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PubMed1995

Atherectomy (directional, rotational, extractional) and its role in percutaneous revascularization.

After an initial wave of enthusiasm, atherectomy devices face a number of difficult issues today. The first two randomized studies comparing balloon angioplasty with directional atherectomy, the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) and the Canadian Coronary Atherectomy Trial (CCAT), showed no clinical benefit for atherectomy. Data from these trials, as well as other studies, suggest that the mechanism of lumen enlargement with atherectomy may be less beneficial than expected. A number of investigations are currently evaluating the benefit of even more aggressive debulking with directional coronary atherectomy, but in view of the increased incidence of acute complications, it is unlikely that this technique will increase its share in routine coronary angioplasty in the near future. Clinical evaluation of rotational and extractional atherectomy has not reached a conclusive phase yet, but results from registries and single-center observations show that these devices require adjunctive balloon angioplasty in a large proportion of cases, on the one hand, and that they do not solve the issue of restenosis, on the other. The difficulty in delineating the rationale for use of these devices highlights the urgent need for controlled and carefully designed device trials.

Angioplasty, Balloon, Coronary↗
PubMed1995

A modified directional atherectomy catheter for resection of calcified atherosclerotic plaques.

BACKGROUND: The purpose of this study was to determine the feasibility of resecting calcified atherosclerotic plaques in human cadaveric vessels by using a modified directional coronary atherectomy catheter and to correlate these results with bench tests using an in-vitro sea coral model. METHODS: The conventional directional coronary atherectomy catheter was modified by changing the cutter blade to a tungsten carbide material and by increasing the torsional strength of the drive cable. The performance of the modified directional coronary atherectomy (DCA) catheter was compared with the conventional catheter using a sea coral model to simulate calcified material. Then, 10 human ex-vivo arteries (eight with calcification) were treated with both conventional and modified catheters, and the results studied with intravascular ultrasound and confirmed by histologic examination. RESULTS: Using the modified directional coronary atherectomy catheter it was possible to perform effective and consistent longitudinal cutting, and to resect a significantly larger amount of coral (1.0 +/- 0.1 mm2 versus 0.2 +/- 0.1 mm2 with conventional cutter, P < 0.0001). In heavily calcified ex-vivo arteries, the modified catheter was more effective in removing calcified plaques (13 +/- 11 mg versus 3.7 +/- 1.4 mg with conventional cutter, P = 0.07). Intravascular ultrasound confirmed the effective atherectomy (residual area stenosis 28 +/- 16% versus 47 +/- 10% with the conventional device, P < 0.05), and histologic examination showed calcified nodules in the atherectomy samples obtained with the modified cutter (area of calcium 1.43 +/- 0.89 mm2 versus 0.93 +/- 0.83 mm2 with the conventional cutter). CONCLUSIONS: The modified directional coronary atherectomy catheter effectively removed both non-calcified and calcified plaques in the ex-vivo human cadaveric arteries, thus demonstrating the feasibility of directional coronary atherectomy of calcified plaques. This modified device shows promise for treating calcified coronary lesions, especially in larger vessels.

Animals↗
PubMed1998

Quantitative assessment of transient regional ischemia during rotational atherectomy.

