the success of directional atherectomy in the treatment of long lesions, a cohort of 88 patients with lesions greater than 10 mm were evaluated and compared to 376 patients with long lesions treated with conventional balloon angioplasty. Directional atherectomy was successful in 97% and PTCA was successful in 93% of patients with long lesions. There were no differences in complication rates for these cohorts (< 2%). Directional atherectomy and PTCA appear to have safely and successfully broadened the percutaneous treatment of coronary disease to include long coronary stenoses.

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PubMed1993

Bail-out directional atherectomy for abrupt coronary artery occlusion following conventional angioplasty.

Abrupt coronary occlusion following conventional balloon angioplasty (PTCA) remains a serious complication afflicting up to 10% of patients. Although repeat PTCA for prolonged durations can restore blood flow in approximately 50% of patients, if this technique fails, the patient is generally referred for emergent coronary bypass surgery. In this report, we describe the use of directional coronary atherectomy (DCA) as a bail-out technique on 16 patients (17 lesions) undergoing angioplasty who demonstrated a flow limiting dissection and clinical evidence of ongoing ischemia following the procedure which could not be reversed with repeat dilatation (mean 3.5 inflations) at prolonged balloon inflations (mean 6.9 min). Ten of these patients presented to the hospital with a diagnosis of unstable angina and the remaining patients were admitted with acute myocardial infarction. The majority of the incidences of abrupt occlusion (83%) occurred while the patient was still in the cardiac catheterization laboratory. Successful rescue atherectomy was achieved in 15 of the target arteries (88%). In two patients, this technique failed to stabilize the artery and emergent coronary bypass surgery was performed. A complication related to the bail-out procedure developed in three of the successfully treated patients during the same hospitalization. Two patients experienced recurrent abrupt occlusion which was successfully treated with a repeat bail-out atherectomy procedure and one patient developed a non Q wave myocardial infarction. All patients were followed clinically for a mean interval of 9.93 months. Ten patients (71%) remained free of symptoms and cardiovascular events for this period. Stress electrocardiography was performed on eleven (79%) of the successfully treated patients and in no case was ischemia demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)

Angina, Unstable↗

PubMedDate not supplied

Percutaneous rotational atherectomy in peripheral vascular disease for lesions unsuitable for balloon angioplasty.

Percutaneous rotational atherectomy (Rotablator), a high speed (> 140,000 RPM) rotational burr was used to relieve 90-99 percent obstruction in 3 superficial femoral and 2 axillary arteries. These patients had severe claudication in respective extremities. In 4 patients, the lesion was considered to be unsuitable for balloon angioplasty and one patient underwent rotational atherectomy after failure to cross the lesion with balloon catheter. The burr size used ranged from 1.5 to 2.5 mm. After rotablation, the stenosis was reduced from 94.6 +/- 4.5 percent to 42 +/- 8.4 percent. The residual narrowing was further reduced by adjunctive balloon angioplasty to 14 +/- 5.5 percent (p < 0.001). Except for hemoglobinuria in one patient, there were no complications. All patients had good distal pulsations and were relieved of their claudication. On follow-up of 5-18 months, there has been no restenosis. Thus, our preliminary experience suggests that rotational atherectomy is safe and produces gratifying results in patients with peripheral vascular disease having lesions unsuitable for primary balloon angioplasty.

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PubMed1996

Safety and efficacy of elective stent implantation following rotational atherectomy in large calcified coronary arteries.

Rotational atherectomy is an effective transcatheter therapy for calcified coronary lesions. In large (> 3-mm) calcified coronary arteries, stent implantation following rotational atherectomy may further improve acute and especially, long-term benefit. To determine the safety and efficacy of this device synergy approach, we studied 24 consecutive patients undergoing this procedure electively in native coronary arteries. Procedural success was achieved in 100% without any major ischemic complications. There was also no incidence of subacute thrombosis or cardiac event during 30-day follow-up period. Thus, we conclude that elective stent implantation following rotational atherectomy in large, calcified coronary arteries is safe and results in excellent clinical benefit up to 30 days.

