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PubMed1990

Techniques in cardiac care: lasers, stents, and atherectomy devices.

Various new technologies are currently being investigated to treat cardiovascular disease less invasively than with conventional open heart surgery. Although lasers have been used in other health disciplines, their use in the cardiovascular field is relatively new. Even newer is the use of atherectomy devices and endovascular stents. It is important for the critical care nurse to be knowledgeable concerning these techniques in order to provide optimal patient care.

Angioplasty, Balloon, Coronary↗
PubMed1992

Atherectomy tools for arterial treatment.

When considering limb salvage in patients with failed bypass or angioplasty, the threshold for cost effective use of atherectomy devices is important. Rotational ablation, in these cases, has offered a significant contribution to patient care. Decreased hospital stay, morbidity and mortality, plus improved quality of life are all factors in the calculation. Interventional radiologists, vascular surgeons and interventional cardiologists aim to maintain function, not to perfectly restore original anatomy. In this respect, percutaneous rotational ablation has a role as a useful device when indicated. Indications should include consideration of the pattern of disease and underlying pathology as much as the site and selection of the lesion. The Rotablator may be the device of choice in many coronary cases and it is an important device in planning peripheral revascularization procedures. It provides an option for patients and physicians who wish to achieve minimal invasion with the best possible results.

Aged↗
PubMed1993

Update on PTCA: what are its limitations? Can they be overcome by new devices? A look at atherectomy, intra-arterial stents, and laser catheters.

Complications limiting the use of percutaneous transluminal coronary angioplasty (PTCA) include abrupt vessel closure and restenosis. Certain coronary lesions, such as chronic total occlusions and diffuse or long stenoses, pose serious technical difficulties. New devices may overcome some of these limitations. For example, atherectomy may prove useful for thrombotic vessels or diffusely diseased vein grafts, and it may lower restenosis rates in larger vessels. Stents are currently used as a bailout measure when acute dissection occurs. Although lasers produce smoother margins than does conventional PTCA and effectively ablate atherosclerotic plaque material, the restenosis rate associated with use of these devices may be similar to that of conventional PTCA.

Angioplasty↗
PubMedDate not supplied

Atherectomy, stents and lasers. An annotated bibliography of recent references.

This is an annotated bibliography of selected references on atherectomy, stents and lasers that have appeared in the literature since the particular issue of the Journal of Invasive Cardiology covering that device was published. It has been structured to include pertinent details about each citation, including the site at which the device was used (coronary or peripheral), the type of article in which the research was reported (clinical paper, case report, abstract, review, editorial), the number of subjects or procedures and lesions treated, the design of the study (case study, single group, group comparison, or randomized trial), acute and late results, and comments about the study and its findings.

Angioplasty, Laser↗
PubMed1997

Extraction Atherectomy for Recently Occluded Saphenous Vein Grafts: A Retrospective Study.

BACKGROUND: Over 300,000 coronary artery bypass operations are performed annually in the U.S., in which saphenous vein grafts remain the most often utilized conduit for myocardial revascularization. Still, the relatively short life-span of reverse saphenous vein grafts (SVG) demands that revascularization techniques be developed for SVG occlusions. Extraction atherectomy (EA) as a pre-treatment to percutaneous transluminal coronary angioplasty (PTCA) may offer advantages to PTCA alone in the treatment of these lesions. While a randomized study would best define the potential advantages of this treatment strategy, a retrospective comparison to historical data may provide some practical insights. PATIENTS AND METHODS: One hundred and six patients treated with EA + PTCA (Group 1) were retrospectively compared to a historical subset of 101 patients treated with PTCA alone (Group 2). Both groups presented with similar clinical profiles with respect to gender, age, graft age, percent diameter stenosis, and location of the target lesion. However, Group 1 had a significantly higher incidence of pre-procedure class III-IV angina than did Group 2 (92.4% vs. 70.3%, p < 0.002), and more recent occlusions. Both groups were compared at one year for the presence of angina, myocardial infarction, and death. Chi-square analysis was performed on the categorical variables. RESULTS: At one-year follow-up, 62.1% of the Group 1 patients were free from cardiac events (defined as absence of angina, myocardial infarction or death) and 58.9% of the Group 2 patients were event free (p = 0.78). A total of 27.0% of the Group 1 patients suffered from class I or Il angina compared to 35.9% of the Group 2 patients (p = 0.40). A total of 10.8% of the Group 1 patients had suffered a myocardial infarction compared to 28.2% of the Group 2 patients (p = 0.06). A total of 2.7% of the Group 1 patients had died compared to 10.5% of the Group 2 patients (p = 0.16). CONCLUSIONS: Patients with recently occluded SVGs (within 3 months) and refractory angina (class III or IV) treated with EA + PTCA have a similar clinical outcome at 1 year follow-up to a historical population treated with PTCA alone, despite the higher incidence of class III-IV angina, and more recent occlusions upon presentation. However, 1-year follow-up results reveal a trend towards less frequent myocardial infarctions for patients treated with EA + PTCA than the historical group of patients treated with PTCA alone (p = 0.06).