UNLABELLED: Sustained myocardial ischemia with angina pectoris, electrocardiographic changes and subsequent non-Q-wave infarctions has been reported during percutaneous transluminal rotational atherectomy of complex coronary lesions. The purpose of this study was to evaluate the effect of rotational atherectomy on regional myocardial perfusion as assessed by serial 99mTc-sestamibi SPECT imaging with semiquantitative tracer uptake analysis. METHODS: Twenty-nine consecutive patients with anginal symptoms, complex coronary lesions (all Type B and Type C) and preserved left ventricular function were studied using resting 99mTc-sestamibi SPECT before rotational atherectomy, during and 2 days after the procedure. For semiquantitative computerized analysis, the left ventricular myocardium was divided into 24 regions, and regional perfusion was expressed as percentage of maximal sestamibi uptake. RESULTS: Visual analysis of scintigraphic images revealed transient perfusion defects corresponding to the revascularized vessel in 26 of 29 patients, whereas three patients had no transient hypoperfusion. During rotational atherectomy, perfusion decreased significantly (>2 s.d. below normal mean) in 3.1 +/- 2.4 regions (range 1-10). Perfusion in the territory of the revascularized vessel was 75% +/- 11% at baseline, decreased to 67% +/- 12% during rotational atherectomy (p < 0.001) and normalized again after rotational atherectomy to 78% +/- 8% (p < 0.001). Similarly, perfusion in the region with the maximal reduction decreased from 74% +/- 15% at baseline to 55% +/- 14% (p < 0.001) during the procedure and returned to 74% +/- 16% (p < 0.001) following the intervention. In calcified stenoses, the extent of perfusion defects was larger as compared to noncalcified (4.2 +/- 2.5 versus 2.3 +/- 2.0 regions/patient, p < 0.05). CONCLUSION: During rotational atherectomy, myocardial hypoperfusion occurs. The transient nature of this perfusion defect can be demonstrated and quantified by serial 99mTc SPECT. This model may prove useful to assess the effects of pharmacological approaches to reducing myocardial hypoperfusion during coronary rotational atherectomy.

Atherectomy, Coronary↗
PubMed1998

Preliminary clinical experience with the pullback atherectomy catheter and the study of proliferation in coronary plaques.

BACKGROUND: Clues to the biology of coronary artery disease can be obtained through the study of proliferation in human coronary artery plaques. Previously, immunocytochemistry has been used to detect the proliferating cell nuclear antigen to demonstrate low levels of proliferation in directional coronary atherectomy tissue fragments resected from human coronary arteries. OBJECTIVES: To describe the proliferative profile of coronary artery tissue by using a more sensitive marker for cell replication. PATIENTS AND METHODS: Ten patients with unstable or stable angina pectoris underwent coronary atherectomy with a newer coronary atherectomy device, the Arrow-Fischell pullback atherectomy catheter. The histological features of the specimens were studied by using light microscopy, and cell proliferation was assessed with the use of in situ hybridization for the S phase-specific mRNA species, histone H3. RESULTS: Pullback coronary atherectomy immediately followed by percutaneous transluminal coronary angioplasty resulted in angiographic improvement in the lumen diameter in all but one patient, who required insertion of a stent. The atherectomy specimens consisted of a combination of atheromatous plaque and media. Four specimens had a small amount of adventitia. Five of the 10 specimens had no proliferating cells. Three specimens had between one and five proliferating cells per slide, while two specimens had relatively high proliferation indexes (2.5% and 4.2% of all cells per atherectomy cross-section). Both smooth muscle cells and macrophages were identified in areas with proliferating cells. The histology and proliferation profiles of the tissue resected from patients with stable and unstable angina were similar. CONCLUSIONS: Pullback atherectomy can be used effectively to debulk coronary artery lesions. By using a sensitive marker for cell replication, it was determined that the majority of the tissue specimens have low proliferation indexes.

Angioplasty, Balloon, Coronary↗
PubMed1990

Ex-vivo results using a new pullback atherectomy catheter (PAC).

In order to evaluate the feasibility of performing definitive atheromatous plaque removal using a novel retrograde cutting (Pullback) atherectomy catheter, pullback atherectomy was performed in 13 severely diseased cadaveric superficial femoral arteries. All experiments were performed using cadaver tissue either mounted in a perfusion/mounting chamber (n = 10) or left in situ (n = 3). In general, a single cut was made with each of three sequentially larger atherectomy catheters (2.5 mm, 3.0 mm, and then 3.5 mm devices). The results were evaluated by angiography and by light microscopy. Nine of the 13 experiments were performed in totally occluded vessels. The mean pre-atherectomy stenosis (all specimens) was 95 +/- 3%, with a final mean postatherectomy stenosis of 21 +/- 5%. There was one vessel performation. We conclude from these preclinical studies that retrograde atherectomy with the Pullback Atherectomy Catheter is a feasible means of performing definitive atherectomy. Despite the promising potential of retrograde atherectomy, little can be said with certainty about the clinical utility of such a device at this early stage.

