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At least 649 records · Page 36Linked to original sources
PubMed2000

Treatment of in-stent restenosis with excimer laser coronary angioplasty versus rotational atherectomy: comparative mechanisms and results.

BACKGROUND: Atheroablation yields improved clinical results for balloon angioplasty (percutaneous transluminal coronary angioplasty, PTCA) in the treatment of diffuse in-stent restenosis (ISR). METHODS AND RESULTS: We compared the mechanisms and clinical results of excimer laser coronary angioplasty (ELCA) versus rotational atherectomy (RA), both followed by adjunct PTCA; 119 patients (158 ISR lesions) were treated with ELCA+PTCA and 130 patients (161 ISR lesions) were treated with RA+PTCA. Quantitative coronary angiographic and planar intravascular ultrasound (IVUS) measurements were performed routinely. In addition, volumetric IVUS analysis to compare the mechanisms of lumen enlargement was performed in 28 patients with 30 lesions (16 ELCA+PTCA, 14 RA+PTCA). There were no significant between-group differences in preintervention or final postintervention quantitative coronary angiographic or planar IVUS measurements of luminal dimensions. Angiographic success and major in-hospital complications with the 2 techniques were also similar. Volumetric IVUS analysis showed significantly greater reduction in intimal hyperplasia volume after RA than after ELCA (43+/-14 versus 19+/-10 mm(3), P<0.001) because of a significantly higher ablation efficiency (90+/-10% versus 76+/-12%, P = 0.004). However, both interventional strategies had similar long-term clinical outcome; 1-year target lesion revascularization rate was 26% with ELCA+PTCA versus 28% with RA+PTCA (P = NS). CONCLUSIONS: Despite certain differences in the mechanisms of lumen enlargement, both ELCA+PTCA and RA+PTCA can be used to treat diffuse ISR with similar clinical results.

Angioplasty, Balloon, Coronary↗
PubMed1995

Predictors and sequelae of distal embolization during saphenous vein graft intervention from the CAVEAT-II trial. Coronary Angioplasty Versus Excisional Atherectomy Trial.

BACKGROUND: The purpose of this study was to identify the predictors and sequelae of distal embolization from a multicenter, randomized trial of saphenous vein graft intervention. The CAVEAT-II trial demonstrated that saphenous vein graft directional coronary atherectomy (DCA) was associated with greater angiographic success and less need for repeat intervention compared with percutaneous transluminal coronary angioplasty (PTCA) but at the cost of more acute complications--notably distal embolization. METHODS AND RESULTS: In CAVEAT-II, 305 patients were randomly assigned to DCA (149 patients) or PTCA (156 patients) for lesions with > 60% diameter stenosis in vein grafts > or = 3 mm in diameter. Distal embolization occurred in 20 patients (13.4%) assigned to DCA and 8 patients (5.1%) assigned to PTCA (P = .011). Independent predictors of distal embolization were use of DCA (71% in distal embolization patients versus 47% in patients without distal embolization, P = .011) and presence of thrombus (39% in distal embolization patients versus 14% in patients without distal embolization, P < .00). In-hospital adverse events were more frequent after distal embolization; 71% versus 20%, odds ratio plus (95% confidence intervals) 9.87 (4.65, 20.94). At 12-month follow-up, adverse event rates were also higher in patients with distal embolization (odds ratio, 3.05 [1.95, 4.76]). CONCLUSIONS: In this first prospective multicenter trial of saphenous vein graft intervention, distal embolization was more common after DCA than PTCA and in lesions containing thrombus. It also was associated with worse in-hospital and 12-month outcomes. The risk and sequelae of distal embolization should be considered when choosing a treatment strategy for vein graft disease.

Aged↗
PubMedDate not supplied

Prolongation of QT interval as a predictor of no-reflow induced by rotational atherectomy.

