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PubMed2005

Snare retrieval of the distal tip of a fractured rotational atherectomy guidewire: roping the steer by its horns.

Numerous methods have been described for retrieving fractured guidewires from the coronary circulation. We report a case of a fractured rotational atherectomy guidewire retained within a coronary artery. The standard technique of snaring the proximal end of the retained fragment was impossible because its radiolucency rendered it invisible. The snare was passed beyond the retained fragment and retracted to capture the distal tip. When snaring a foreign body, identifying the most accessible part is critical to the success of the procedure.

Aged↗
PubMed2005

Comparison of directional coronary atherectomy-based intervention and stenting alone in ostial lesions of the left anterior descending artery.

BACKGROUND: Balloon angioplasty yields suboptimal results and increases the rate of restenosis in the ostium of the left anterior descending coronary artery (LAD). Several non-balloon devices have been used to improve the outcome of dilatation of such lesions. METHODS: This investigation retrospectively compared the results of a directional atherectomy (DCA)-based intervention and stenting alone on the ostial lesions of the LAD, and the effect on the left circumflex artery (LCX) ostium. Sixty-five patients with a successful angioplasty of LAD ostial lesions were studied. Patients were divided into 2 groups: group I (DCA, n = 34) and group II (stenting, n = 31). RESULTS: After intervention and at the 3-month follow-up, group I exhibited a larger minimal lumen diameter (MLD), smaller-diameter stenosis, and a lower loss index than group II. At 6 months, group I showed a lower cumulative restenosis rate of 32% as compared to 48% for group II (p = 0.04). In group I, the MLD of the LCX ostium had not changed after DCA or at follow-up. In contrast, the MLD of the LCX was significantly reduced with stenting alone and during follow-up (p < 0.01). The strategy of optimal debulking plus stenting exhibited a restenosis rate of 9%, in contrast to 33% in the optimal debulking alone strategy (p = 0.05) after 3 months. CONCLUSIONS: During the intervention for LAD ostial lesions, the DCA-based strategy seemed to be superior compared to stenting alone both in terms of acute and late target lesion revascularization and in terms of the risk of plaque shifting. The best results however were obtained when optimal DCA was combined with stenting.

Adult↗
PubMed2006

Treatment of stent-jailed side branch stenoses with rotational atherectomy.

UNLABELLED: While debulking with rotational atherectomy (RA) prior to balloon angioplasty (BA) improves acute results by reducing elastic recoil, treatment of an ostial side branch lesion that is covered (jailed) by a stent represents a particular challenge. We report our experience with RA in conjunction with BA for the treatment of ostial stenosis in jailed side branches. METHODS AND RESULTS: Thirty-two lesions in side branches jailed by a stent were treated with RA and BA 39 times in 30 patients. The mean age was 65.5 +/- 11.5 years; 26.3% were women; 18.4% had diabetes mellitus; and 18.4% had a history of prior bypass surgery. Of the treated side branches, 53.9% were diagonals, 71.8% were jailed by a slotted-tube stent, and 86.5% were previously dilated prior to RA. The burr sizes used to treat the jailed side branch origin ranged from 1.25 to 2.25 mm, with a mean burr size of 1.62 +/- 0.31 mm. An average of 1.53 +/- 0.72 burrs were used per lesion. Quantitative coronary angiography was performed prior to, and after, intervention. The mean diameter stenosis of the side branch prior to revascularization was 77.8% +/- 12.6%; this was reduced to a mean stenosis of 23.0% +/- 17.9% following treatment with RA and BA. Angiographic success (residual stenosis < 50% and TIMI 3 flow) in the side branch occurred in 36 of 39 lesions (92.3%). Procedural success (angiographic success in both the side branch and the parent vessel in the absence of death, emergent CABG, urgent TVR, and myocardial infarction (CK-MB > or = 3 times normal) during the index hospitalization) was achieved in 33 of 38 cases (86.8%). One patient suffered a periprocedural myocardial infarction; another patient presented with stent thrombosis in the parent vessel requiring emergency revascularization 36 hours after the index procedure. Clinically-driven revascularization of either the side branch or the side branch or parent was performed in 44.8% and 46.4% of patients, respectively. The estimated freedom from any target lesion revascularization was 47.7% at 300 days. One patient died of unknown causes 253 days following the index procedure. CONCLUSIONS: RA in conjunction with BA can effectively treat stent-jailed ostial side branch stenosis with excellent acute angiographic and procedural results. However, the long-term efficacy is limited by a high rate of repeat revascularization.