Arteriosclerosis↗
PubMed1990

Comparison of dissection rates and angiographic results following directional coronary atherectomy and coronary angioplasty.

Directional coronary atherectomy is a new percutaneous transluminal technique for treating occlusive coronary artery disease. In this study, angiographic results (i.e., residual stenosis and angiographic evidence of postprocedure dissection) after directional coronary atherectomy and balloon angioplasty were compared. The atherectomy group consisted of 91 lesions in 83 consecutive patients who underwent either left anterior descending artery or right coronary artery atherectomy. The angioplasty group consisted of 91 lesions in 84 patients that were matched with the atherectomy lesions with respect to vessel and whether the lesion was a restenosis lesion. The mean preprocedure diameter stenosis was 76% in both groups as measured quantitatively with electronic calipers. After the procedure, the mean residual diameter stenosis of the atherectomy lesions was 13 +/- 17%, whereas for the angioplasty lesions it was 31 +/- 18% (p less than 0.001). Success rates in both groups were similar (94.5 and 93.4%, respectively). The incidence of postprocedure dissection was 11% in the atherectomy group and 37% in the angioplasty group (p less than 0.0001). Directional coronary atherectomy results in significantly improved postprocedure angiographic appearances due to significantly less severe residual stenosis and lower incidence of dissection.

Angioplasty, Balloon, Coronary↗
PubMed1991

Clinical, angiographic and procedural correlates of quantitative coronary dimensions after directional coronary atherectomy.

To define the clinical, angiographic and procedural correlates of quantitative coronary dimensions after directional coronary atherectomy, 400 lesions in 378 patients were analyzed with use of qualitative morphologic and quantitative angiographic methods. Successful atherectomy, defined by a less than 75% residual area stenosis, tissue retrieval and the absence of in-hospital ischemic complications, was performed in 351 lesions (87.7%). After atherectomy, minimal cross-sectional area increased from 1.2 +/- 1.1 to 6.6 +/- 4.4 mm2 (p less than 0.001) and percent area stenosis was reduced from 87 +/- 10% to 31 +/- 42% (p less than 0.001). By univariate analysis, device size (p less than 0.001) and left circumflex artery lesion location (p = 0.004) were associated with a larger final minimal cross-sectional area. Conversely, restenotic lesion (p = 0.002), lesion length greater than or equal to 10 mm (p = 0.018) and lesion calcification (p = 0.035) were quantitatively associated with a smaller final minimum cross-sectional area. With use of stepwise multivariate analysis to control for the reference area, atherectomy device size (p = 0.003) and left circumflex lesion location (p = 0.007) were independently associated with a larger final minimal cross-sectional area, whereas restenotic lesion (p = 0.010), diffuse proximal disease (p = 0.033), lesion length greater than or equal to 10 mm (p = 0.026) and lesion calcification (p = 0.081) were significantly correlated with a smaller final minimal cross-sectional area. The number of specimens excised, the number of atherectomy passes and atherectomy balloon inflation pressure did not correlate with the final minimal cross-sectional area. Thus, directional atherectomy results in marked improvement of coronary lumen dimensions, at least in part correlated with the presence of certain clinical, angiographic and procedural factors at the time of atherectomy.

Aged↗
PubMed1996

Rotational atherectomy with a new device: initial clinical experience.