Journal Article↗
PubMed1998

Early Changes in Minimal Luminal Diameter After Balloon Angioplasty and Directional Coronary Atherectomy.

Early elastic recoil has been implicated in the pathophysiology of restenosis after balloon coronary angioplasty (PTCA). Directional atherectomy (DCA) may significantly attenuate this vessel wall reaction by altering the vessel wall architecture, specifically by removing or injuring the medial smooth muscle cells. We compared the magnitude of early changes in minimal lumen diameter (MLD) after DCA followed by adjunctive PTCA (group I) in comparison to PTCA alone (group II). In two groups of 30 lesions, matched for vessel size and location, group I cases showed significantly less recoil than group II cases, as assessed by routinely performed 15 minute post-procedure angiograms: mean changes in post-procedure MLD +0.06mm (increase) vs. -0.31mm (decrease) respectively, p = 0.02. In a histopathologic substudy of the DCA treated patients, those without early recoil had significantly higher incidence of media removal compared to patients with recoil (50% vs. 7%, p = 0.03). Therefore, early changes in MLD, presumably related to elastic recoil, are less with DCA and adjunct PTCA in comparison to PTCA alone. Attenuation of early recoil may be an additional mechanism accounting for the acute lumen gain achieved with this technique.

Journal Article↗
PubMed1999

Early and Intermediate Outcomes After Rotational Atherectomy in Octogenarian Patients.

OBJECTIVE: To provide information about the use of rotational atherectomy in octogenarians. MATERIAL AND METHODS: From 1993-1996, 26 octogenarians underwent coronary intervention with rotablator at Emory University Hospitals. The total number of lesions were 28 (57% of them in the left artery descending). Adjunctive balloon angioplasty was utilized in 26 lesions. The lesions were eccentric in 82%, calcified in 75%, with a mean length of 10.2Â+/-8.5 mm. RESULTS: The angiographic success rate was 96.2%. The only in-hospital complications was the death of 1 patient (3.8%) after an abrupt closure, and a dissection of 1 lesion of another patient, with a favorable subsequent outcome. The mean follow up was 1.3Â+/-0.4 years. The Kaplan-Meier survival rate at 1 year was 96.2% and at 2 years 78.3%. The freedom from death, myocardial infarction (MI), and coronary artery bypass graft (CABG) was 88.5% at 1 year and 59.7 % at 1.5 and 2 years. The freedom from death, MI, CABG, and percutaneous transluminal coronary angioplasty (PTCA) was 69.2% at one year and 36.3% at 1.5 and 2 years. CONCLUSIONS: In octogenarians with complex lesions, rotablator was performed in conjunction with balloon angioplasty, and showed a high rate of angiographic success, a relatively low complication rate, and a favorable 2 years survival rate. Nevertheless, the event free rates did not show the same favorable evolution after 1 year. If feasible, it would be useful to conduct randomized trials in the elderly to compare interventional procedures to medical treatment or surgery. (c)1999 by CVRR, Inc.

Journal Article↗
PubMed1992

Clinical efficacy of transluminal extraction coronary atherectomy.