Aged↗
PubMed2006

Blunt microdissection and rotational atherectomy: an effective combination for the resistant chronic total occlusion.

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) has a lower success rate than nontotal occlusions. Like nontotal coronary occlusions, successful procedural outcomes of CTOs confers improvement in clinical outcomes. Reasons for unsuccessful PCI of CTOs may stem from various steps of the procedure including failure to cross the occlusion with a guidewire or a balloon, or failure to adequately dilate or modify the lesion. The Frontrunner blunt microdissection device is designed to improve the odds of guidewire passage through coronary occlusions, whereas the Rotablator rotational atherectomy device is intended for plaque modification, especially in resistant, elastic or calcific lesions. The Frontrunner and Rotablator can each facilitate the procedure at their respective junctures; the combined use of these technologies can enhance the overall PCI success rates, especially regarding difficult CTOs. This case presentation encounters two technical challenges: the inability of the balloon catheter to cross the CTO, and the inability to recross the occlusion with the less favorable RotaWire. In this case, the combined use of the Frontrunner and Rotablator devices was necessary to achieve overall procedural success. When tackling difficult CTOs, a comprehensive strategy that encompasses multiple devices and technologies can enable ultimate procedural success.

Aged↗
PubMed2006

Clinical experience with rotational atherectomy in patients with severe left ventricular dysfunction.

OBJECTIVE: To evaluate the safety and efficacy of rotational atherectomy (RA) in patients with severe left ventricular (LV) dysfunction. BACKGROUND: RA, using a rotating diamond-crystal burr, is most commonly used to open lesions with severe calcification or diffuse disease that may prove difficult to cross or dilate. However, RA generates microparticular debris that may attenuate the coronary microcirculation, inducing transient myocardial stunning and LV dysfunction. In fact, the manufacturer does not support RA use in patients with severe LV dysfunction. METHODS: We retrospectively identified patients with a LV ejection fraction < 30% who underwent RA in our institution over a 4-year period. The medical records were reviewed and risk factors for cardiac disease were recorded. The procedural reports and subsequent hospitalization records were reviewed to identify predetermined positive and negative outcomes. RESULTS: Twenty-three patients (17 males) who underwent RA with severe LV dysfunction (mean LVEF 21.3%) were identified. The majority of these patients had multivessel coronary artery disease, hypertension, hyperlipidemia and/or tobacco use. Also, a substantial subset had diabetes, renal insufficiency and or in-stent restenosis. RA was 100% successful in opening the lesions without any in-hospital procedure-related mortality. Three patients experienced periprocedural myocardial infarctions. One patient died from malignancy during hospitalization. There were no major adverse cardiac events at 30 days. CONCLUSION: The transient effect of RA on ventricular function did not adversely affect short-term outcomes in our study population. These results suggest that RA, when performed by experienced operators, is safe and feasible in patients with severe LV dysfunction.

Aged↗
PubMedDate not supplied

Clinical, angiographic and histopathological predictors of restenosis after directional coronary atherectomy.

Out of 127 directional coronary atherectomy (DCA) procedures done in our laboratory, there were 81 patients who had completed a minimum of six months of follow-up. To study the factors predisposing restenosis after successful DCA, we analysed the clinical and angiographic profile of the patients and the histopathological findings of the excised tissue in 44 patients whose complete follow-up data was available with us. The indication of DCA was an extremely eccentric significant stenosis located in the proximal or midsegment of a large vessel (> or = 3 mm size) in 97 percent of the cases. Angiographic restenosis, defined as more than 50 percent luminal diameter stenosis was absent in 24 (54.5%, Group A) and present in 20 (45.5%, Group B) patients. On univariate analysis, the factors which predisposed to restenosis were: (i) left anterior descending location, (ii) longer lesion length (9.6 +/- 3.1 mm vs 5.2 +/- 1.6, p < 0.01) and (iii) greater post-procedure residual luminal diameter stenosis (13.1 +/- 10.8% vs 4.3 +/- 6%, p < 0.01). No significant difference was found between the two groups for other variables like unstable angina, the location and the morphological characteristics of the lesion and the ratio of the vessel diameter to the size of the Atherocath. Histopathological examination of the retrieved tissue revealed the presence of media with or without external elastic lamina in 8 (33%) patients in Group A--without restenosis compared to only 1 (5%) patients in Group B--with restenosis (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Atherectomy, Coronary↗
PubMed1994