The Bard Atherectomy Catheter is a new rotational atherectomy device that consists of a flexible, hollow, thin-walled cutting catheter that, while rotated at 1,500 revolutions per minute, is advanced across the lesion over a special spiral guidewire system. We report the initial clinical experience with this device in 20 peripheral lesions in ten patients. The majority of patients were treated for limb salvage. All lesions were successfully intervened on by atherectomy followed by adjunctive balloon angioplasty. A reduction to less than 50% stenosis was achieved in 13 of the 20 lesions (65%) after atherectomy but in all 20 lesions (100%) after adjunctive angioplasty for all lesions and stenting for dissections in two. Baseline minimal lesion lumen diameter was 0.8 +/- 0.7 mm with a reference vessel diameter of 4.2 +/- 1.7 mm (75 +/- 21% stenosis). The lumen improved to 2.0 +/- 0.8 mm (45 +/- 19% stenosis) (P < 0.001) following atherectomy and to 3.9 +/- 1.9 mm (13 +/- 16% stenosis) (P < 0.001) after adjunctive angioplasty. The average weight of removed atheroma was 45 +/- 58 mg. All ten patients had initial improvement in symptoms. At 6 months follow-up there was persistent improvement in eight patients and two subjects had undergone amputations. Our early clinical experience with this low profile, flexible atherectomy device, that enables extraction of a large amount of atheroma, suggests that it will become a valuable addition to current atherectomy technologies in small- and medium-sized vessels. The value of this device in coronary vessels is under investigation.

Angioplasty, Balloon↗
PubMed1997

Directional atherectomy and balloon angioplasty for lower extremity arterial disease.

This study was undertaken to evaluate the use of directional atherectomy, balloon angioplasty, and video angioscopy in highly selected patients with superficial and popliteal artery stenoses. Directional atherectomy and balloon angioplasty for superficial femoral and popliteal artery stenosis (> 80%) were performed in 96 limbs (88 patients) between 1990 and 1994. All procedures were performed by the authors with angioscopy and C-arm angiography. Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) categorical classification of chronic limb ischemia and run off scoring was utilized pre- and postoperatively to assess outcome. The indicators for atherectomy were moderate claudication (category 2, 15% of limbs), severe claudication (category 3, 65%), ischemic rest pain (category 4, 12%), and tissue loss (category 5, 12%). Morbidity was 6.0% with no perioperative mortality. All technically and (angiographically) successfully treated patients demonstrated postoperative improvement. Clinical assessment, vascular laboratory studies (outcome criteria), and/or angiography were monitored at follow-up visits. Intraoperative failures occurred in 6% of limbs due to inability to pass a guide wire (3%), impacted atherectomy catheter (1%), or vessel perforation (2%). In the remaining 90 limbs, 23% failed due to either progression of disease (7.7%) or restenosis at the original site (15.3%). Seventy-one percent of limbs maintained their postoperative categorical improvement at a mean follow up of 24 months. Combining atherectomy and balloon angioplasty may be more durable than angioplasty or atherectomy alone. A long-term prospective study of the role of directional atherectomy and balloon angioplasty by vascular surgeons appears to be warranted utilizing SVS/ISCVS guidelines for lower extremity chronic ischemia categories, run-off score, and outcome criteria for patency.

Adult↗
PubMed1995

Abrupt closure: the CAVEAT I experience. Coronary Angioplasty Versus Excisional Atherectomy Trial.

OBJECTIVES: This study sought to assess the incidence and consequences of abrupt closure in a series of patients undergoing directional coronary atherectomy versus percutaneous coronary angioplasty. BACKGROUND: Abrupt closure with coronary angioplasty has been associated with adverse outcome. The results from the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) I, a randomized trial of coronary angioplasty versus directional coronary atherectomy, were analyzed. METHOD: This multicenter trial enrolled 1,012 patients from 1991 to 1992. All records from patients with abrupt closure, which was coded as a discrete complication, were reviewed. RESULTS: Abrupt closure occurred in 60 patients (5.9%) and was associated with a significantly longer hospital stay (median 8 vs. 3 days). Severe proximal target vessel tortuosity was more common in patients with abrupt closure (20.3% vs. 11.6%, p = 0.046), as was preexistent coronary artery thrombus (30.5% vs. 18.3%, p = 0.02). Abrupt closure was associated with a marked increase in subsequent complications (myocardial infarction 46.7% vs. 2.1%, emergency bypass surgery 38.3% vs. 0.32%, death 33% vs. 0%) and occurred more frequently in the directional coronary atherectomy group (8.0% vs. 3.8%, p = 0.005). In the coronary angioplasty group, the occlusion usually occurred at the target lesion (91%), presumably related to the effects of barotrauma. In the directional coronary atherectomy group, the site of the occlusion was the target lesion in only 58% (p = 0.045). The remaining occlusions related to problems with the technique (guide catheter or nose cone trauma), reflecting the fact that directional coronary atherectomy is a more complex procedure. CONCLUSIONS: Abrupt closure remains the principal determinant of adverse outcome after percutaneous procedures for the treatment of coronary artery disease. Although abrupt closure is more common with directional atherectomy than angioplasty, the sequelae are similar.