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PubMed1997

[Predictive factors of coronary restenosis after optimal directional atherectomy. A multivariate analysis apropos of 102 patients].

The authors studied 102 patients prospectively who were undergoing coronary atherectomy optimised by balloon dilatation in order to assess the restenosis rate at 6 months. The coronary lesions were measured in a reproducible manner by quantitative angiography. The vessels dilated were the left anterior descending in 66 patients and the right coronary artery in 36 patients. The reference diameter was on average of 3.57 +/- 0.64 mm. Atherectomy increased the minimal diameter of the lesion of 1.20 +/- 0.44 to 3.01 +/- 0.44 mm giving a residual stenosis of 15 +/- 11%. At six months, 25% of patients had developed a restenosis (> 50% stenosis) with a residual lumen of 2.15 +/- 0.77 mm. The predictive factors of restenosis were the initial absolute gain, the length of the lesion, the reference diameter of the vessel and the presence of an endoluminal thrombus. In multivariate analysis, a small initial gain (p < 0.02) and length of stenosis (p < 0.02) were independently correlated with restenosis. The authors conclude: 1) that optimal atherectomy is associated with acceptable restenosis rates in selected vessels, 2) that short stenoses of large diameter arteries may be a privileged indication of the technique if the best results are obtained.

Adult↗

PubMed1991

Disruption of a coronary stent during atherectomy for restenosis.

Directional coronary atherectomy is being used in the treatment of atherosclerotic lesions in coronary vessels and vein grafts. This report describes the use of atherectomy for the treatment of restenosis of a coronary stent. The procedure was complicated by disruption of the stent which was snared by the atherectomy cutter.

Aged↗

PubMed1991

Effects of rotational atherectomy in normal canine coronary and diseased human cadaveric arteries: potential for plaque removal from distal, tortuous, and diffusely diseased vessels.

To test the hypothesis that tortuous, diseased vessels could be successfully treated with a flexible rotational atherectomy device we evaluated the BARD atherectomy device with quantitative angiography and histology in normal canine coronary arteries and diseased human below-knee amputation specimens. The mid left anterior descending and the circumflex vessels were treated in 4 dogs serially with 1 wk separating treatments. The acute and follow-up anterior descending artery size was unchanged (1.41 mm before, 1.39 mm after, and 1.59 mm at 1 week). Similar findings were obtained in the circumflex vessels. In 4 adult human amputated legs, diseased peroneal or tibial arteries were treated with a significant reduction in the percent luminal diameter stenosis from 62.75 prior to intervention to 36.5 following intervention (p = 0.021). The luminal diameter increased from 0.81 to 1.54 mm (p = 0.06). In 2 canine arteries there was histologic evidence of localized perforation of the arterial wall, but there was no angiographic evidence of perforation or dissection and no significant myocardial necrosis in the distribution of the treated vessels at 1 wk. The majority of the diseased human vessels demonstrated smoothly cut atheromas with sparing of the media. The rotational atherectomy catheter system holds promise for removal of plaque in relatively small, diffusely diseased, tortuous vessels.

Animals↗

PubMed1991

Ultrasound guidance of laser atherectomy.

Intravascular ultrasound imaging catheters and forward firing laser atherectomy systems are both being used in the coronary vascular tree of man. When used in conjunction, ultrasound imaging may reduce the probability of perforation and dissection related to laser atherectomy. A novel system is presented which combines ultrasound imaging and laser atherectomy capabilities on the same catheter. The system incorporates a holmium YAG laser directed perpendicular to the long axis of the catheter along with a co-directional ultrasound sensor. Ultrasound images are assembled by computer using the angle of the catheter tip and its linear advance associated with each ultrasound echo signal. In vivo experimental results are presented.

Angioplasty, Laser↗

PubMed1988

Rotational atherectomy in atherosclerotic rabbit iliac arteries.

