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PubMed1999

[Follow-up of dissection of the right coronary artery and wall of the ascending aorta after directional coronary atherectomy. A case report].

We report on a patient in whom a restenosis after two PTCA procedures was treated with directional coronary atherectomy. In the second DCA maneuvre a spiral dissection, type D, developed from ostium to restenosis with a balloon shaped part in the wall of the aorta ascendens. This part disappeared nearly completely by next day. The dissection in the right coronary artery persisted three months later until a bypass operation and was not visible after two years.

Aortic Dissection↗

PubMed2000

Impact of intravascular ultrasound guidance on directional coronary atherectomy.

In contrast to the luminogram of coronary angiography, intravascular ultrasound (IVUS) has proven to accurately assess both coronary lumen and vessel morphology due to its 360 degrees imaging capacity. Directional coronary atherectomy (DCA) improves the coronary lumen by removing plaque mass rather than stretching the vessel and compressing the plaque as with conventional percutaneous transluminal coronary angioplasty. In an attempt to optimize the procedural result of DCA we prospectively investigated the impact of IVUS guidance in a head to head comparison to on-line quantitative coronary angiography (QCA) on the result of DCA. In 16 consecutive patients IVUS demonstrated significant residual plaque mass after DCA irrespective of a satisfactory angiographic result. After a mean of 9 +/- 2 cuts luminal improvement was obtained with an area stenosis by angiography of 39 +/- 17% and by IVUS of 50 +/- 10% (p < 0.05), a diameter stenosis by angiography of 23 +/- 10% and IVUS of 35 +/- 14% (p < 0.05) and finally a minimal lumen diameter (MLD) by angiography of 2.9 +/- 0.5 mm and by IVUS of 2.3 +/- 0.5 mm (p < 0.005). After both on-line QCA and IVUS measurements a second series of 7 +/- 2 cuts were initiated to debulk more atheroma and improve stenosis dimensions. After additional cuts IVUS revealed further luminal improvement with an area stenosis by angiography of 25 +/- 16% and IVUS of 21 +/- 18% (n.s.), a diameter stenosis by angiography of 16 +/- 11% and by IVUS of 13 +/- 19% (n.s.) and finally a MLD by angiography of 3.1 +/- 0.5 mm and by IVUS of 2.8 +/- 0.3 mm (p < 0.05). Intraprocedural use of IVUS is superior to on-line QCA to assess the immediate result of DCA. IVUS-guided DCA results in more effective atheroma debulking than luminographic evaluation. Results of larger follow-up studies are needed to substantiate the intraprocedural advantage of IVUS with DCA.

Adult↗

PubMed2001

[Intravascular ultrasound guided directional atherectomy and stent implantation of an unprotected main stem in a heart transplant patient with comorbidity].

Following orthotopic heart transplantation (HTx), development of transplant vasculopathy (TVP) is the limiting medical entity leading to significant morbidity and mortality beyond the first year after HTx. Selection of a suitable strategy for repeat revascularisation--transcatheter angioplasty, coronary artery bypass grafting or repeat HTx--depends on various parameters including coronary morphology, left ventricular performance, comorbidity, availability of graft material and donor organs. Catheter-based interventions on the main stem of the left coronary artery are feasible, but a relatively lower primary success rate and a higher complication rate and significantly increased mortality have to be expected. We report on a patient who underwent HTx 9 years ago and developed severe transplant vasculopathy revealing significant main stem stenosis, making reintervention necessary. Due to age, coronary artery morphology and comorbidity the patient was not considered for coronary artery bypass grafting or repeat HTx. We performed successful IVUS-guided directional coronary atherectomy and stent implantation on a distal stenosis of the unprotected main stem. Our case demonstrates a predictable procedural risk and favourable primary result of left main stem angioplasty procedures, thus providing a therapeutic option for patients who are poor candidates for operative revascularisation strategies.

Aged↗

PubMed2001

Troponin T elevation after successful directional atherectomy.

