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PubMed1992

Status of peripheral atherectomy.

So far, all atherectomy devices have failed to reduce the restenosis rate of standard balloon angioplasty. Despite actual removal, debulking, and even polishing of the atherosclerotic intima, the arterial wall trauma invariably incites intimal hyperplasia. Until the problem of restenosis can be solved, atherectomy will be limited to those instances when balloon angioplasty is ineffective or contraindicated. Each device has its own peculiarities. We prefer to use the Simpson catheter for eccentric lesions in the iliofemoral or femoropopliteal regions, the Auth Rotablator for short lesions in the infrageniculate vessels, and the TEC for longer lesions in the femoropopliteal regions. Adjunctive balloon angioplasty may or may not be required. Ahn and Moore have illustrated specific clinical strategies for peripheral atherectomy.

Arteriosclerosis↗
PubMed1990

Directional peripheral atherectomy: histopathologic aspects of a new interventional technique.

Among the new transluminal vascular interventions currently being explored, directional atherectomy is unique in that it improves vessel patency by resecting intact portions of atherosclerotic plaque. Experimental atherectomy studies show that strips of plaque are cut away, leaving behind confluent defects within the stenotic lesions. Histologic examination of tissues excised during clinical peripheral atherectomy documents the heterogeneous morphology of peripheral atherosclerosis and shows that intimal hyperplasia is the most common cause of restenosis after therapeutic vascular interventions.

Arteriosclerosis↗
PubMed1990

Peripheral atherectomy: experimental results with a new device.

The size of present rotational atherectomy devices is limited in part by a tendency to produce vessel torsion. The authors designed and investigated a large-bore rotational atherectomy device for peripheral atherectomy in a single pass without significant torsion. A plaque was retrieved from 36 of 40 cadaveric iliac arteries. The mean plaque size was 8.4 x 3.9 mm, and the average number retrieved per artery was two. Thirty of 34 severely calcified arteries were treated successfully. Effluent study revealed no distal embolization; however, six perforations and four dissections occurred. Preliminary results suggest that a cutting surface with a relatively large diameter can be designed to be effective without producing vessel torsion. Changes in future designs will include added flexibility and expandable cutting surfaces to enhance safety and minimize entry diameter.

Arteriosclerosis↗
PubMed1990

[Percutaneous atherectomy of the pelvic and leg arteries].

Percutaneous atherectomy, using a Simpson atherectomy catheter, was performed in 70 patients (43 men, 27 women) whose average age was 72 years (range 42 to 87 years). Between June 1988 and July 1989 all patients with disease in suitable localisations were treated in this way. The Doppler sonographic index before treatment was 0.6 (SD = 0.15), after treatment 0.89 (SD = 0.13). Recurrence was 21% after six months and 29% after twelve months. Atherectomy is superior to balloon dilation in the treatment of solitary eccentric stenoses of the superficial femoral artery and of the popliteal artery.

Adult↗
PubMed1990

The Simpson atherectomy catheter in the management of complete obstructions.

The Simpson atherectomy catheter has been used successfully to recanalise eleven complete occlusions of the iliac and femoropopliteal arteries. Atherectomy and angioplasty were used in combination in 8 cases. Following atherectomy, all patients showed clinical improvement. Distal pulses returned in 7; rest pain and/or claudication disappeared in the other 4. Ischaemic ulcers healed in the 2 affected patients. Overall, ankle-arm indices (AAI) improved by an average of 0.43, with the improvement being greatest (0.55) in patients in whom the lumen was recanalised to within 91-100% of the native luminal diameter. Seven patients have remained with stable AAI values and without change in their clinical status at 18 months follow-up.

Adult↗
PubMed1988

Removal of focal atheromatous lesions by angioscopically guided high-speed rotary atherectomy. Preliminary experimental observations.