Although coronary rotational atherectomy (RA) is widely applied to clinical cases, the incidence of coronary no-reflow associated with it is higher than in percutaneous transluminal coronary angioplasty (PTCA) and stenting. This study was undertaken to predict no-reflow by using conventional electrocardiograms (ECGs). A total of 105 patients who underwent RA (group 1) and 40 who underwent PTCA (group 2) were studied. Eight patients of group 1, all of whom had long calcified coronary lesions, were complicated with no-reflow following RA. Standard 12-lead ECGs were recorded before and throughout the interventional procedures. Maximum and minimum QT intervals and QT dispersion were measured and corrected by heart rate. Corrected and uncorrected QT intervals and QT dispersion were significantly prolonged by RA in group 1 patients without no-reflow: maximum QTc, 428 +/- 28 ms --> 485 +/- 53 ms, p<0.001. The increases in QT intervals were more remarkable in group 1 patients with no-reflow: maximum QTc, 434 +/- 15 ms --> 552 +/- 39 ms, p<0.001. Of the 33 patients with maximum QTc > or = 500 ms, 8 were complicated with no-reflow. No patients with maximum QTc < 500 ms had no-reflow. There was no significant increase in QT intervals in group 2. Adsorption of calcium ions from the myocardium by pulverized calcified atheromatous debris when these pass through coronary capillaries, resulting in transient myocardial hypocalcemia, was considered as a possible mechanism of QT prolongation. Because QT prolongation appears during the initial RA trial, prolonged QT intervals could be a predictor of no-reflow. It is recommended to avoid repetitive RA if marked QT prolongation is observed at the initial RA trial.

Aged↗
PubMed1997

New stenosis on proximal coronary segment after directional atherectomy. Two case reports.

Two patients with new coronary stenotic lesions subsequently developed proximal to the sites accepting directional coronary atherectomy (DCA) are reported. One lesion developed at the left main coronary artery and the other at the proximal segment of the left anterior descending artery. The mechanisms of the development of such new stenotic lesions after DCA were studied and procedure-related mechanical trauma over the proximal segment of the primary lesion may be the possible mechanism for such complication.

Aged↗
PubMed2002

Effect of intracoronary nicorandil administration on preventing no-reflow/slow flow phenomenon during rotational atherectomy.

A major limitation of the rotational atherectomy (RA) procedure is the occurrence of the no-reflow/slow flow phenomenon and the optimal strategy is still evolving. Recent clinical studies have demonstrated the beneficial effects of nicorandil, an adenosine triphosphate (ATP)-sensitive potassium channel opener, on no-reflow in patients with acute myocardial infarction. The purpose of this study was to evaluate the effect of nicorandil on no-reflow/slow flow phenomenon during RA procedures. Sixty-one patients who underwent RA of complex coronary lesions were randomly divided into 2 groups: (i) nicorandil cocktail (n=24 patients, 37 lesions) and (ii) verapamil cocktail (n=37 patients, 63 lesions). In each group, the drug cocktail mixed with pressurized saline was infused through the 4Fr Teflon sheath of the rotablator system during the RA procedure. In the nicorandil group, the drug cocktail consisted of 24 mg of nicorandil, 5 mg of nitroglycerin, and 10,000 U of heparin. In the verapamil group, the drug cocktail consisted of 10 mg of verapamil, 5 mg of nitroglycerin, and 10,000 U of heparin. Baseline and procedure characteristics did not differ between the 2 groups. RA was performed successfully, and death, Q-wave myocardial infarction, or emergency coronary artery bypass surgery did not occur in any patients. The no-reflow/slow flow phenomenon was observed in 11/63 (17.4%) lesions of the verapamil group, but in only 1/37 (2.7%) lesions of the nicorandil group (p=0.03). No untoward complications were observed during nicorandil infusion. These data indicate that the intracoronary continuous infusion of nicorandil during RA procedures is easy and safe, and prevents no-reflow/slow flow phenomenon more effectively than infusion of verapamil.

Aged↗
PubMed2002

Role of plaque proliferation in late lumen loss after directional coronary atherectomy.

Previous reports suggest that vessel remodeling is the most important factor in late lumen loss in non-stented lesions, but because results of directional coronary atherectomy (DCA) show that increased plaque area (PA) is also important, the aim of this study was to redefine the mechanism of late lumen loss after DCA. One hundred and twenty lesions that underwent DCA with intravascular ultrasound (IVUS) guidance and serial IVUS analysis were studied, and vessel area (VA), lumen area (LA), PA (VA-LA) and corrected values (each value divided by the value of VA pre procedure to correct the vessel size) were analyzed. During follow-up, corrected VA (cVA) decreased by 0.058 +/- 0.191, whereas corrected PA (cPA) increased by 0.087 +/- 0.159. Though the %PA (PA/VA) after the procedure showed significant negative correlation with the subsequent change in cPA, it did not correlate with the subsequent change in cVA. In conclusions, the mechanism of late lumen loss after DCA consists of both arterial remodeling and plaque proliferation, and the residual %PA after the procedure determines the subsequent lumen loss. With a lower %PA, a change in the PA contributes more to late lumen loss than do changes in VA. With a high %PA, a change in the VA contributes more to late lumen loss.