BACKGROUND: The incidence and correlates of postinterventional cardiac troponin T (cTnT) elevation have not been evaluated in patients with successful directional atherectomy (DCA). METHODS: Total creatine kinase (CK) activity, CK-MB mass concentrations and cTnT levels were measured in 36 patients before, and serially 4, 24, 48 and 72 hours after successful DCA. Patients were followed for death, Q-wave infarction, need for emergency bypass surgery, periprocedural vascular complications (transient in-lab vessel closure, side branch compromise, large dissection), and non-Q-wave infarction on ECG. Patients were followed for clinical outcomes and angiographic restenosis for 6 months. Vascular correlates were studied by coronary angiography and intravascular ultrasound before, immediately after and 4 hours after elective and successful DCA. RESULTS: 25 patients (69.4%) had elevated levels of cTnT, whereas CK-MB mass > or = 6 ng/ml and mild elevations of total CK activity were present in only 36.1 and 5.6%, respectively. Elevated cTnT was related to vascular complications in 44% of cases. Inapparent microembolization of platelets or plaque debris was considered responsible for most of the remaining micronecroses. During 6 month follow-up rates of clinical restenosis (44 vs 9%, p = 0.059) tended to be higher in patients with as compared to patients without cTnT release after DCA. CONCLUSION: Successful DCA is associated with postprocedural elevations of cTnT which relate to minor vascular complications and presumably microembolization of platelets or plaque debris. The superior diagnostic performance of cTnT compared to CK-MB mass may relate to more sensitive identification of microinfarction. Further studies are mandatory to confirm the association between elevation of cTnT and risk of restenosis and TVR.

Atherectomy, Coronary↗

PubMed1997

Immunohistochemical analysis of hepatocyte growth factor in human coronary atherectomy specimens: comparison with transforming growth factor beta isoforms.

The expression and localization of hepatocyte growth factor/scatter factor (HGF/SF) were examined immunohistochemically in 59 human coronary artery lesions retrieved by directional coronary atherectomy and compared with the localization of transforming growth factor beta isoforms (TGF-beta 1, -beta 2, and -beta 3). In 21 of the 59 specimens (35.6%) HGF-like immunoreactivity (HGF-IR) was revealed. The HGF immunopositivity rate of 45% (14/31) in thrombotic tissue was significantly (P < 0.05) higher than the rates of 7.3% (4/55), 7.1% (3/42), and 0% (0/14) in fibrous tissue, neointimal hyperplasia and atheromatous gruel, respectively. Immunoreactivity for HGF was much weaker than that for TGF-beta isoforms in these components except in thrombotic tissue. These cells exhibiting strong HGF-IR were inflammatory cells such as monocytes/macrophages in thrombotic tissue, in tissue lesions adjacent to a thrombus, and outside the capillary walls in a portion of the neovascularized lesions. Smooth muscle cells (SMCs) hardly demonstrated HGF-IR. In contrast, in control coronary arteries obtained at autopsy, the HGF-IR was strongly expressed in SMCs. These findings suggest that HGF produced by macrophages play a part in the process of coronary plaque formation attributable to thrombus in man.

Adult↗

PubMed1994

Angiographic follow-up of patients after transluminal coronary extraction atherectomy.

The transluminal coronary extraction-endarterectomy catheter (TEC) consists of a torquing tube with a distal, conical rotating blade. We successfully treated 26 patients (27 lesions) using this catheter with adjunctive balloon angioplasty. Twenty-five patients (26 lesions) had serial angiography before, 1 day after, and 3 months after the procedure. All 17 patients without restenosis 3 months after the procedure had angiography at 6 months. Restenosis, defined as > 50% diameter stenosis, was noted in nine lesions at 3 months (early restenosis) and in five lesions at 6 months (late restenosis). Between vessels with and without early restenosis, the percentage of diameter stenosis seen 1 day after the procedure and the luminal diameter were significantly different (38% +/- 14% vs 22% +/- 12%, respectively, p < 0.01; 2.3 vs 2.9 mm, p < 0.01, respectively). However, between vessels with and without late restenosis, these variables were not significantly different. The overall restenosis rate was 54% (native vessels 50%; grafts 80%). This observational study suggests that very early diameter narrowing seen 1 day after the procedure has greater contribution to early restenosis than to late restenosis after successful TEC atherectomy with adjunctive balloon angioplasty.