Mechanical revascularization has revolutionized the treatment of coronary artery disease. The transluminal extraction-endarterectomy catheter (TEC) system was developed recently and permits the excision and extraction of atherosclerotic lesions of the coronary artery and the bypass graft. The system includes a motor-driven flexible torque catheter with rotating conical shaped stainless steel blades distally. The proximal end of the TEC system consists of a mechanical housing which controls the vacuum, the rotating cutter (750 RPM) and the cutter excursion (4 cm). After safety testing of the TEC system in dogs and human peripheral arterial disease, percutaneous transluminal coronary atherectomies employing the TEC have been performed in 25 patients (six women, 19 men, mean age, 64 +/- 12 years) with the diameter of the stenosis greater than or equal to 75% in one or more coronary arteries. Twenty-eight atherosclerotic lesions were treated in 26 native coronary arteries. The overall success rate (less than 50% residual stenosis in all lesions) was 92%. There was one instance of hematoma proximal to the excised target lesion, and one instance of atherectomized debris embolization. There were no instances of dissection, perforation, coronary spasms or death related to the procedure. The results indicate that the TEC system can be used safely and effectively to treat coronary artery disease with a high success rate.

Adult↗
PubMed1992

Coronary atherectomy with the transluminal extraction endarterectomy catheter.

Percutaneous transluminal coronary atherectomy was attempted in 25 consecutive patients with the transluminal extraction-endarterectomy catheter. Successful revascularization with residual stenosis less than 50% in diameter was achieved in 23 patients (92%). There were 2 cases of major complications: one with distal embolization which subsided after rtPA infusion and the other with occlusion of RCA underwent bypass surgery. One patient who had restenosis 3 months after the procedure, was successfully treated with PTCA. The technical aspects, advantages and limitations of this method were discussed.

Adult↗
PubMed1991

[Ultrastructural and proliferation studies of human, catheter atherectomy extracted plaque material].

Atherectomy with a Simpson catheter enables a detailed characterization of percutaneously removed human atheromatous plaque material. Cell biological investigations (flow-cytometric analyses, cell type-specific antibodies, immunohistological labelling methods of selected extracellular matrix proteins) are aimed at a comparative characterization of excised material from primary lesions and restenoses to yield further insight into the mechanisms of plaque formation. First results on 17 specimens would like to contribute to a better understanding of the structure and composition of the extracellular matrix and their interaction with cells in atherosclerotic plaques.

Aged↗
PubMed1991

[Percutaneous coronary atherectomy by the Simpson's technique].

The directional coronary atherectomy (DCA) is a percutaneous procedure which can be performed to cut and retrieve the plaque of coronary arteries. This procedure was performed by Simpson's technique at Hospital de Clínicas de Porto Alegre with success in three patients with restenosis of percutaneous transluminal coronary angioplasty (PTCA) in the anterior descending coronary. The criteria of successfully treated lesions are: tissue yield of the plaque, residual stenosis less than 30%, smoothness borders of the lesions in the end of procedure and absence of complications. Our initial experience with the method is satisfactory and DCA is an alternative to PTCA for selected cases of coronary artery disease.

Aged↗
PubMed1990

Autopsy findings after coronary rotational atherectomy.

We describe the findings at autopsy in a patient who underwent Rotablator atherectomy of the right coronary artery. During the procedure, the artery became occluded. Despite attempts to reopen the vessel with balloon angioplasty and emergency coronary artery bypass grafting, the patient developed irreversible cardiac failure and expired 2 days after the Rotablator procedure. At autopsy, the right coronary artery was found to be occluded by thrombus. No evidence of dissection or perforation of the vessel wall was seen. Small intramyocardial arteries and arterioles, downstream from the treated vessel, were embolized by pulverized atheroma.

Angioplasty, Balloon, Coronary↗
PubMed1989

[Experiences with rotation atherotomy and atherectomy].