Aged↗
PubMed1996

Clinical and angiographic comparison of matched patients with successful directional coronary atherectomy or stent implantation for primary coronary artery lesions.

OBJECTIVES: This study was designed to compare the long-term clinical and angiographic effects of successful directional atherectomy and stent implantation and to examine whether restenosis is related to the mechanism of lumen improvement as well as the extent of lumen gain. BACKGROUND: Directional atherectomy and coronary stent implantation have been shown to achieve a more optimal immediate result that may lead to a more favorable long-term angiographic outcome and fewer target vessel revascularizations than does angioplasty. However, it remains to be determined whether one of the devices used in these interventions provides consistently better results than the other. METHODS: To allow meaningful comparisons a prospectively collected series of 117 patients successfully treated with atherectomy were individually matched with a prospectively collected series of 117 patients successfully treated with stent implantation. Matching for baseline characteristics identified patients with identical lesion location and lesion severity, and immediate and late angiographic and clinical outcome were compared. To evaluate the possibility of a procedure effect on restenosis, patients were further matched for both immediate angiographic outcome and baseline characteristics, providing 150 matched patients for comparison. As confirmatory analysis, multivariate models were constructed to predict late lumen diameter. RESULTS: Matching resulted in two comparable groups with equivalent baseline clinical and stenosis characteristics (n = 117 pairs). Atherectomy led to a smaller immediate gain than stenting and, because late loss was similar in both groups, stenting resulted in a larger late lumen (1.96 +/- 0.51 vs. 1.66 +/- 0.55 mm, p < 0.0001). When patients were matched for immediate gain and baseline characteristics (n = 75 pairs), lumen loss was more pronounced after atherectomy, and thus the minimal lumen diameter at follow-up differed significantly between the two groups (1.66 +/- 0.53 vs. 1.90 +/- 0.47 mm, p = 0.004). This beneficial angiographic effect of stenting was accompanied by a reduced need for repeat interventions. Multivariate analysis confirmed the independent effect of the interventional device used, whereby less loss and greater lumen diameter at follow-up were predicted for stent implantation than for atherectomy. CONCLUSIONS: Successful stent implantation provided a more favorable long-term angiographic outcome and lower rates of restenosis and need for target lesion revascularization than did atherectomy. This favorable effect of stenting not only is related to a larger, immediate gain, but also seems to attenuate late lumen loss.

Angioplasty, Balloon, Coronary↗
PubMed2003

Comparison of rotational atherectomy with conventional balloon angioplasty in the prevention of restenosis of small coronary arteries: results of the Dilatation vs Ablation Revascularization Trial Targeting Restenosis (DART).