Aged↗

PubMed1995

Intracoronary ultrasound imaging before and after directional coronary atherectomy: in vitro and clinical observations.

The rate of restenosis after directional coronary atherectomy (DCA) is higher than expected. To elucidate why, the current study used intravascular ultrasound (IVUS) imaging to investigate the mechanism of DCA. An in vitro validation study was performed to determine the accuracy of the measurement of plaque removal by IVUS. DCA was performed in eight human atherosclerotic artery segments. The volume of removed plaque was measured by water displacement and was compared with the volume calculated from IVUS images. A clinical study of DCA was performed in 32 lesions. IVUS was performed in 28 lesions after successful DCA. Measurements of lumen dimensions from digital angiograms before and after DCA were compared with observations of lumen and plaque size from the cross-sectional IVUS images. In the in vitro study, the mean plaque volume removed by DCA was 19.9 +/- 8.5 microliters. The calculated estimate of removed plaque volume by IVUS was 18.6 +/- 7.9 microliters and correlated closely with the volume by water displacement (r = 0.92). The calculated volume of plaque removed from histologic sections was 14.3 +/- 6.0 microliters and was linearly correlated with plaque volume by water displacement (r = 0.81). In the clinical study, the angiographic mean minimum lumen diameter increased from 1.0 +/- 0.4 to 2.7 +/- 0.5 mm and the percentage stenosis decreased from 70% to 19% (p < 0.0001). The IVUS images before and after DCA showed that the lumen DCA improved from 2.9 +/- 1.5 to 7.0 +/- 1.5 mm2 (p < 0.0001). In addition the vessel cross-sectional area (CSA) increased from 17.1 +/- 5.9 to 18.7 +/- 5.5 mm2. The atheroma CSA was reduced from 14.2 +/- 5.0 to 11.7 +/- 4.8 mm2. This combined effect of reduction in atheroma CSA and stretching of the outer vessel diameter resulted in an improvement in percentage plaque area stenosis from 83% +/- 7% to 61% +/- 9%. It is concluded that despite a successful angiographic appearance, DCA removed an average of 2.5 mm2 from the atheroma, which corresponds to only 18% of the atheroma CSA. The total lumen CSA increased 4.1 mm2; 61% of the new lumen was created by cutting and removal of plaque, whereas 39% of the new lumen was made by stretching the external wall of the artery. Despite an excellent angiographic result, IVUS imaging reveals that after DCA a significant amount of residual atheroma remains. As in balloon dilatation, a stretching effect is a significant component of DCA.

Aged↗

PubMed1995

Mechanism of high-speed rotational atherectomy and adjunctive balloon angioplasty revisited by quantitative coronary angiography: edge detection versus videodensitometry.

High-speed rotational coronary atherectomy (RA) is primarily used to treat complex lesions. Quantitative angiographic analysis of such complex lesions by edge detection is often unsuitable, whereas videodensitometry, measuring vessel dimensions independently of the target stenosis contours, may offer potential advantages. To gain insight into the operative mechanism of RA and to study the agreement between the two quantitative angiographic methods in measuring the minimal luminal cross-sectional area, the edge detection and videodensitometry techniques were applied to coronary angiograms of 21 lesions in 19 patients with symptoms who underwent successful RA and balloon angioplasty (BA). Obstruction diameter as determined by edge detection increased from 1.00 +/- 0.31 mm before intervention to 1.35 +/- 0.29 mm after RA (p < 0.001) and further increased to 1.74 +/- 0.33 mm after adjunctive BA (p > 0.001). The mean between-method difference (edge detection minus videodensitometry) was 0.34 mm2 before intervention, 0.13 mm2 after RA, and 0.09 mm2 after adjunctive BA (not significant). The standard deviation of the differences decreased from +/- 0.87 mm2 before intervention to +/- 0.80 mm2 after RA (not significant) and increased after BA significantly to +/- 1.21 mm2 (p < 0.05). Thus edge detection and videodensitometry provided equivalent immediate angiographic results after RA and adjunctive BA. The good agreement after RA may reflect the operative mechanism of RA, which by ablation of noncompliant plaque material yields a circular symmetric lumen with smooth surface. The increased dispersion of the between-method differences observed after adjunctive BA presumably results from dissections, plaque ruptures, and loss of luminal smoothness after balloon dilatation.