[Diagnostic and research potential of directional atherectomy].

Directional coronary atherectomy (DCA) is the sole technique for the in vivo study of coronary artery plaques which are responsible for myocardial ischemia. The technique confers the following advantages to the pathologic study of plaque samples: the brevity, in general, of the interval between acute myocardial ischemia and sampling of the guilty plaque; the absence in samples of autolytic phenomena (such as those that affect autopsy samples), an effect that enables the use of conventional histopathology, immunohistochemistry and molecular biology; the certainty with which the researcher can identify, and thus sample, the truly guilty lesions. The drawbacks of the technique are: the fragmentation of the plaque; the difficulty the pathologist has in correctly orientating the samples in the embedding phase, in distinguishing pre- from post-procedural lesions, and in providing a detailed description of the findings. Given the foregoing, the diagnostic information to which DCA sampling enables access is as follows: plaque derivation--the recognition of whether tissue removed with DCA originates from eccentric or concentric, atheromatous of fibrosclerotic, calcified or not calcified plaques; histopathology of coronary lesions that cause ischemia with regard to: evidence of acute events, such as thrombosis, ulceration and hemorrhage, thrombus composition, when it occurs, and definition of its age and presence of material deriving from the vascular wall that lies beyond the plaque; identification and immunophenotypical characterization of inflammatory infiltrates. As regards research, the main implications of DCA are for the study of the pathogenetic mechanisms that lead to plaque instability in acute ischemic syndromes.(ABSTRACT TRUNCATED AT 250 WORDS)

Atherectomy, Coronary↗
PubMedDate not supplied

Does the method of transluminal coronary revascularisation influence re-stenosis? Balloon angioplasty, atherectomy and stents compared.

Luminal renarrowing after successful coronary angioplasty is now recognised as a continuously distributed process which is determined largely by the extent of luminal increase achieved at angioplasty. In this study an alternative analytical approach is applied to determine whether luminal renarrowing following coronary intervention is related to the mechanism of luminal increase (ie by balloon, by atherectomy, by a self-expanding stainless steel mesh stent, or by a balloon-expandable tantalum coil stent). The results confirm the known proportional relationship between luminal renarrowing during follow-up and luminal improvement at intervention, regardless of the device used. However, significant differences were observed between the devices, which may reflect device-specific characteristics of the hyperplastic response to vessel injury and may have clinical implications.

Aged↗
PubMed1994

[Directional coronary atherectomy: effect of vessel size on primary results and long-term results].

Of 325 consecutive patients undergoing DCA, 263 patients with 277 stenoses were successfully treated with DCA alone and had angiographic follow-up 3-6 months later. Depending upon the initial reference diameter (RD) patients were divided into two subgroups: group I (n = 159) with a RD > 3 mm and group II (n = 104) showing a RD < or = 3 mm. In contrast to other series DCA was predominantly performed with 7F atherectomy devices using balloon inflation pressures of approximately 5 atm. Angiographic data including the minimal luminal diameter (MLD), percentage of stenosis (%D) and reference diameter (RD) were assessed by quantitative computer-assisted analysis before (pre), after (post) DCA and at a 3-6 months angiographic follow-up (FU). The percentage of diameter stenosis pre/post/FU in group I was 59.9 +/- 12.6%/18.4 +/- 12.8%/29.8 +/- 17.6%, and in group II 55.6 +/- 10.8%/17.8 +/- 12.3%/33.7 +/- 16.1% with a net gain at FU of 1.0 +/- 0.89 mm for group I and 0.86 +/- 0.66 mm for group II. Based on an angiographic restenosis criterion of at least 50% diameter obstruction at FU and or recurrence of symptoms warranting interventional re-treatment of the target lesion, the incidence of restenosis in group I was 20.6% and in group II 28.0% (p: n.s.). There was no significant difference between the two groups concerning complications. Our data show that DCA leads to a satisfying long-term result.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

[Coronary artery perforation after directional coronary atherectomy (DCA)].