PTCA is not technically possible in many patients with symptoms of coronary artery disease. In addition, atheroma is not physically removed by PTCA, and restenosis of the treated vessel is common. We have tested a new, rotating, abrasive-tipped angioplasty device in vivo in 13 atherosclerotic rabbit iliac vessels. Atherosclerosis was generated in rabbit iliac vessels by a 2% cholesterol diet combined with balloon endothelial injury for 10 weeks. The diseased vessels were then treated with the rotational atherectomy device. Before treatment, contrast angiograms demonstrated that initial percent diameter stenosis was 81% +/- 9%. After atherectomy, there was significant improvement, with residual 38% +/- 22% narrowing (p less than 0.001). One perforation resulted from distal guidewire manipulation, and one vessel was occluded by the device. Histologic examination demonstrated loss of portions of the diseased intima in all cases. Particles were produced for analysis in vitro by operating the atherectomy device in atherosclerotic rabbit aortas perfused with saline solution. Ninety-eight percent of the particles produced by the device were less than 10 micron in diameter. We conclude that this new rotational device can remove atheromatous material from diseased arteries in rabbits. Such a device may complement other angioplasty techniques and lead to wider application of catheter-based therapeutic interventions.

Animals↗

PubMed1992

Efficacy of directional coronary atherectomy in cases unsuitable for percutaneous transluminal coronary angioplasty (PTCA) and after unsuccessful PTCA.

Directional coronary atherectomy (DCA) was used in 10 female and 50 male patients with an average age of 58 years. They were categorized into three different groups depending on the indications for atherectomy. Group 1 included all patients who had atherectomy as their primary intervention (n = 20) because they were assumed to be unsuitable for percutaneous transluminal coronary angioplasty (PTCA). Group 2 consisted of patients in whom DCA was used after failed balloon dilatation with unsuccessful but uneventful treatment (n = 17). Group 3 (n = 23) included patients in whom DCA was performed as a "rescue" or "bailout" procedure after unsuccessful PTCA resulting in critical ischemia (ECG changes, chest pain, hypotension, and shock). The target lesions were located in the left main artery in two, left anterior descending artery in 43, right coronary artery in 15, and aortocoronary venous bypass in five. The mean length of the lesions was 8 mm (2 to 25 mm). The overall success rate for 65 lesions was 92%. The mean stenosis was reduced from 87 +/- 12% to 19 +/- 17% in patients with primary success. Presently available follow-up angiograms (30) showed six restenoses. Major complications occurred in seven patients (myocardial infarction in two and coronary artery bypass graft surgery within 24 hours in five); there were no deaths. Our results show that DCA is a safe and effective technique that can extend the use of percutaneous procedures and provide a promising nonsurgical option in cases of unsuccessful PTCA.

Angioplasty, Balloon, Coronary↗

PubMed1992

Frequency and outcome of chest pain after two new coronary interventions (atherectomy and stenting).

Between June 1988 and July 1991, 464 new device interventions (Palmaz-Schatz stent or Simpson directional atherectomy) were performed in 410 patients. Chest pain occurred within 72 hours after the procedure in 94 patients (23%). All patients were evaluated with electrocardiograms and cardiac isoenzymes on the day after the procedure, and urgent repeat coronary angiography was performed in 29 chest pain patients (31%). Whereas all 14 patients with abnormal findings on repeat angiography had electrocardiographic changes, 6 of the 20 restudied patients (30%) with electrocardiographic changes had no angiographic explanation for chest pain. Non-Q-wave myocardial infarction occurred in 22 patients (5%) (10 of 35 [29%] with chest pain and electrocardiographic changes, 3 of 44 [7%] with chest pain and no electrocardiographic change, and 9 of 316 [3%] without chest pain). Factors associated with chest pain after new device intervention included a decreased residual percent stenosis (p = 0.05), incomplete revascularization (p = 0.005) and the presence of multivessel disease (p = 0.001). Vessel dissection after stenting but not atherectomy was associated with postprocedure chest pain. Chest pain is common (23%) after new device intervention. Electrocardiographic changes are a sensitive marker of angiographic abnormality and confer a higher risk of non-Q-wave myocardial infarction, but no increase of in-hospital mortality. Determinants of postprocedure chest pain are lower residual percent stenosis, incomplete revascularization and the presence of multivessel disease. Patients with chest pain but no electrocardiographic changes early after successful stent placement or atherectomy need not routinely undergo urgent recatheterization.