Atherectomy, Coronary↗
PubMed2002

Guidewire bias in rotational atherectomy in the angled lesion: evaluation based on the thickness of the ablated intima and media.

The effect of guidewire bias on angled-lesion ablation by rotational atherectomy (RA) was assessed by measuring the changes in vertical lumen diameter, horizontal lumen diameter and the intima-media thickness of the coronary artery, using intravascular ultrasound in 10 lesions with an angle greater than 10 degrees. The vertical and horizontal diameters significantly increased after RA. The intima-media thickness at the 4 orthogonal sites significantly decreased. There was a significant positive correlation between vertical diameter change and angle (r=0.642, p=0.045), but none between horizontal diameter change and angle. There was no correlation between intima-media thickness change at 0 degrees and angle; however, at 180 degrees there was a tendency to correlation with angle (r=0.602, p=0.066). These data suggest that in cases of angled lesions, the increase in vertical lumen diameter is caused more by ablation of the 180 degrees wall than by that of the 0 degrees wall, which is brought about by guidewire bias toward the vascular wall at 180 degrees.

Angina Pectoris↗
PubMed2003

Clinical outcome of percutaneous transluminal coronary rotational atherectomy in patients with end-stage renal disease.

The clinical results of percutaneous transluminal coronary rotational atherectomy (PTCRA) in dialysis patients were retrospectively evaluated in comparison with coronary artery bypass grafting (CABG). From 1997 to 2001, 44 consecutive dialysis patients with 61 lesions underwent PTCRA and 55 consecutive dialysis patients underwent CABG. The initial success rate of PTCRA was 98%. The PTCRA group had a shorter hospital stay (13+/-17 vs 60+/-35 days, p=0.0001) and a lower rate of complications (11% vs 42%, p=0.001) than the CABG group. Although neither event-free survival without death nor myocardial infarction (MI) was significantly different between the CABG and PTCRA groups during the mean follow-up period of 21+/-14 months, 20 patients (45%) in the PTCRA group needed repeat revascularization of the target lesion. In conclusion, PTCRA may be a safe alternative modality for revascularization of high-risk CABG candidates, with excellent short-term results although the long-term outcome is inferior to that of CABG because of the higher restenosis rate.

Aged↗
PubMed2004

Distal shower embolization during directional coronary atherectomy and stenting for diffuse stenosis of right coronary artery: current limitations of intravascular ultrasonography for evaluating fragile plaque.

A 74 year-old male with old anterior and inferior myocardial infarctions was treated with staged percutaneous coronary intervention. A chronic total occlusion of the middle segment of the left anterior descending branch was successfully stented during the first stage, and during the second stage, preprocedural intravascular ultrasonography (IVUS) revealed that the proximal segment of the right coronary artery was diffusely stenosed by mixed plaque. Directional coronary atherectomy under IVUS guidance was performed, but coronary slow flow appeared during the procedure. After successfully bailing out with intracoronary nicorandil, percutaneous thrombectomy and manual blood pumping, 2 coronary stents were implanted to fully cover the lesion. Quite contrary to expectation, the no-reflow phenomenon appeared just after post-dilatation and a repeat of the same maneuver could not completely recover coronary flow. Plaque fragility could not be predicted from the IVUS examination.

Aged↗
PubMed1995

A successful surgical treatment of coronary perforation associated with directional coronary atherectomy--a case report.

We encountered a patient with coronary perforation showing cardiac tamponade and shock that occurred during debulking by directional coronary atherectomy. We successfully performed emergent pericardial drainage and aorto-coronary bypass procedures. Bypass surgery is recommended to avoid perioperative myocardial infarction in cases such as ours since the native coronary artery may be at risk of being occluded or narrowed due to oppression by the hematoma and destroyed intima.

Aged↗
PubMed1995

A case of unprotected left main coronary stenosis rescued by directional coronary atherectomy as a last resort.

The prognosis of left main coronary stenosis complicating cardiogenic shock is very poor. Unprotected left main coronary stenosis usually preclude percutaneous transluminal coronary angioplasty because of the appearance of elastic recoil and the risk of hemodynamic collapse after acute closure of the artery. An 85-year-old woman with no history of heart disease developed cardiogenic shock. Coronary arteriography showed an unprotected left main coronary stenosis. Due to her advanced age, her family opposed coronary artery bypass surgery. We report here the successful treatment of this case of unprotected left main coronary stenosis by directional coronary atherectomy as a last resort.

Aged↗
PubMed1999

Expression of cytokine and adhesion molecule mRNA in atherectomy specimens from patients with coronary artery disease.