Directional coronary atherectomy (DCA) was performed on a 51-year-old man with unstable angina due to a 90% stenosis of the proximal side of the left anterior descending artery (LAD). A coronary angiography after the DCA showed the coronary artery perforation communicating with the pericardial space. He suffered cardiac tamponade and cardiogenic shock, and was taken to the emergent surgical intervention. The both side of the perforation was ligated to control active bleeding and coronary artery bypass grafting to the distal portion of the LAD was performed. It is stated that the incidence of tamponade resulting from vessel perforation after DCA is extremely rare.

Angina, Unstable↗
PubMedDate not supplied

Directional coronary atherectomy: a new treatment for coronary artery disease.

BACKGROUND: Directional Coronary Atherectomy (DCA) was developed to overcome the deficiencies and limitations of conventional balloon angioplasty. Now with FDA approval, DCA has been proved to be a safe and effective treatment alternative for coronary artery disease in a select group of patients. OBJECTIVE: To provide critical care nurses with a comprehensive overview of DCA and the associated nursing implications. PATIENTS: Patients selected to receive DCA were those who showed evidence of myocardial ischemia (positive exercise stress test or symptoms), were free of significant peripheral vascular disease, and were candidates for coronary artery bypass graft surgery. Additional selection criteria was based on the detailed coronary anatomy. DESIGN/SETTING: A review of one direct experience of more than 200 patients treated with DCA in a university-affiliated hospital. CONCLUSION: DCA appears to be a valuable alternative for the treatment of select coronary lesions. DCA appears to have a low incidence of dissection and abrupt closure and a restenosis rate slightly lower than conventional balloon angioplasty.

Aged↗
PubMed1994

[Short-term efficacy of high speed rotational atherectomy with and balloon angioplasty in the treatment of lesions located at the ostium of a coronary branch].

In the treatment of branch-ostial lesions (BOL) balloon angioplasty (PTCA) is associated with suboptimal results and a higher complication rate. Rotational atherectomy (RA) before PTCA might improve results. This approach was used in 37 patients (mean age 62 +/- 10 years; 27 men, 10 women) with 42 BOL. Mean burr size was 1.7 +/- 0.3 mm; burr-artery ratio was 0.75 +/- 0.10. Procedural success was achieved in 39 (93%) BOL; the only major complication was a periprocedural myocardial infarction (CPKMB=58IU/ml). In 2 cases the stenosis was not crossed by the guidewire. Diameter stenosis (DS) decreased from 72 +/- 14% before RA to 30 +/- 12% after RA (p < 0.001) and 15 +/- 10% after PTCA (p < 0.001). All patients with a successful procedure underwent repeat angiography 24 hours DS was 18 +/- 15 (NS versus after PTCA); no lesion had DS > or = 50%. RA with adjunctive PTCA is a safe and effective treatment of BOL, with short-term stable results.

Adult↗
PubMed1994

Percutaneous coronary rotational atherectomy: New Jersey experience.

Complex coronary lesions can be approached percutaneously with rotational atherectomy. The first 70 procedures were performed at Newark Beth Israel Medical Center with a success rate of 94 percent. Despite treating a high-risk patient population, the complication rate was low.

Atherectomy, Coronary↗
PubMedDate not supplied

[Histopathological findings of coronary artery lesions resected by directional coronary atherectomy].