A new high-speed rotary atherectomy device, inserted over a guide wire and directed with an angioscope, offers the potential of restoring patency of outflow vessels by "boring out" the atheromatous lesion of the orifices of runoff vessels. The device was tested on 68 cadaver arteries with atheromatous lesions involving the superficial femoral, popliteal, and tibial arteries. This was performed with either free segments or in situ with the device placed through a popliteal arteriotomy. The gross results of rotary atherectomy were assessed by angioscopy, angiography, or both. The luminal surfaces were studied with scanning electron microscopy and transverse sections of vessels were studied with light microscopy. The pulverized atheroma, in colloidal suspension, was analyzed for particle size by Coulter counter. The effect of a colloidal suspension of atheromatous particles on distal capillary circulation was measured in animal experiments. Obstructive lesions were successfully removed in 36 of 37 stenotic arteries (97%) and 18 of 31 completely occluded arteries (58%), an overall efficacy of 54 of 68 (79%). In successfully atherectomized arteries, angioscopy and angiography demonstrated a widely patent, smooth, polished surface. Light microscopy demonstrated removal of the diseased intima with maintenance of the outer media and adventitia. The pulverized atheroma particles were generally smaller than red blood cells and injection of the colloidal atheroma into canine femoral arteries failed to produce local tissue injury. We conclude that in the human cadaver this atherectomy device effectively enlarges and recanalizes obstructed superficial femoral, popliteal, and tibial arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiography↗
PubMed1990

Coronary atherectomy. Clinical, angiographic, and histological findings and observations regarding potential mechanisms.

Between August 5, 1988 and August 1, 1989, we attempted percutaneous directional coronary atherectomy of 76 lesions, including 42 primary lesions and 34 restenosis lesions that developed after one or more prior interventions. The procedure was successful in 67 lesions (88%), with a decrease in diameter stenosis from 80 +/- 11% to 5 +/- 15% after atherectomy (p less than 0.01). One or more complications occurred in six patients (9%), including non-Q wave myocardial infarction (three patients, 4.5%), femoral arterial injury requiring surgical repair (two patients, 3%), and proximal dissection leading to emergency bypass surgery (one patient, 1.5%). Despite these favorable acute results, the 6-month lesion restenosis rate was 30% by life-table analysis. Light microscopy of retrieved tissue revealed atherosclerotic plaque in 94%, media in 67%, and adventitia in 27%. Intimal proliferation was present in 97% of the restenosis lesions but was also evident in 33% of primary lesions. Tissue weight from 27 lesions averaged 18.5 mg (range, 5.8-45.1 mg), which is not adequate to explain the entire angiographic improvement. Thus, part of the improvement in lumen diameter appears to be due to mechanical dilatation rather than to tissue removal alone. Atherectomy can predictably treat selected coronary lesions with overall safety comparable to that of conventional balloon angioplasty, although the procedure as currently performed does not derive all of its benefit from tissue removal and does not appear to prevent restenosis.

Angiography↗
PubMedDate not supplied

Directional coronary atherectomy for the treatment of coronary lesions with abnormal contour.

Directional coronary atherectomy is a newly developed percutaneous transluminal procedure which excises and removes obstructive tissue from coronary arteries or saphenous vein grafts. This procedure was performed on 47 lesions with abnormal contour; 24 ulcerative lesions, 10 lesions with dissection, 7 flap-like lesions and 6 lesions with aneurysm dilatation. Overall success rate was 89%; 96% in ulcerative lesions, 70% in lesions with dissection, 86% in flap-like lesions and 100% in lesions with aneurysmal dilatation. Complications with this procedure were as follows: Vessel occlusion in 2 patients (4.5%), perforation in 1 patient (2.3%), and guiding catheter induced dissection in 1 patient (2.3%). Coronary artery bypass surgery was required in 4 patients (9.4%) for these complications. Of these, 3 patients had lesions with dissections prior to the atherectomy procedure. The success rate for lesions with abnormal contour was similar to those of 270 lesions with normal contour. In conclusion, directional coronary atherectomy is a safe and effective procedure for lesions with abnormal contour, however, outcome of a lesion with dissection is suboptimal and it needs to be approached cautiously.