Absorptiometry, Photon↗

PubMed1995

Correlation of atherectomy specimen histology with coronary arteriographic lesion morphologic appearance in patients with stable and unstable angina.

Complex lesions on coronary arteriography are seen commonly in patients with unstable angina and have been considered to be evidence of ruptured plaque with or without thrombus. To investigate the cause of complex lesions the histologic findings in atherectomy-derived specimens in 111 patients were correlated with lesion morphologic appearance on coronary arteriography. Among 91 patients with complex lesions, 81.3% had thrombus and 57.1% had evidence of plaque rupture. Of 20 patients with smooth lesions, 15% had thrombus and 10% had plaque rupture on histologic evaluation (p < 0.01). On clinical correlation in 86 (83.3%) patients unstable angina was associated with thrombus, or plaque rupture (63.3%), or both on histologic evaluation (p < 0.001 compared with stable angina). Complex lesions not associated with thrombus or plaque rupture occurred mainly (83.3%) in patients with stable angina. Our findings support the concept that complex lesions are usually due to recent thrombus, plaque rupture, or both in patients with unstable coronary syndromes but may be due to remote plaque disruption in patients with stable angina.

Adult↗

PubMed1993

Experience with directional coronary atherectomy since pre-market approval.

Directional coronary atherectomy (DCA) received Food and Drug Administration (FDA) Pre-Market Approval in September 1990 and was then released through formal training certification of physicians at each new site. Procedure volume has increased dramatically since approval, with > 17,000 DCA procedures performed in 1991 and a cumulative total of > 33,000 procedures by mid-1992, at > 670 centers in the United States. Clinical application and results since approval have generally been similar to preapproval multicenter investigational results. Comparison of pre- and postapproval usage at the Medical College of Virginia shows similar baseline characteristics and indications, although recent patients show a higher proportion of "salvage" DCA for failed or suboptimal angioplasty (6% vs 14%) or DCA in combination with multidevice multiple vessel intervention (30% vs 38%). Overall results in 300 patients and 345 procedures included procedural success in 95%, clinical success in 94%, with major complications in 4.6% (including urgent bypass surgery in 3.8%, Q wave myocardial infarction in 1.7%, and hospital mortality in 0.3%). Results before and after FDA approval were similar for procedural success (94% vs 96%), clinical success rate (94% vs 94%), and major complications (5.5% vs 4.4%). There was a trend toward lower urgent surgery rate (5.4% vs 3.3%) in the more recent experience. In addition to its established efficacy for highly eccentric lesions, newer applications for which DCA is being used following FDA approval include treatment of saphenous vein grafts, thrombus-associated lesions, aorto-ostial lesions, failed or suboptimal percutaneous transluminal coronary angioplasty result, bifurcation lesions, and use as part of multivessel intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty, Balloon, Coronary↗

PubMed1994

Effect of prior coronary restenosis on the risk of subsequent restenosis after stent placement or directional atherectomy.

Lesions that have developed restenosis after a prior intervention may be more likely to develop restenosis after subsequent percutaneous interventions. To determine if this is an independent effect, the clinical characteristics and immediate angiographic outcomes of 179 prior restenosis lesions were compared with those of 254 primary lesions after stenting or directional atherectomy. Six-month angiographic follow-up was obtained for 79% of successfully treated lesions. Univariable and multivariable logistic regression was used to determine how binary restenosis (defined as > or = 50% diameter stenosis at follow-up) was influenced by postprocedure luminal diameter, left anterior descending artery location, diabetes mellitus, as well as prior restenosis. At 6-month follow-up, prior restenosis lesions had a significantly smaller late diameter (1.77 vs 2.18 mm, p < 0.001), more absolute late loss (1.35 vs 1.14 mm, p = 0.051), a higher loss index (0.58 vs 0.45, p < 0.02), and a higher binary restenosis rate (37.3% vs 24.4%, p = 0.01). Whereas univariable analysis revealed that left anterior descending artery location, diabetes mellitus, postprocedure luminal diameter < 3.1 mm, and prior restenosis were each strong predictors of binary restenosis (all p < 0.02), multivariable analysis showed that after adjustment for left anterior descending artery location, diabetes, and postprocedure luminal diameter, prior restenosis was no longer an independent predictor of restenosis (odds ratio 1.57, 95% confidence interval 0.95-2.60, p = 0.073). In conclusion, although prior restenosis lesions do show more restenosis than primary lesions, much of this effect is due to preselection of a population enriched in other known factors that predispose to restenosis.