Angina Pectoris↗

PubMed1992

Mechanical rotational atherectomy.

Percutaneous transluminal coronary angioplasty (PTCA) is practiced widely in the United States and is indicated for the majority of stenosed vessels that have de novo, type A lesions. Despite extensive experience with the procedure and improvements in balloon technology, periprocedural dissection and restenosis remain major limitations of PTCA. Research indicates that certain lesion types and patient populations may be treated more effectively with other technologies. New mechanical devices have been designed to help improve the safety of PTCA and hold promise for correcting coronary dissection and abrupt closure--the sources of such angioplasty complications as myocardial infarction, urgent bypass surgery, and death. Among the results achieved with the new atherectomy techniques are a more stable lumen after atherectomy; a decrease in elastic recoil; a smoother, less thrombogenic lumen; and the feasibility of extensive debulking or endarterectomy. Experience indicates that mechanical rotational atherectomy will be an extremely useful addition to the armamentarium for percutaneous revascularization.

Angioplasty, Balloon, Coronary↗

PubMed1991

High speed rotational coronary atherectomy for patients with diffuse coronary artery disease.

High speed rotational coronary atherectomy was undertaken using the Rotablator in 42 patients who were suboptimal candidates for balloon angioplasty. Most patients (71%) had diffuse coronary artery disease, defined as a stenosis greater than 1 cm in length. Previous restenosis after balloon angioplasty was present in 21% and 10% had an ostial lesion. Adjunctive balloon angioplasty was not used to reduce residual stenosis after atherectomy. The procedure was successful in 76% of patients. Procedural success was achieved in 92% of patients with a lesion less than or equal to 1 cm in length, but in only 70% of patients with a lesion greater than 1 cm in length (p less than 0.01). One patient sustained abrupt closure of the target vessel, resulting in emergency bypass surgery and death. Small non-Q wave myocardial infarction occurred in eight patients (19%) and was associated with a longer lesion. The mean peak creatine kinase value in patients with non-Q wave myocardial infarction was 683 U/liter. Transient regional wall motion abnormalities were noted on the postatherectomy left ventricular angiogram in four of the eight patients with non-Q wave myocardial infarction. Follow-up angiography (at a mean interval of 6.2 +/- 2.6 months) was performed in 91% of patients and revealed restenosis (greater than 50% narrowing) in 59% The resistance rate was 22% for short lesions (less than or equal to 1 cm) and 75% for long lesions (greater than 1 cm) (p less than 0.05). In this study, the results of high speed rotational coronary atherectomy were strongly influenced by lesion length.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty, Balloon, Coronary↗

PubMed1989

Coronary atherectomy: first 50 patients at the Mayo Clinic.

The safety and efficacy of a novel coronary atherectomy device were evaluated in the first 50 patients who underwent 53 such procedures at the Mayo Clinic. This treatment was used for atheromatous lesions in 27 patients and for restenosis after percutaneous transluminal coronary angioplasty in 23; in 3 patients, it was repeated for recurrent stenosis (2) or a persistent intimal flap (1). Successful results, defined as a reduction of the stenosis by 40% or more in association with removal of tissue, absence of Q-wave infarction, and no need for a bypass surgical procedure during in-hospital follow-up, were achieved in 47 of the 53 procedures (89%). Atherectomy reduced the stenoses from a mean of 87% to 15%. Failures occurred in 6 of the 53 procedures (11%). Three of these patients subsequently underwent successful conventional balloon angioplasty, and three required surgical treatment. Six patients had minor complications--embolization of atheromatous material in two, intimal dissection in two, and side-branch occlusion and transient thrombosis in one each. Coronary atherectomy with use of this device promises to be a relatively safe and efficient treatment of coronary artery stenosis.

Angioplasty, Balloon↗