Angioplasty, Balloon, Coronary↗
PubMed1992

Alternatives for revascularization: peripheral atherectomy devices.

In the ongoing search for newer methods of treating arterial occlusive disease, endovascular devices have emerged as potential alternatives to distal bypasses and/or balloon angioplasty. There are a variety of peripheral atherectomy devices on the market, four of which are discussed in this article. A description of each device including components, method of operation, advantages and disadvantages is provided. Nursing care following an atherectomy procedure is similar to that following a balloon angioplasty in the lower extremities. Early results indicate that atherectomy devices (in their current state) cannot compare with autogenous femoropopliteal bypasses in their rate of restenosis. However, if patency rates can be improved, the future of these devices will be more encouraging and their indications more clearly defined.

Angioplasty, Balloon↗
PubMed1992

Atherectomy. Early use of three different methods.

The authors report their initial experience in 52 patients with three different techniques of peripheral artery atherectomy--the Tracwright (Kensey), used in 19 patients, the Simpson AtheroCath, used in 19 patients and the transluminal extraction catheter, used in 14 patients. The indications for atherectomy were claudication in 42 (80%) and limb-threatening ischemia in 10 (19%). There were no deaths. Complications included three arterial perforations, one thrombosis and one groin hematoma requiring operative evacuation. There were no distal embolizations. Atherectomy was initially unsuccessful in 15 (29%) patients. For the successfully completed procedures, the 1-year primary patency rates were as follows: Tracwright (Kensey) catheter 56%, Simpson catheter (63%) and transluminal extraction catheter (0%). Use of subsequent nonoperative procedures on recurrent stenoses produced secondary patency rates of 77% for the Tracwright (Kensey) technique, 80% for the Simpson catheter technique and 78% for the transluminal extraction catheter technique. The authors conclude that their early results justify further evaluation of these three techniques. Use of the transluminal extraction catheter is associated with higher rates of occlusion and restenosis.

Aged↗
PubMed1991

[Current status of directional coronary atherectomy in interventional cardiology].

Directional coronary atherectomy (DCA) was used in 74 patients with an average age of 56 years. They were categorized into three different groups depending on the indications for atherectomy. Group I included all patients who had atherectomy as their primary intervention (n = 26), because they were assumed to be unsuitable for PTCA. Group II consisted of patients in whom DCA was used after failed balloon dilatation with unsuccessful but uneventful treatment (n = 20). Group III (n = 28) included cases where DCA was performed as a "rescue" or "bail-out" procedure after failed PTCA resulted in critical ischemia (ECG changes, chest pain, hypotension, and shock). The target lesions were located in LM 2, LAD 52, RCA 16, ACVB 4. The mean length of lesion was 8 mm (2-25 mm). The overall success rate was 94%. The mean stenosis was reduced from 90.6 +/- 10% to 17.2 +/- 14.8% in cases with primary success. The presently available follow-up angiography (n = 31) showed six restenoses. Major complications occurred in seven cases (death: 0, myocardial infarction: 2, CABG within 24 h: 5). Histological analysis revealed highly cellular areal as a major characteristics of a coronary lesion and also of restenotic tissue. Tissue of the lamina elastica was present in 44% and of media in 14%. Thrombus was found only rarely. Ultrastructure showed a significant amount of extracellular matrix in the primary coronary lesions and isolated smooth muscle cells without gap-junctions. RER, mitochondria were typical for the synthesizing type of smooth muscle cell. In restenotic tissue a focal high density of smooth muscle cells with increased synthesizing activity and gap-junctions was present. Endothelial cells (and macrophages) were found only rarely. Furthermore, altered smooth muscle cells from restenotic tissue showed a significantly increased migration and proliferation. 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 failed PTCA. Histological analysis revealed a proliferative process as a characteristics of restenosis development.

Angioplasty, Balloon, Coronary↗
PubMed1991

[The role of directional atherectomy in the study of postangioplasty restenosis].