BACKGROUND: The optimum treatment of obstructive coronary disease in small (<3.0 mm diameter) arteries remains unknown. Rotational atherectomy is an approved treatment that might reduce the vascular injury during percutaneous coronary intervention compared with angioplasty. We report on a multicenter, randomized, blinded end point trial comparing rotational atherectomy with balloon angioplasty in the prevention of restenosis of obstructed small coronary arteries. METHODS: A total of 446 patients with myocardial ischemia associated with an angiographic stenosis in a native coronary artery 2 to 3 mm in diameter and < or =20 mm in length without severe calcification were randomly assigned to receive rotational atherectomy (n = 227) or balloon angioplasty (n = 219). The primary end point was target vessel failure at 12 months (defined as the composite of death, Q-wave myocardial infarction, and clinically driven repeat revascularization of the target vessel). RESULTS: The mean reference vessel diameter was 2.46 +/- 0.40 mm, the mean lesion length was 9.97 +/- 5.59 mm, and the prevalence of diabetes mellitus was 32%. Acute procedural success (91.6% for rotational atherectomy, 94.1% for balloon angioplasty, P =.36) and target vessel failure at 12 months were not significantly different (30.5% vs 31.2%, P =.98). At 8 months, there were no significant differences in minimum lumen diameter (1.28 +/- 0.63 mm vs 1.19 +/- 0.54 mm, P =.26), percent diameter stenosis (28% +/- 12% vs 29% +/- 15%, P =.59), binary restenosis rate (50.5% vs 50.5%, P = 1.0), or late loss index (0.57 vs 0.62, P =.7). No Q-wave myocardial infarctions occurred in either arm of the study, and non-Q-wave myocardial infarctions (defined as creatine kinase level >2 times normal with an elevated creatine kinase-myocardial band isoenzyme level) occurred in 2.2% and 1.4% of the patients in the rotational atherectomy and balloon angioplasty groups, respectively (P =.72). CONCLUSION: Rotational atherectomy was found to be safe in the treatment of obstructed small arteries, but lower rates of target vessel failure were not achieved compared with balloon angioplasty. Because the acute gain and loss index ratios of the 2 treatments were similar, there was no evident beneficial antirestenosis mechanism seen for rotational atherectomy.

Angioplasty, Balloon, Coronary↗
PubMed1997

Impact of diabetes mellitus on percutaneous revascularization (CAVEAT-I). CAVEAT-I Investigators. Coronary Angioplasty Versus Excisional Atherectomy Trial.

We examined the relation between diabetes mellitus and outcomes in patients undergoing percutaneous coronary revascularization in the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-I), a randomized trial comparing treatment with either percutaneous transluminal coronary angioplasty or directional atherectomy for de novo lesions in native coronary arteries. Acute success and complication rates, 6-month angiographic restenosis rates, and 1-year clinical outcomes were compared between diabetic and nondiabetic patients undergoing each procedure. Acute success rates between diabetic (n = 191) and nondiabetic (n = 821) patients were similar for both revascularization techniques. Except for the need for dialysis, complication rates were also similar. Six months after atherectomy, diabetic patients had significantly more angiographic restenosis than nondiabetics (59.7% vs 47.4%) and significantly smaller minimum luminal diameters (1.20 vs 1.40 mm). Diabetics undergoing atherectomy required more frequent bypass surgery (12.8% vs 8.5%) and more repeat percutaneous revascularizations (36.5% vs 28.1%) than nondiabetics undergoing atherectomy. Restenosis rates, minimum luminal diameters and repeat revascularizations between diabetics and nondiabetics undergoing angioplasty were similar. The higher restenosis and repeat revascularization rates and the smaller minimum luminal diameter at follow-up in diabetic patients suggest that atherectomy may provide only modest benefit for these patients. The increased restenosis rate in diabetics undergoing atherectomy (but not angioplasty) requires further evaluation.

Acute Disease↗
PubMed1998

Quantitative angiography of coronary artery dimensions 24 hours after rotational atherectomy.

