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PubMed1998

Low restenosis rate in lesions of the left anterior descending coronary artery with stenting following directional coronary atherectomy.

The present study evaluated acute and late results with stenting following directional coronary atherectomy (DCA) for the lesions in the left anterior descending coronary artery (LAD). Between April 1995 and January 1997, 200 LAD lesions with > or =3 mm reference vessel diameter were treated with coronary stents. The lesions were divided as to whether or not DCA was performed before stenting; 1) stenting alone (n = 163) and 2) debulking and stenting (n = 37). There were no significant differences in the incidences of complications except for non-Q-wave myocardial infarction that was more frequent in patients with debulking and stenting than in those with stenting alone (13.5% vs. 2.4%, P < 0.05). A greater acute lumen gain (2.85 +/- 0.66 vs. 2.25+/-0.60 mm, P < 0.01) and minimal lumen diameter (3.64+/-0.56 vs. 3.15+/-0.41 mm, P < 0.01) after stenting were observed in patients with debulking and stenting than in those with stenting alone. At follow-up patients with debulking and stenting continued to have a greater minimal lumen diameter (2.88+/-0.72 vs. 2.15+/-0.85 mm, P < 0.01) and had a lower restenosis rate (6.3% vs. 23.1%, P < 0.05) than those with stenting alone. Stenting following DCA appears to be advantageous in the LAD lesions with > or =3 mm reference vessel diameter.

Aged↗
PubMed1998

Analysis of low-speed rotational atherectomy for the reduction of platelet aggregation.

Platelet activation is an important determinant of acute outcomes of percutaneous intervention. The objective of this study was to assess the effect of rotational atherectomy on platelet activation in an in vitro model. Freshly collected heparinized porcine blood was exposed to a 2.0-mm Rotablator burr rotating at one of three speeds: 180,000, 140,000, or 0 rpm. The specimens were analyzed immediately for concentration and size of platelet aggregates and plasma-free hemoglobin. There were significantly more platelet aggregates of >20-microm diameter at higher speeds (7,434+/-2,193 at 180,000, vs. 2,269+/-627 at 140,000, vs. 633+/-258 aggregates/ml at 0 rpm; P < 0.001). Plasma-free hemoglobin, a simple measure of cell damage, decreased with decreasing rotational speed (429+/-168 mg/dl at 180,000, vs. 88+/-44 mg/dl at 140,000, vs. 9+/-9 mg/dl at 0 rpm; P < 0.0001). In vitro, platelet activation decreases with decreasing burr speed, suggesting that the use of the Rotablator system at its minimum approved speed (140,000 rpm) could prove clinically beneficial.

Animals↗
PubMed1998

Orgaran during rotational atherectomy in the setting of heparin-induced thrombocytopenia.

Heparin is considered necessary during percutaneous coronary interventions; however, heparin is contraindicated in patients with heparin-induced thrombocytopenia and/or heparin antibodies. We describe the successful use of the heparinoid Orgaran (danaparoid sodium) in addition to abciximab (ReoPro) in a patient with heparin antibodies who required rotational atherectomy.

Abciximab↗
PubMed1999

Adjunctive abciximab improves outcomes during recanalization of totally occluded saphenous vein grafts using transluminal extraction atherectomy.

Degenerative disease of aortocoronary saphenous vein grafts is a major cause of late morbidity and mortality in patients after coronary bypass surgery. We previously described a technique for recanalization of totally occluded grafts using extraction atherectomy (TEC) as a primary modality. While success was comparable to overnight urokinase, distal embolization, no-reflow, and non-Q myocardial infarction were common. Recently, abciximab has been used adjunctively in angioplasty and stenting with a reduced incidence of periprocedural complications. In order to determine whether abciximab can reduce the incidence of distal embolization, no-reflow, and myocardial infarction during TEC in totally occluded saphenous vein grafts, we compared patients treated with adjunctive abciximab with control subjects not receiving the drug. Male patients with previous coronary bypass surgery, class III-IV angina, and totally occluded saphenous vein grafts serving a vascular territory with ischemia not approachable by standard catheter-based techniques underwent TEC with or without adjunctive abciximab. Recanalization of the graft was achieved in 8/10 (80%) of subjects without abciximab, but complete success was achieved in only 5/10 (50%). In contrast, all procedures in the abciximab group were completely successful, without embolization or no-reflow. Our results suggest that TEC with adjunctive abciximab may be a highly effective approach for management of totally occluded saphenous vein grafts.