Angioplasty, Balloon, Coronary↗

PubMed1992

Post-atherectomy coronary artery aneurysm.

A 52-year-old man underwent an uneventful directional atherectomy of the left anterior descending coronary artery. Four months after the procedure unstable angina developed and on angiogram an aneurysm of the left anterior descending coronary artery was noted. The patient underwent bypass of the left anterior descending coronary artery. An attempt to exclude the aneurysm resulted in hemodynamic compromise and was discontinued. Follow-up angiogram 2 months after operation showed the aneurysm to be smaller. The patient is doing well 6 months after operation.

Atherectomy, Coronary↗

PubMed1995

Coronary artery aneurysms after angioplasty and atherectomy.

Coronary artery aneurysm formation after percutaneous transluminal coronary angioplasty and directional coronary atherectomy is unusual. We report the case of a left anterior descending coronary artery aneurysm that formed in such a patient. The left anterior descending coronary artery was bypassed and the aneurysm was plicated with the aid of coronary angioscopy. The English-language medical literature on the topic of coronary artery aneurysms is reviewed.

Angioplasty, Balloon, Coronary↗

PubMed2005

Comparison of angiographic and clinical outcomes between rotational atherectomy and cutting balloon angioplasty followed by radiation therapy with a rhenium 188-mercaptoacetyltriglycine-filled balloon in the treatment of diffuse in-stent restenosis.

BACKGROUND: Rotational atherectomy (RA) and cutting balloon angioplasty (CBA) have been shown to effectively dilate in-stent restenosis (ISR). It is not known, however, which of these technique, when followed by beta-radiation, is more effective. Therefore, we performed a prospective randomized study comparing RA and CBA before beta-radiation therapy for diffuse ISR. METHODS: Patients with diffuse ISR were randomly assigned to receive RA (group 1, n = 58) or CBA (group 2, n = 55) before beta-radiation therapy with a rhenium 188-mercaptoacetyltriglycine-filled balloon, with the radiation dose being 18 Gy at a depth of 1.0 mm into the vessel wall. The primary end point was angiographic restenosis at 6 months, and the secondary end point was major adverse cardiac events (myocardial infarction, death, target lesion revascularization) at 9 months. RESULTS: The 2 groups were similar in baseline characteristics. Mean lesion length was 21.0 +/- 11.2 mm in group 1 and 20.8 +/- 10.2 mm in group 2 (P = .77). Radiation was delivered successfully to all patients. We obtained 6-month angiographic follow-up in 90 patients (80%). The rates of angiographic restenosis were 14.9% (7 of 47) in group 1 and 14.0% (6 of 43) in group 2 (P = .89). No patient experienced myocardial infarction or death during the 9-month follow-up period. Rates of target lesion revascularization or major adverse cardiac events were 3.4% in group 1 and 3.6% in group 2 (P = .94) during the 9-month follow-up. CONCLUSIONS: Either RA or CBA, followed by beta-radiation using a rhenium 188-mercaptoacetyltriglycine-filled balloon, is equally safe and effective for diffuse ISR in 6-month angiographic and 9-month clinical outcomes.

Angioplasty, Balloon↗

PubMed2006

Preprocedural statin use is associated with a reduced hazard of postprocedural myonecrosis in patients undergoing rotational atherectomy--a propensity-adjusted analysis.

Incidence of myonecrosis in patients undergoing rotational atherectomy was evaluated by preprocedural statin use. The incidence of any myonecrosis (24.1% vs 52.3%, P < .001) or significant myonecrosis (7.5% vs 21.8%, P < .001) was significantly lower among patients pretreated with statins. This difference remained significant after multivariable and propensity adjustment.

Aged↗

PubMed2003

A comparative study of rotational atherectomy in acute and stable coronary syndromes in the modern era.