Rotational atherectomy results in platelet activation and heat generation, which may impact artery size immediately after treatment. In addition, arteries treated with balloon angioplasty may exhibit recoil within 24 hours. In this study, arteries treated with rotational atherectomy, with and without adjunctive balloon angioplasty, were analyzed by quantitative coronary angiography to determine the effect of rotational atherectomy on the dynamic behavior of the arterial wall within 24 hours after the procedure. Quantitative coronary angiography was performed at a core laboratory. Coronary angiogram acquisitions were preceded by intracoronary nitroglycerin injections and were repeated using identical angles of projection. Proximal and distal reference vessel diameters were 2.55 +/- 0.60 and 2.28 +/- 0.51 mm, respectively, and did not change from pre- to postprocedure. Both were larger the following day increasing to 2.72 +/- 0.65 and 2.52 +/- 0.52 mm, respectively, (p <0.001). Minimum luminal diameter (MLD) increased from 0.70 +/- 0.28 mm before to 1.49 +/- 0.34 mm after the procedure and to 1.72 +/- 0.37 mm at 24-hour follow-up (p <0.001). Subset analysis of patients treated with rotational atherectomy alone or rotational atherectomy with adjunctive balloon angioplasty revealed that the increase in luminal diameters occurred in both subsets. Patients treated with adjunctive angioplasty had a smaller initial MLD, a larger postprocedure MLD, and no difference in MLD at 24-hour follow-up compared with stand-alone rotational atherectomy. Subset analysis of 100 patients who had 6-month follow-up angiography revealed that both a calculated acute gain and chronic late loss, based on a 24-hour film, differed significantly from values using a film acquired immediately after the procedure. However, the slope of the linear regression between acute gain and chronic late loss did not differ. Coronary arteries treated with rotational atherectomy with or without adjunctive balloon angioplasty increase significantly in size during the first 24 hours after the procedure. This phenomenon has implications for the calculation of absolute gain and chronic late loss, but not for the linear relation between the 2 quantitative outcomes.

Aged↗
PubMed1994

"Rescue" directional coronary atherectomy after unsuccessful percutaneous transluminal coronary angioplasty.

OBJECTIVE: To evaluate the outcome in patients who underwent directional coronary atherectomy after unsuccessful balloon angioplasty. DESIGN: We conducted a retrospective computerized data bank search of patients in whom unsuccessful balloon angioplasty and subsequent "rescue" coronary atherectomy had been performed at the Mayo Clinic between Nov. 1, 1988, and May 1, 1993. MATERIAL AND METHODS: Among the 336 patients who underwent directional coronary atherectomy during the study period, in 16 the procedure was a rescue attempt. The mean age of these 16 study patients was 67 years. The following vessels were treated: left anterior descending coronary artery, six patients; right coronary artery, six; circumflex artery, two; and saphenous vein graft, two. Coronary angioplasty had failed because of dissection in eight patients, elastic recoil without evident dissection in seven, and recurrent thrombus without evident dissection in one. RESULTS: After coronary atherectomy, the mean stenosis was 41% (in comparison with 90% before coronary angioplasty and 71% after coronary angioplasty). Both angiographic success (20% or more decrease in stenosis after tissue removal and a final stenosis of less than 50%) and clinical success (angiographic success without in-hospital Q-wave myocardial infarction, bypass operation, or death) were achieved in 10 patients. Adventitia was obtained in two patients, both of whom underwent atherectomy for elastic recoil. In six patients, a stenosis of more than 50% remained after atherectomy; one patient suffered a Q-wave myocardial infarction, and one underwent emergent coronary artery bypass grafting. No deaths occurred in the study group. During follow-up (mean, 22 +/- 19 months), one patient suffered a non-Q-wave myocardial infarction, and two others underwent elective coronary artery bypass grafting. Eleven patients were asymptomatic at last contact. Repeated angiography, done in five patients a mean of 3.4 +/- 3.1 months after the procedure, showed restenosis in three. CONCLUSION: Rescue directional coronary atherectomy seems to be safe and effective in achieving angiographic and clinical successes in carefully selected patients after unsuccessful coronary angioplasty.

Aged↗
PubMed1996

Mid-term and long-term results with directional atherectomy of vein graft stenoses.