Abciximab↗
PubMed1999

Rotational atherectomy: improved procedural outcome with evolution of technique and equipment. Single-center results of first 1,000 patients.

We present our single-center experience of rotational atherectomy (RA) in the first 1,000 consecutive patients divided arbitrarily into three different time periods corresponding to significant changes in technique or equipment for RA. Period I (August 1994 to April 1995; 172 cases) is characterized by early experience, longer ablation, and frequent use of intra-aortic balloon pump; period II (May 1995 to January 1996; 254 cases) is characterized by short ablation runs (20-30 sec) and use of rotaflush; period III (February 1996 to February 1997; 574 cases) is characterized by ReoPro use, neosynephrine boluses to avoid hypotension, and rota floppy wire and flexible shaft burrs. The procedural success rate has improved and complication rates have progressively declined over these three time periods. The incidence of lesion complexity (long and type C lesions) and patients with unstable rest angina have increased over these time periods of RA. Therefore, modification in procedural techniques and equipment over time have made RA a safe technique despite its use in very complex lesion subsets.

Aged↗
PubMed1999

Intravascular ultrasound for evaluation of initial vessel patency and early outcome following directional coronary atherectomy.

Elastic recoil and thrombus formation may potentially occur following directional coronary atherectomy (DCA) confounding the assessment of late vascular remodeling. Since intravascular ultrasound (IVUS) data on early outcome of DCA is not available, we used IVUS to investigate whether elastic recoil or thrombus formation can affect early (4 hr) outcome. Quantitative coronary angiography (QCA) and IVUS were performed in high-grade coronary lesions in 32 consecutive patients before, immediately after, and 4 hr after DCA. Late clinical follow-up was obtained after a maximum interval of 2 years. Significant acute elastic recoil was observed by both IVUS (19%+/-14%) and QCA (19%+/-12%), but there was no further recoil after 4 hr. DCA reduced plaque area by 51%+/-13%, an effect that was stable after 4 hr, indicating the absence of relevant thrombus formation. Residual area stenosis by IVUS was not related to the occurrence of late clinical events (n = 8). Mechanical recoil or thrombus formation do not hamper initial lumen gain achieved by DCA. Although QCA significantly underestimated residual plaque burden after DCA when compared to IVUS, the degree of residual area stenosis did not identify patients suffering from cardiac events on follow-up.

Aged↗
PubMed1999

Risk of distal embolization and infarction with transluminal extraction atherectomy in saphenous vein grafts and native coronary arteries. NACI Investigators. New Approaches to Coronary Interventions.

Lower success rates have been reported when treating high-risk lesions in saphenous vein grafts (SVGs) and native coronary arteries with balloon angioplasty. The transluminal extraction atherectomy catheter (TEC) has been proposed to reduce the incidence of distal embolization (DE) in subsets of high-risk lesions. To define the utility of TEC in reducing the incidence of DE, all patients who were enrolled in the New Approaches to Coronary Interventions (NACI) Registry and had TEC planned as the sole treatment were studied (329 patients with 381 lesions). Of the lesions treated, 75.9% were in SVGs; 37.5% were thrombotic; and 15% were total occlusions. Adjunctive percutaneous transluminal coronary angioplasty (PTCA) was performed in 87.4% of lesions. Multivariate predictors of DE were: noncardiac disease, stand alone TEC, thrombus, and larger vessel size. DE was associated with an 18.5% in-hospital mortality vs. 3.0% without DE (P < 0.01) and a 25.9% MI rate vs. 5.0% without DE (P < 0.01). In conclusion, in this high-risk subset of patients, TEC is associated with an 8.3% incidence of DE with thrombotic and SVGs lesions. DE associated with TEC appears to carry high morbidity and mortality. Additional techniques to control DE are needed to reduce the frequency of complications in these patients.

Aged↗
PubMed2000

Computerized analysis of myocardial echocardiographic enhancement during coronary revascularization by high-speed rotational atherectomy.