In addition to currently available, low risk procedures for reestablishment of patency in arteriosclerotic vascular segments with bougier techniques as described by Dotter and the balloon dilatation modification according to Grüntzig, as necessary together with local thrombolysis, important new developments based on mechanical principles are the atherectomy according to Simpson as well as the rotation atherotomy with a flexible catheter and slowly rotating milling head or rapidly rotating head as used by Kensey. To provide a larger lumen of recanalization, we developed an atherotomy lathing catheter with a rapidly rotating head and various diameters which is now available for intraoperative use. The thrombendarterectomy as described by Vollmar with the "ring stripper" is used only intraoperatively and can only be performed retrograde. The effect of laser systems encompasses disintegration and ablation of occlusive material. The rotation atherotomy is based on the capability of discrimination between hard occlusive material and elastic vascular wall through suitable construction of the lathe head (Figures 1 a to 1 e). Since, in passive catheters, the capability of lathing at the tip is associated with a high risk of perforation and a lateral possibility for lathing is not achievable, the lathing performance should be small, at the center of rotation and orthogonal to the axis of rotation at the outer radius. Through combination with a spherical disc face perpendicular to the axis of rotation, which protrudes only slightly from the hemispherical catheter tip, with a maximum at the center and minimum at the lateral borders, the lathing head has only a slight risk of perforation and no undesired sheering forces (Figures 2a to 2d).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1988

Percutaneous atherectomy catheters.

Percutaneous atherectomy catheters have been developed as an alternative to balloon angioplasty for the treatment of atherosclerotic disease. This article summarizes the preliminary experimental and clinical results with these catheters.

Catheterization, Peripheral↗
PubMed1987

Rotational approaches to atherectomy and thrombectomy.

We have developed and tested a rotational, mechanical approach to arterial plaque removal (PTRA or Percutaneous Transluminal Rotational Atherectomy). An elliptical burr is rotated by a helical driveshaft at 150,000 rpm. The tip of the burr is embedded with small diamond chips, 30 micron in diameter. Plaque is thus abraded and particles of 2-5 micron in diameter are released downstream. Preliminary studies in a rabbit model of iliac atherosclerosis showed a reduction in percent diameter stenosis from more than 80% to less than 40%. Perforations are the current principal complication, occurring in 2 of the 13 rabbit arteries. A second rotational catheter system has been developed for removal of fresh thrombus (PRT-Percutaneous Rotational Thrombectomy). Low speed rotation (5000 rpm) of a non-cutting catheter promotes the selective winding of fibrin with subsequent lysis of thrombus. This was effective in 20 out of 21 total thrombotic occlusions in a canine model of fresh clot, with a single perforation early in the experiment.

Animals↗
PubMed1993

Directional coronary atherectomy for saphenous vein graft disease.

Saphenous vein grafts (SVG) comprise a significant and increasing proportion of coronary interventional procedures at most centers. Directional coronary atherectomy (DCA) is well suited for treating focal SVG disease and is an effective therapy for lesions located in the ostium, shaft or body, and distal insertion site of saphenous vein grafts. Aorto-ostial SVG lesions may be technically difficult due to angulation and inability to fully engage the guide catheter, but success rates are relatively high and excellent angiographic results are usually achieved. Use of alternative guide catheters and stiffer guide wires can facilitate successful DCA of aorto-ostial lesions. DCA of SVG shaft segments or distal insertion sites are also associated with high success and low complication rates. Complex and thrombus-containing vein graft lesions are often well suited for DCA, and both patent and occluded grafts with extensive thrombus may also be effectively treated with DCA following selective intragraft thrombolysis. Technical aspects of vein graft DCA for these applications are reviewed.

Angioplasty, Balloon, Coronary↗
PubMed1999

Histologic comparison of coronary and iliac atherectomy tissue from cases of in-stent restenosis.

Pathologically, restenotic lesions after stenting were investigated by use of atherectomized tissues of seven coronary and seven iliac arteries. The mean interval of the stent deployment to restenosis was 9.1 months for the coronary artery and 33.7 months for the iliac artery, indicating a 3.7-fold longer interval for the latter. This study does not include cases of acute thrombotic occlusion. The atherectomized tissue from restenotic coronary arteries showed abundant neointima with alpha-actin-positive and ultrastructually synthetic-type smooth muscle cells in a rich myxomatous extracellular matrix. In the iliac arteries, the predominant component of restenosis consisted of organized thrombi. The neointima of the iliac arteries was mature, and only a small amount of spindle cells were observed in the hyalinized matrix. The tissue that developed restenosis after stenting was different in the coronary and iliac arteries included in this series. This study on the atherectomized tissue suggests that even in the chronic stage, a major cause of in-stent restenosis among the larger caliber vessels such as the iliac artery is not neointima but stent thrombosis.

Aged↗