Restenosis is the major limit of arterial recanalization devices. Directional atherectomy has allowed for the first to remove atheroma samples by a percutaneous approach. A group of patients affected by superficial femoral artery disease who underwent directional atherectomy were studied. The patients were treated for primitive stenosis, restenosis after balloon angioplasty and thermal laser angioplasty. Intimal hyperplasia was the distinctive feature of restenosis and the cells were identified by immunohistochemistry and transmission electron microscopy as smooth muscle cells in an active synthetic phenotype. No differences were found in the restenosis process after balloon angioplasty and laser thermal angioplasty. Directional atherectomy is a useful tool to ameliorate our knowledge in the restenosis process after invasive procedure of recanalization.

Aged↗
PubMed1991

[Directional coronary atherectomy: acute results and angiography follow-up in 42 treated patients].

We used directional coronary atherectomy (DCA) as a therapeutic option for coronary lesions unsuitable for PTCA (eccentric, ostial, branching or restenotic) and as "rescue device" for failed PTCA. Forty-two patients were treated by DCA using the Simpson coronary atherectomy device, including four female and 38 male patients with an average age of 55.7 years. Atherectomy as primary intervention was performed in 16 patients (Group I), because morphology of their lesions was assumed to be unsuitable for PTCA. DCA was also used after failed balloon dilatation in eight patients with unsuccessful, but uneventful treatment (Group II). In 18 cases (Group III) DCA was performed as "rescue procedure" after failed PTCA and resulting critical ischemia (local dissection, signs and symptoms of ongoing ischemia, occlusion after PTCA). Target lesions were located in LM 1, LAD 33, RCA 9, CABG 3. Mean length of lesion was 8.1 mm (2-25 mm). The overall success rate for 46 lesions was 93%. Mean stenosis was reduced from 92% to 17% in cases with primary success. Presently, available follow-up angiography (24) showed six restenoses (defined as greater than 50% stenoses). Major complications occurred in seven cases (death: 0, MI: 2, CABG within 24 h: 5; 3 in Group III). "Rescue indication" (Group III) after failed balloon dilatation procedure showed a favorable primary result with a success rate of 78%; only three cases of this group needed CABG. Our results show that DCA is a safe and effective technique which can extend the indication for percutaneous procedures and gives a successful nonoperative option in cases of failed PTCA.

Angioplasty, Balloon, Coronary↗
PubMed1990

[Peripheral Simpson atherectomy. Indications and results of a new transluminal procedure for vascular recanalization].

A report is given on the experience acquired to date with a new catheter method (Simpson atherectomy, S-AE) for reducing arteriosclerotic stenoses in the pelvic and leg arteries of 47 patients. If the correct instrument size is selected, one can regularly perform complete atherectomies in femoropopliteal vessels. The result of recanalization is not affected by the form of the stenosis, but eccentric, calcified or ulcerated lesions are ideal indications. Percutaneous transluminal angioplasty and atherectomy can be used as complementary methods to optimize percutaneous peripheral vascular recanalization. The histological findings, methodological limitations, and clinical results are discussed.

Adult↗
PubMed1990

Recent developments in coronary atherectomy.

Percutaneous coronary atherectomy (PCA) is one of the newest treatments for coronary artery disease. In this technique, arterial plaque is mechanically removed from the interior of the artery by a tool located on the tip of a catheter placed inside the coronary artery nonsurgically. Clinical studies of several coronary atherectomy devices are in process in the United States and abroad. As atherosclerotic material is removed or debulked, abrupt reclosure or restenosis rates may potentially be lower compared with conventional percutaneous transluminal coronary angioplasty (PTCA). PCA may also clear longer and more diffuse lesions, with long-term clinical success, than are successfully being treated by PTCA. Due to the rigidity of the atherectomy catheter, only lesions in major coronary arteries may be approached with these devices at present. It is hoped that PCA may supplement current methods of treating coronary artery disease, including coronary artery bypass graft surgery and PTCA.