A previous report demonstrated transient myocardial echocardiographic contrast (MEC) enhancement following high-speed rotational atherectomy (HSRA). This phenomenon was found to be correlated to the speed and duration of rotation and related to creation of cavitations. To determine other correlations and the significance of MEC, continuous echocardiographic recording was performed in 10 patients undergoing HSRA. Images were digitized and videointensity-time curves generated. Curve parameters were calculated and correlated with procedural variables, plaque mass, and side effects. Twenty-nine ablation passes in 10 patients were analyzed. Videointensity peaked 9-44 sec from initiation of ablation and decayed to a higher baseline level after each consecutive ablation. Increase in peak contrast intensity (PCI) from baseline and the percentage of the left ventricle undergoing enhancement were highest (33 +/- 31 gray level/pixel and 32% +/- 8%, mean +/- SD, respectively) after the second rotation and were not influenced by the duration of rotation. PCI, side effects, and transient left ventricular wall motion abnormalities were positively correlated with plaque mass, defined by the product of lesion length, diameter, and percent stenosis. HSRA resulted in significant myocardial echocardiographic contrast. PCI is related to ablation sequence and plaque mass. Plaque debris embolization is probably responsible for myocardial echocardiographic contrast and transient wall motion abnormalities. Cathet. Cardiovasc. Intervent. 49:39-44, 2000.

Aged↗
PubMed2003

Percutaneous transluminal rotational atherectomy for coronary artery disease.

BACKGROUND: Percutaneous transluminal coronary rotational atherectomy (PTCRA) debulks atherosclerotic plaque from coronary arteries using an abrasive burr. On rotation, the burr selectively removes hard tissue. OBJECTIVES: To assess the effects of PTCRA for coronary artery disease in patients with non-complex and complex lesions (e.g., ostial, long, or diffuse lesions or those arising from in-stent restenosis) of the coronary arteries. SEARCH STRATEGY: We searched the Heart Group specialised register, the Cochrane Library to Issue 2, 2001, and MEDLINE, CINAHL, EMBASE and Current Contents to December 2002 and reviewed reference lists for relevant articles. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials of PTCRA compared with placebo, no treatment or another intervention and excluded cross-over trials. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two authors. We asked authors of trials to provide information when missing data was encountered. Statistical summaries used risk ratios (RR) and weighted mean differences. MAIN RESULTS: We included 9 trials enrolling 3,066 patients. There was no evidence of the effectiveness of PTCRA in non-complex lesions. In complex lesions, there were no statistically significant differences in restenosis rates at 6 months (relative risk 1.00; 95% confidence interval 0.83 to 1.20) and 1 year (relative risk 1.21; 95% confidence interval =0.95 to 1.55) in those receiving PTCRA with adjunctive PTCA (PTCRA/PTCA) compared to those receiving PTCA alone. Morphological characteristics distinguishing complex lesions have not been examined in parallel-arm randomised controlled trials. There is equivocal evidence of the effectiveness of PTCRA in in-stent restenosis. Compared to angioplasty alone, PTCRA/PTCA did not result in a statistically significant increase in the risk of major adverse cardiac events (myocardial infarction, emergency cardiac surgery or death) during the in-hospital period (relative risk 1.19; 95% confidence interval =0.78 to 1.83). Compared to angioplasty, PTCRA was associated with 9 times the risk of an angiographically-detectable vascular spasm (relative risk 9.23; 95% confidence interval 4.61 to 18.47), 4 times the risk of perforation (relative risk 3.87; 95% confidence interval 0.82 to 18.21) and about 2 times the risk of transient vessel occlusions (relative risk 2.28; 95% confidence interval 1.00, 5.19) while angiographic dissections (relative risk 0.49; 95% confidence interval 0.33 to 0.75) and stents used as a bailout procedure (relative risk 0.38; 95% confidence interval 0.22 to 0.65) were less common. REVIEWER'S CONCLUSIONS: When conventional PTCA is feasible, PTCRA appears to confer no additional benefits. There is limited published evidence and no long-term data to support the routine use of PTCRA in in-stent restenosis. In certain circumstances (e.g., patients ineligible for cardiac surgery, those with architecturally complex lesions, or those with lesions that fail PTCA), PTCRA may achieve satisfactory revascularisation in subsequent procedures.

Angioplasty, Balloon, Coronary↗
PubMed2000

Bail-out rotational atherectomy to ablate stent struts after treatment of a LAD bifurcation lesion with the Trousers technique.

We present a previously unreported complication of the "trousers" stent procedure used for treatment of a bifurcation lesion in the left anterior descending artery and the first diagonal branch. Closure of the main vessel occurred. A balloon, however, could not be advanced across the side-branch stent to open the struts toward the main branch. Therefore, a bailout rotational atherectomy was performed to ablate the stent that then allowed a further dilatation with a PTCA balloon. This procedure resolved a potentially lethal outcome for the patient who subsequently underwent uneventful coronary by-pass grafting.