Coronary arteriosclerosis is an underlying condition in acute myocardial infarction (AMI), unstable angina pectoris (UAP) and stable angina pectoris (SAP), and is also related to restenosis (RS) following coronary intervention. To investigate the pathogenesis of this condition, a quantitative reverse transcriptase polymerase chain reaction was used to determine relative levels of mRNA for interleukin (IL)-1beta, IL-6, IL-8, transforming growth factor beta (TGF-beta), intercellular adhesion molecule (ICAM)-1, E-selectin and vascular cell adhesion molecule (VCAM)-1 using directional coronary atherectomy (DCA) specimens. Eleven patients with AMI, 7 with UAP, 10 with SAP and 6 with RS following a previous coronary intervention underwent DCA. The mRNA intensity for each molecule was expressed by comparing it with that of beta-actin mRNA. The AMI and UAP patients showed high frequencies of mRNA for IL-1beta, IL-8, TGF-beta, and ICAM-1 together with strong intensities of expression, whereas SAP patients showed decreased mRNA expression for these molecules. Increased IL-6 mRNA expression was observed only in AMI samples. Specimens from RS patients revealed an accumulated expression of proinflammatory cytokines, except for IL-6, as well as of TGF-beta. The study suggests that variation in mRNA expression may reflect the pathophysiology of specific types of coronary artery disease, and remodeling following vascular injury.

Aged↗
PubMed2001

Histopathologic evaluation of coronary artery thrombi obtained by directional coronary atherectomy in patients with restenosis-induced unstable angina pectoris.

The pathogenesis of unstable angina pectoris (UAP) following percutaneous transluminal coronary angioplasty (PTCA) or directional coronary atherectomy (DCA) has not been adequately investigated, so the present study aimed to determine whether thrombi are present in restenotic lesions. The study group comprised 14 patients (16 arterial branches) with angina pectoris in whom either PTCA or DCA was performed and who had developed UAP associated with restenosis, and who then underwent DCA of the restenosed lesion (R-UAP group). The control groups comprised individuals with UAP undergoing DCA with no prior history of PTCA or DCA (P-UAP group; n=29, 29 branches), patients with acute myocardial infarction (AMI group; n=34, 34 branches), and patients with stable angina pectoris (SAP group; n=31, 33 branches). The presence of thrombi was determined by light microscopy of histologic specimens. Thrombus was present in only 1 of the 16 (6.3%) branches in the R-UAP group. 21 of the 29 (72.4%) branches in the P-UAP group, and in 25 of the 34 (73.5%) in the AMI group. In the SAP group, it was detected in only 2 of the 33 (7.1%) branches. The incidence of thrombus was significantly lower in the R-UAP group than in the P-UAP group. In conclusion, the role of thrombus is limited in causing post-interventional UAP at restenosed sites.

Aged↗
PubMed2000

Peripheral directional atherectomy evaluated with a rotational digital angiography system.

BACKGROUND: One of the factors that affect the recurrence rate after peripheral directional atherectomy (DA) is the degree of residual stenosis. A new method of peripheral DA to reduce residual stenoses was evaluated with a rotational digital angiography (RDA) system that provides both angiography and fluoroscopy at multiple projections within 360 degrees. PATIENTS AND METHODS: Between March 1995 and July 1999, severe short segmental stenoses of six iliac arteries and two superficial femoral arteries (SFA) in eight patients were treated with the Simpson DA catheter under RDA system guidance. After pre-procedural RDA evaluation, the first series of DA were performed under ordinary PA fluoroscopic guidance. The residual stenoses were evaluated with RDA. If the residual stenoses exceeded 30%, a second series of DA were performed covering the residual plaque with the cutter window of the DA catheter. To this purpose the fluoroscopy of the RDA system was fixed in the direction in which the residual stenoses were largest and most eccentric. The end point was defined to be a residual stenosis of less than 30% evaluated with the RDA system, and the procedures were repeated until the end point was achieved. RESULTS: Five of six iliac artery lesions were curved at the pre-procedural RDA evaluation. After the first series of DA, only two of six iliac lesions but all SFA lesions achieved the end point. Among the four other iliac lesions, three achieved the end point with one or two additional series of DA using the RDA system guidance to control the selective cuts of the residual plaques. One patient had a residual stenosis of 50% because the procedure could not be completed by balloon rupture of the DA catheter. In the patients with iliac stenoses, there was no final residual stenosis in one, and the range was from 20% to 25% in the four patients. The residual stenoses were located on the greater curvature side of the curved artery in three of these four patients. CONCLUSION: The RDA system is a valuable tool in aiding reduction of the residual stenoses during peripheral DA. Minimal stenoses often remain on the greater curvature side of the wall because the rigid and straight metallic capsule (cylindrical housing) of the Simpson DA catheter does not completely fit the curved wall. This phenomenon was thought to be a mechanical limitation of this device.