Angioplasty, Balloon, Coronary↗
PubMed1989

[Percutaneous transluminal atherectomy of the femoropopliteal arteries. Technic, indications, results after 6 months].

Percutaneous atherectomy was performed in 25 patients with 30 symptomatic femoro-popliteal stenoses. Twenty-three patients were successfully treated with resolution of claudication and a mean 0.35 increase in the ankle-arm-index. Two early thromboses occurred. Residual stenosis was less-than 30% in 25 lesions, with no dissection, and no embolization. Atherectomy seems to be an effective treatment for eccentric and calcified lesions. At 6 months follow-up (17 patients, 19 lesions) clinical and Doppler improvement remained stable in 14 patients; 2 restenosis and 1 new disease occurred. Atherectomy restores a large lumen with minimal wall trauma, thereby possibly decreasing the restenosis rate.

Adult↗
PubMed1989

[Coronary atherectomy using a Rotablator].

A system or rotary atherectomy (Rotablator) was evaluated on coronary stenoses in Man. This device consists of catheter presenting an abrasive olive-shaped knob at one end, and sliding over a central metallic guide, rotating at more than 150,000 tpm. This drill liquifies the atheroma in small microparticles able to cross the microcirculation. The atherectomy surface is perfectly smooth and the risk of thrombosis is minimum. The atherectomy technique is quite simple, similar to PTCA, the balloon being replaced by a drill with a diameter ranging from 1.25 to 2 mm. 48 stenoses in 45 patients were treated with this technique. Twice, the Rotablator's guide was unable to cross the stenosis. In other cases, the stenosis was decreased, in an average, by 75 p. cent (SD 24%) to 43 p. cent (SD 20%) (p less than 0.001). The segment treated is characterized by smooth, linear edges without parictal minithrombi. Complications are most unusual (no deaths, no extended infarction, no emergency bypass related an early reobstruction). The coronary artery may react to the passage of the Rotablator by a spasm; this coronary spasm disappears (sometimes in a few hours) under nitrates derivatives perfusion. The middle term results are very encouraging; in fact, in 19 patients who underwent a control coronary angiography 3 months later, 3 (15%) presented a stenosis. In conclusion, rotary angioplasty is an easy, effective and harmless technique. The exact percentage of re-stenosis remains to be specified in larger series.

Coronary Artery Disease↗
PubMed1993

[Coronary angioplasty combining rotational atherectomy and balloon dilatation. Results in 67 complex stenoses].

The treatment of complex coronary stenoses by conventional angioplasty is limited by a relatively low angiographic success rate, associated with a high risk of major complications. The role of new angioplasty techniques in the treatment of these lesions has not yet been determined. The aim of this prospective study was to evaluate the systematic association of rotational atherectomy (Rotablator) with balloon angioplasty on coronary stenoses characterised by at least 2 type B criteria of the ACC/AHA classification (type B2 lesions). The procedures was begun with rotational ablation with a medium-sized burr (50 to 70% of the reference diameter of the artery) and completed systematically by balloon angioplasty (balloon/artery ratio = 1), using the lowest possible inflation pressures for successful dilatation. This technique was used in 61 patients who had 67 coronary stenoses with a primary success rate (residual stenosis < 50% and no major complications) of 93.4% (57 patients). One emergency coronary bypass procedure was necessary and another patient developed transmural infarction on the 3rd day after the procedure. There were two technical failures (3.3%). The mean inflation pressure of the balloon was 4.1 +/- 1.2 atmospheres. There were no fatalities. During atherectomy, transient conduction defects were observed in 4 patients (6.6%): severe hypotension in 2 patients (3.3%) and complete spasm in 3 stenoses (4.5%). A significant increase in cardiac enzyme levels was observed in 4 patients (6.6%). The authors conclude that rotational atherectomy with a medium-sized burr, followed by systematic low pressure balloon dilatation allows treatment of certain complex coronary stenoses with a high primary success rate and few major complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty, Balloon, Coronary↗