Aged↗
PubMed2000

Side-branch occlusion after rotational atherectomy of in-stent restenosis: incidence, predictors, and clinical significance.

We evaluated the incidence, predictors, and clinical significance of side-branch occlusion (SBO) after rotational atherectomy (RA) for treatment of in-stent restenosis (ISR) and compared it with those of native coronary artery (NC). RA was performed in 64 patients with 34 ISR (42 side branches) and 30 NC (40 side branches). SBO occurred 14% after RA in ISR group compared with 0% in NC group (P < 0.05), and 33% after adjunctive balloon inflation in ISR group compared with 2.5% in NC group (P < 0.01). Non-Q myocardial infarction developed in seven patients in ISR group and four patients in NC group (P = NS). The presence of significant side-branch (SB) ostial disease (OR = 4.7, P < 0.05) and ISR lesions (OR = 15.5, P < 0.05) were the only independent predictors of SBO by multivariate analysis. The incidence of SBO is higher after RA of ISR than RA of NC and may be associated with an increased risk of non-Q myocardial infarction.

Angioplasty, Balloon, Coronary↗
PubMed2001

Effect of abciximab on cardiac enzyme elevation after transluminal extraction atherectomy (TEC) in high-risk saphenous vein graft lesions: comparison with a historical control group.

Saphenous vein graft (SVG) intervention has been associated with an increased incidence of distal embolization. Long lesions and lesions associated with thrombus are particularly at increased risk. This study was performed to determine whether abciximab may decrease this risk in high risk SVG angioplasty. From June 1994 to June 1998, 84 patients with at least one high risk factor, i.e., lesion length >20 mm or angiographic evidence of thrombus, underwent Transluminal extraction atherectomy (TEC) procedure followed by balloon dilatation or stenting. Of these 84 patients, 37 who had procedure after September 1995 underwent TEC with abciximab (Abciximab Group) and 47 who had their procedure before that date had TEC without abciximab thereby serving as historic control (Non-Abciximab Group). All patients had normal pre-procedure CK and CK-MB. Total creatine kinase (CK) and CK-MB were measured every 8 hr post-procedure for 24 hr. Baseline demographics, angiographic characteristics, incidence of LV dysfunction and triple vessel disease were similar between the two groups. Graft age was similar between two groups (122 +/- 70 vs. 117 +/- 54 months). Graft diameter, pre and post-procedure percent stenoses were not different between the two groups. Stents were used in 65% in the Abciximab group and 45% in Non-Abciximab group (P = 0. 14). There was no in-hospital repeat PTCA, urgent bypass surgery, or cardiac death. There was no difference between the two groups in regards to the incidence of any elevation of total CK (27% vs. 21. 3%) or CK-MB (54% vs. 51%). When used in conjunction with TEC in treating high risk vein graft lesions, abciximab did not reduce post procedure CK-MB elevation in this patient population.

Abciximab↗
PubMed2001

Rotational atherectomy (stentablation) in a lesion with stent underexpansion due to heavily calcified plaque.

We report treatment of a lesion with coronary stent underexpansion due to heavily calcified plaque. Conventional balloon angioplasty was attempted for in-stent restenosis, but the lesion was undilatable despite 25-atm inflation pressure. Intravascular ultrasound (IVUS) revealed stent underexpansion due to heavily calcified plaque. Rotational atherectomy was performed using a stepped burr approach, after which repeat IVUS revealed marked ablation of the stent-calcium complex. Adjunctive balloon angioplasty then easily resulted in full balloon and stent expansion, with an excellent angiographic and IVUS result. The patient's hospital course was uneventful.

Aged↗
PubMed2003

Successful rotational atherectomy in the setting of extensive coronary dissection: a case of failed balloon angioplasty in a nondilatable calcified lesion complicated by balloon rupture and extensive dissection.

We describe a case of rotational atherectomy (RA) used in the setting of extensive coronary dissection. Unsuccessful predilitation of a heavily calcified proximal LAD stenosis resulted in balloon rupture, which produced occlusive dissection extending into the mid LAD. Limited options for this patient required that we perform RA to permit stent delivery and deployment and avoid anterior myocardial infarction. A brief discussion of reasons for balloon angioplasty failure and the potential role for subsequent RA is given. Predictors for coronary perforation when performing RA are reviewed. Our rationale and strategy to avoid the increased risk of perforation with RA in this contraindicated setting of extensive dissection is given.