Aged↗
PubMed1995

Proliferative activity in coronary atherectomy tissue. Clinical, histopathologic, and immunohistochemical correlates.

STUDY OBJECTIVE: Although cellular proliferation is considered one of the dominant processes leading to restenosis following coronary intervention, controversy exists over the extent of cellular replication in atherosclerotic tissue. Accordingly, we sought to investigate the level and clinicopathologic correlates of proliferative activity in atherosclerotic tissue obtained via directional coronary atherectomy (DCA). DESIGN: Prospective observational study. SETTING: Tertiary care referral hospital. PATIENTS: Specimens retrieved via DCA from 37 lesions (primary, 26; restenosis, 11) were studied using single-label immunohistochemical staining for the proliferating cell nuclear antigen and basic fibroblast growth factor (bFGF). RESULTS: Restenosis tissue was significantly more likely than primary tissue to contain areas of intimal hyperplasia (64 vs 23%; p < 0.03). However, the frequency of positive staining for proliferating cell nuclear antigen (PCNA) was similar in primary and restenosis lesions (25 vs 30%; p = NS), and the mean percentage of positive cells per slide was similar in the two groups. Positive immunostaining for bFGF was present in 20 lesions (61%), and tended to be more frequently seen in restenotic lesions (80 vs 52%; p = 0.25). However, there was no correlation or colocalization between immunostaining for bFGF and proliferating cell nuclear antigen. We found no clinicopathologic correlations with respect to clinical outcome. CONCLUSIONS: Cellular replication, as measured by expression of the PCNA, occurs in a heterogeneous pattern in both primary and restenotic atherosclerotic tissue obtained from patients undergoing coronary intervention.

Atherectomy, Coronary↗
PubMed1998

Directional coronary atherectomy versus coronary angioplasty in vessels larger than 3 mm in diameter.

It has been proposed that directional coronary atherectomy (DCA) should be an intervention of choice in larger vessels as one can achieve a greater minimal luminal diameter with DCA than with percutaneous transluminal coronary angioplasty (PTCA). This in turn should translate into a higher success rate and may even reduce the restenosis rate. The aim of this study was to compare DCA versus PTCA in vessels > 3 mm in diameter. One hundred fifty consecutive patients who met the inclusion criteria and had DCA were compared to 150 similarly selected PTCA patients. PTCA patients were selected from the era immediately preceding the advent of DCA so that selections bias could be excluded. All patients with ostial lesions, restenosis, vessels < 3 mm in diameter, and vessels with more than two significant lesions were excluded. Distal segments and circumflex cases were excluded as they formed a small subsegment. Both groups were similar in terms of demographic, clinical and angiographic variables. Quantitative analysis showed that the initial net gain was significantly greater in the DCA group than in the PTCA group (2.36 +/- 0.8 mm vs. 1.78 +/- 0.7 mm; p < 0.05). Residual stenosis was 11% with DCA compared to 33% with PTCA (p < 0.05). Despite these improved anatomical results the procedural success rates were similar (91.5% vs 84%). Major in hospital complications (death, acute occlusion, MI, emergency CABG, re-do) were higher in the DCA group than in the PTCA group (12% vs 6%). Clinical follow-up on 276 patients (150 DCA vs 126 PTCA) showed a 6 month clinical restenosis rate of 18% vs 28%, respectively. The incidence of re-do in 24 hours for acute occlusion was 6% for DCA and 1% for PTCA. In large-sized vessels DCA results in a lower restenosis rate. However, despite a lower incidence of residual stenosis, the complication rate tends to be higher with DCA (p < 0.05).

Aged↗
PubMedDate not supplied

Infrainguinal arterial intervention: is there a role for an atherectomy device?

Excision of atheromatous plaque is an attractive option for the minimally invasive treatment of peripheral arterial disease. Approved for use in 2003, the SilverHawk Plaque Exicison System (FoxHollow Technologies, Redwood City, CA) is a catheter-based plaque excision device allowing percutaneous removal of atheromatous material. This device represents the most recent generation of atherectomy tools. Overall experience with plaque debulking in the peripheral arteries spans almost two decades, and understanding of the technique continues to evolve. This article reviews the technology, current practices, and data on plaque excision.

Atherectomy↗