Eleven directional coronary atherectomy procedures were performed in seven patients with angina pectoris and four patients with myocardial infarction, 10 men and 1 woman aged 41 to 69 years (mean 57 +/- 7 years). The onset of angina pectoris or myocardial infarction had occurred 2 months to 17 years previously. The preoperative mean diameter of stenosis was 80 +/- 8%, and the mean residual diameter of stenosis was 6 +/- 9% (p < 0.01). Seven left anterior descending arteries and four right coronary arteries were treated. Five of the 11 patients received partial-thickness resections of medial tissue and two of the five patients received full-thickness resections of the media with adventitial tissue. No lesions showed aneurysms or perforations during coronary arteriography after the procedure. The resected tissue was examined microscopically. Intimal tissues stained with Masson's trichrome were classified into four groups according to the characteristics fibrous tissue and the amount of proliferative cells: Type I was old dense fibrous tissue, type II was relatively old fibrous tissue containing many proliferative cells, type III was new loose fibrous tissue containing many proliferative cells, and type IV was atheromatous plaque. The intimal tissues were type I in 48.0%; type II in 35.5%; type III in 14.8%; and type IV in 1.7%. Resected lesions without prior treatment (primary lesions) from five patients with histories of 3 months or less were characterized by much type II and type III tissue; (type I tissue, 33.8%; type II tissue, 51.1%; type III tissue, 14.5%; type IV tissue, 0.6%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

[Cellularity and ultrastructural characteristics of human atherectomy specimens: comparison between restenosis and primary stenotic tissue of coronary and peripheral lesions].

Restenosis in patients treated by angioplasty is clinically and angiographically defined. The question remains to which extent each restenotic lesion can be attributed to residual plaque material and/or neointimal tissue formation post primary intervention. In an effort to reveal distinct anatomical characteristics which may allow conclusions to pathogenetic mechanisms involved in restenosis, histopathologic and electron microscopic examinations of human restenotic tissue were performed. To compare tissue samples from clinically restenotic lesions with those from untreated primary lesions for cell number and ultrastructural characteristics, a total of 64 percutaneously excised tissue specimens from coronary (n = 9) and femoral lesions (n = 18) of 27 patients treated by directional atherectomy were analyzed. Semiquantitative assessment of plaque slices for cell number (12 fields of view/lesion; magnification x500) revealed a spectrum of 11.7 to 35.3 cell nuclei/field of view (C/F) for clinical restenoses (n = 10) and of 0.9 to 28.2 C/F for primary lesions (n = 17). When comparing tissue specimens from restenotic origin with those of native lesions, there was a highly significant (p < 0.001) difference in cell number (ave: 22.2 +/- 7.1 versus 8.6 +/- 7.9 C/F; x +/- SD). Hypercellularity (mean cell density defined with > 20 C/F) was observed in 6/10 restenoses, hypocellularity (< 10 C/F) in 0/10 restenoses. For primary lesions, hypocellularity was found in 10/17 lesions, but hypercellularity in 2/17 lesions. Ultrastructural analysis of hypocellular lesions by transmission electron microscopy revealed large extracellular matrix fields with infrequently embedded smooth muscle cells (SMCs). These cells were characterized by a microfilament-rich intermediate phenotype, thereby indicating decreased metabolic activation.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1993

Directional atherectomy of aorto-ostial stenoses.

Balloon angioplasty of aorto-ostial right coronary artery (RCA) and aorto-ostial saphenous vein graft (SVG) stenoses has been reported to be associated with a suboptimal acute success rate, a higher incidence of restenosis and an increased risk of emergent coronary artery bypass surgery. In this report, we describe the use of directional coronary atherectomy (DCA) as a treatment alternative in a series of twenty three patients who were documented to have a > 60% stenosis within 3 mm of the origin of the RCA (15 patients) or SVG (8 patients) as measured by on-line quantitative angiography. DCA was successfully performed in 14 of 15 RCA ostial lesions and in all eight SVG lesions. This yielded an acute success rate of 93% and 100% with a mean reduction in percent stenosis from 87% to 9% and from 85% to 8% respectively. Only one patient, presenting with an ostial RCA lesion, was unable to be revascularized using DCA. All successfully treated patients underwent exercise treadmill testing or repeat cardiac catheterization in follow-up. Clinical evidence of restenosis defined as recurrent chest pain or ischemic evidence on exercise treadmill and > 50% angiographic restenosis was demonstrated in three of twenty two patients (14%). Of the nine successfully treated patients who underwent repeat cardiac catheterization, three (33%) had restenosed for an angiographic rate of 25% for RCA and 50% for SVG lesions. In conclusion, DCA of aorto-ostial stenoses is technically feasible and can be performed with good initial results.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Lesion-specific technique considerations in directional coronary atherectomy.