Percutaneous rotational coronary atherectomy (PRCA) is commonly used in the percutaneous treatment of diffuse, calcified coronary lesions in stable coronary syndromes (SCSs) and facilitates successful delivery and deployment of balloons and stents. Early experience with PRCA cautioned its use in acute coronary syndromes (ACSs). However, the evolution of the PRCA technique and improved antiplatelet pharmacotherapy has broadened its use in ACSs also. A total of 1,112 consecutive patients with an ACS (n=269) or SCS (n=843) who underwent PRCA of 1,483 lesions were examined retrospectively to evaluate the angiographic and short-term clinical outcomes. Troponin-I was elevated in 33.3% of the ACS group and in 0.6% of the SCS group at baseline (p<0.001). Angiographic complications occurred more frequently in the ACS group (18.6% vs 13.1%, p=0.02). There was no difference in major complications between the groups (ACS 1.1% vs SCS 0.8%; p=0.44). The incidence of any periprocedural creatinine kinase-MB elevation was 17.1% versus 18.9% (p=NS) and 30-day major adverse cardiac events (death, disabling stroke, creatine kinase-MB >3 times the upper limit of normal, urgent revascularization) was 5.9% versus 4.6% (p=NS) when comparing the ACS and SCS groups, respectively. With current techniques and antiplatelet therapy, PRCA can be safely performed in ACSs when lesion morphology dictates, with outcomes comparable to that achieved in SCSs. Although angiographic complications occurred more frequently in the ACS group, this did not result in a significantly higher incidence of postprocedural myonecrosis or 30-day major adverse cardiac events.

Acute Disease↗

PubMed2004

Effect of preintervention remodeling type on subsequent coronary artery behavior after directional atherectomy.

To evaluate the influence of preintervention remodeling on subsequent vessel behavior after directional coronary atherectomy (DCA) under intravascular ultrasound (IVUS) guidance, serial (before and after DCA and at 6-month follow-up) IVUS data were analyzed for 246 lesions that were classified into 2 categories: positive remodeling (PR) in 77 lesions versus intermediate or negative remodeling in 169 lesions. Although the 2 groups had similar baseline characteristics, IVUS data showed that the PR group had a greater acute lumen area (LA) gain without an increased late LA loss, resulting in a greater net (acute plus late) LA gain and follow-up LA. This suggests that IVUS-guided DCA may neutralize the negative impact of preintervention PR on late vessel patency.

Aged↗

PubMed2004

Quantitative angiographic and intravascular ultrasound study >5 years after directional coronary atherectomy.

Aggressive and optimal directional coronary atherectomy (DCA) using intravascular ultrasound (IVUS) guidance provides favorable outcomes within 1 year. However, no previous data are available on the changes that occur in target lesions for the long term after stand-alone DCA. This study's aim evaluates, using quantitative angiography and intravascular ultrasonography, the natural history of changes that occur in target lesions between short- (about 6 months) and long-term (>5 years) follow-up angiography after stand-alone DCA. Of 186 patients (221 lesions) with successful stand-alone DCA, 48 patients (53 lesions) underwent revascularization within 6 months, and 14 patients subsequently died, leaving a study population of 124 patients (154 lesions). Complete quantitative coronary angiography (QCA) was obtained in 91 patients (101 lesions) and complete serial IVUS assessment was obtained for 38 lesions before and after intervention and during follow-up. From short- to long-term follow-up angiography, the minimal luminal diameter significantly increased (from 2.12 to 2.56 mm; p <0.0001); lesion subgroups with >30% diameter stenosis at short-term follow-up angiography showed significant late regression as assessed by QCA. Serial IVUS assessment revealed that the vessel cross-sectional area did not change (from 17.3 to 17.4 mm(2); p = NS); however the lumen cross-sectional area significantly increased (from 7.3 to 9.5 mm(2); p <0.0001) due to the reduction of plaque plus media cross-sectional area (from 10.0 to 7.9 mm(2); p <0.0001). The change in lumen cross-sectional area correlated with the change in plaque plus media cross-sectional area (r = -0.686, p <0.0001). Target lesions show late regression due to plaque reduction at >5 years after stand-alone DCA.

Adult↗