Aged↗
PubMed2003

Insufficient tissue ablation by rotational atherectomy leads to worse long-term results in comparison with balloon angioplasty alone for the treatment of diffuse in-stent restenosis: insights from the intravascular ultrasound substudy of the ARTIST randomized multicenter trial.

The ARTIST trial demonstrated a worse outcome for patients with in-stent restenosis (ISR) treated with rotational atherectomy (RA) and adjunctive balloon angioplasty (PTCA) as compared to PTCA alone. This intravascular ultrasound (IVUS) substudy compares effects of lumen enlargement and examines reasons for failure of RA in this setting. IVUS (n = 56) was performed after each interventional step and at follow-up. Volumetric lumen gain measured 79 +/- 68 mm(3) after PTCA (13 +/- 4 atm) as compared to 44 +/- 26 mm(3) after RA and adjunctive PTCA (7 +/- 3 atm; P < 0.0001). RA itself enlarged lumen by only 19 +/- 17 mm(3) and stent volume was 47% smaller as compared to high-pressure PTCA. Low-pressure strategy after RA did not prevent tissue growth during follow-up (19 +/- 25 vs. 36 +/- 38 mm(3); RA vs. PTCA; P = 0.09). Consequently, net lumen gain after PTCA was 82% higher compared to RA (46 +/- 54 vs. 25 +/- 24 mm(3); P = 0.09). Further stent expansion is the key mechanism to achieve luminal gain by PTCA of ISR. Neointimal ablation by RA has only minor effects. Low-pressure PTCA does not prevent recurrent tissue growth and failed for treatment of ISR due to insufficient stent expansion.

Aged↗
PubMed2003

High-speed rotational atherectomy and coronary stenting: QCA and QCU analysis.

To evaluate the acute effect of pretreatment with high-speed rotational atherectomy (HSRA) on stent deployment (rotastenting), we studied 33 patients with rotastenting of 40 segments, 34 patients with 40 coronary segments treated with Palmaz-Schatz stenting alone, and 34 patients with 40 segments treated with HSRA. The HSRA- and stent-alone patient groups were selected retrospectively by matching the quantitative coronary angiography (QCA) reference diameter (D ref). QCA revealed similar baseline percent of stenosis (85.3% +/- 12.4%), minimal luminal diameter (MLD), and D ref. The percent area expansion was calculated as a ratio between the minimal intrastent area and the reference area measured by intracoronary ultrasound. The rotastent group was characterized by more frequent calcification compared to HSRA and stent groups (67.5% vs. 20% and 12.5%; P < 0.01). Lesion length determined by QCA was longer both in the HSRA and the rotastent groups vs. the stent-alone group (21.1 +/- 12.3 and 20.9 +/- 4.3 vs. 17.0 +/- 7.7 mm; P < 0.05). In this small study, there was no difference demonstrated between final MLD in the rotastent and stent-alone groups. However, a smaller MLD was achieved in the HSRA group (3.0 +/- 0.7 vs. 3.1 +/- 0.5 vs. 2.5 +/- 0.7 mm, respectively; P < 0.01). The degree of stent expansion was higher in the rotastent group compared to the stent-alone group (91.9% +/- 4.4% vs. 79.7% +/- 3.4%; P < 0.03) and the % residual area of plaque was less for the rotastent group than for the stent-alone group (12.1% +/- 13.2% vs. 21.1% +/- 17.5%; P = 0.03). These data suggest that antecedent HSRA atheroma debulking using HSRA results in improved intravascular stent expansion and reduction in residual plaque, facilitating optimal stent deployment.

Aged↗
PubMed2004

Predictors of vessel remodeling following directional coronary atherectomy.

The purpose of this study was to clarify predictors of vessel remodeling following directional coronary atherectomy (DCA). Negative remodeling after DCA leads to restenosis. However, little is known about the predictors of the vessel remodeling. Serial IVUS was performed in 43 lesions. The vessel remodeling was defined as adaptive if vessel area at follow-up minus postprocedure vessel area was > 0 mm2, or as constrictive if < 0 mm2. Adaptive remodeling occurred in 21 (49%) lesions. Postprocedure percent plaque area was smaller in the adaptive group (32.9% +/- 5.7% vs. 45.5% +/- 8.8%; P < 0.005). At follow-up, vessel area was larger in the adaptive group. However, plaque area was similar between the two groups. As a result, lumen area was larger in the adaptive group. Multivariate analyses showed that postprocedure percent plaque area < 40% was the only predictor of adaptive remodeling (odds ratio, 6.68; P < 0.05).

Adaptation, Physiological↗