Directional coronary atherectomy (DCA) has expanded over the past several years to include treatment of a wide variety of complex coronary lesions in difficult vessel locations. Ulcerated, eccentric, and hazy lesions; ostial, mid, distal, and bifurcation lesions; saphenous vein graft lesions; tandem and long lesions; and "rescue" of failed angioplasty lesions are all potentially well-suited for DCA. This paper describes a lesion-specific strategy for DCA and outlines equipment selection and techniques helpful for performing DCA in a broad range of cases.

Angioplasty, Balloon, Coronary↗
PubMed1995

[Rotational atherectomy and PTCA in complex coronary lesions (B2 and C): the immediate and long-term results].

BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) in complex coronary lesions (type B2 and C of the modified AHA/ACC classification) presents a lower primary success rate and higher risk of dissection than type A and B1 lesions. An alternative approach to this lesions is coronary rotational ablation (Rotablator, Heart Technology) with complementary PTCA using low inflation pressures ("facilitated angioplasty"). MATERIALS AND METHODS: Twenty-six type B2 and C lesions in 24 patients (pts) (8 female, 16 male, age 37-80 years) were treated with coronary rotational ablation and complementary PTCA between January 1993 and December 1994 (4.7% of all interventional coronary procedures performed in this period in our laboratory). Eleven pts had stable effort angina and 13 pts had unstable, class IB, IIB, and IIC, angina. The treated vessel was the LAD in 15 cases, CX in 5, RCA in 5, and an intermediate branch in one case. Coronary rotational ablation was proposed because of the presence of two or more risk factors for uneffective or complicated PTCA: eccentricity, calcified lesions, bifurcation stenosis, lesion length > 10 mm, severe stenosis (90-99%), ostial location and bend location (45-60 degrees). No lesion showed coronary thrombus, considered as absolute contraindication to coronary rotational ablation. We used small burrs (burr/artery ratio < 0.75), and complementary PTCA was performed using low inflation pressure (< 8 atm) and long balloons for long lesions (> 10 mm) in order to minimize the risk of dissection. RESULTS: Coronary rotational ablation was successfully performed in all but two cases (24/26; 92.3%), with a reduction of the stenosis from 88 +/- 9% to 45 +/- 10% (range 30-60%). In two pts (7.7%) the procedure was complicated by acute occlusion: both pts underwent effective salvage PTCA with 30% residual stenosis. Small type A and B dissections occurred in 4/26 cases (15.4%). All but one lesions complicated by acute occlusion or dissection following coronary rotational ablation were not or only slightly calcified. Complementary PTCA was performed in all but two pts who already presented 30% residual stenosis after rotational ablation. A further reduction of stenosis to 20 +/- 9% (range 5-30%) was achieved. After complementary PTCA four pts (15.4%) developed type A and B dissections; in one of these a Palmaz-Schatz stent was implanted, whereas the remaining three pts presented a residual stenosis below 30% and no further procedures were undertaken. Overall success rate of rotational atherectomy plus salvage or complementary PTCA or stenting was 100%, and no major complications (Q-wave myocardial infarction, emergency bypass surgery or death) occurred. Three pts showed delayed coronary run-off (slow reflow) after rotational ablation, and two of these released a small amount of cardiac specific enzymes (CK MB) without ECG changes and wall motion alteration on echocardiographic examination. Clinical restenosis, defined as recurrent angina and/or positive exercise stress test, developed in 45.8% (11 pts); in all these pts restenosis was angiographically evidenced (75-99%). CONCLUSIONS: Our experience suggests that coronary rotational ablation along with complementary PTCA using low inflation pressure and long balloons is safe and effective in type B2 and C lesions if calcifications are present; however, restenosis rate remains high.

Adult↗