PURPOSE: The purpose of this study was to evaluate the outcomes of our 6-year experience with directional atherectomy used for treatment of stenoses in infrainguinal vein grafts. METHODS: From March 1988 to April 1994, 52 directional atherectomy procedures were undertaken in 42 patients to treat 67 stenoses in 44 vein grafts. Follow-up consisted of periodic physical examinations and graft surveillance; ankle/brachial indexes, pulse volume recordings, and color-flow duplex ultrasonography. Follow-up angiography (n = 18) was performed for recurrent symptoms, reproducible drop in ankle/brachial index of greater than 0.15, a twofold to threefold focal increase in peak systolic velocity, or incidentally during evaluation of the opposite leg. RESULTS: Forty-nine of 52 (94%) procedures were technically successful. In two the residual diameter stenosis was greater than 30%, and in one atherectomy could not be performed. Complications were minor in six (11%) and major in three (6%): two acute graft occlusions and one delayed pseudoaneurysm at the atherectomy site. There were no deaths at 30 days. With a mean follow-up of 21 +/- 18 months, 36 of 44 grafts (82%) remained patent without restenosis; 6 others were patent but considered "failed"--5 (11%) with restenosis, 1 with a pseudoaneurysm; and 2 grafts (5%) occluded. Clinically 33 of 44 extremities (75%) were asymptomatic during follow-up. Claudication improved in five, recurred in three, and was unchanged in one. There was one below-knee amputation. Life-table analysis including all 52 procedures reveals cumulative primary atherectomy patency rates for the 44 grafts of 82%, 78%, and 78%, respectively, at 1, 2, and 3 years after atherectomy, and 86%, 83%, and 83% for the 67 individual stenoses treated. CONCLUSIONS: Directional atherectomy of vein graft stenoses has high technical and clinical success rates, acceptably low morbidity rates, and offers better sustained patency rates than balloon angioplasty. Its long-term patency rate seems to approach that of surgical vein patch angioplasty.

Aged↗
PubMed1996

Association between prior cytomegalovirus infection and the risk of restenosis after coronary atherectomy.

BACKGROUND: Restenosis occurs commonly after coronary angioplasty and atherectomy, but the causes of restenosis are poorly understood. Recently, it has been found that cytomegalovirus (CMV) DNA is present in restenotic lesions from atherectomy specimens. This and other evidence suggest that CMV may have a role in the process of restenosis. METHODS: We prospectively studied 75 consecutive patients undergoing directional coronary atherectomy for symptomatic coronary artery disease. Before atherectomy was performed, we measured blood levels of anti-CMV IgG antibodies to determine whether previous exposure to CMV increased the risk of restenosis, as determined by coronary angiography performed six months after atherectomy. RESULTS: After atherectomy, the mean (+/- SD) minimal luminal diameter of the target vessel was greater in the 49 patients who were seropositive for CMV than in the 26 patients who were seronegative (3.18 +/- 0.51 mm vs. 2.89 +/- 0.45 mm, P=0.01). After six months, however, the seropositive patients had a greater reduction in the luminal diameter (1.24 +/- 0.83 mm vs. 0.68 +/- 0.69 mm, P = 0.003), resulting in a significantly higher rate o restenosis in the seropositive patients (43 percent vs. 8 percent, P = 0.002). In a multivariable logistic-regression model, CMV seropositivity and the CMV titer were independently predictive of restenosis (odds ratios, 12.9 and 8.1, respectively). There was no evidence of acute infection, since the titer of anti-CMV IgG antibodies did not increase over time and tests for anti-CMV IgM antibodies were negative in all patients. CONCLUSIONS: Prior infection with CMV is strong independent risk factor for restenosis after coronary atherectomy. If confirmed, these findings may help identify patients at risk for restenosis.

Adult↗
PubMed2003

Initial clinical experience with percutaneous atherectomy in the infragenicular arteries.

PURPOSE: To evaluate the efficacy and safety of a new atherectomy device for the treatment of infragenicular lesions in arteries with a reference diameter of at least 2.5 mm. METHODS: Twenty-seven below-the-knee lesions in 17 patients (12 men; mean age 69+/-12 years) with chronic peripheral arterial occlusive disease were treated with directional atherectomy. The target lesion was in the popliteal artery (segment 3) in 2 (7%) cases, the tibioperoneal trunk in 12 (44%), the peroneal artery in 8 (30%), the anterior tibial artery in 2 (7%), and the posterior tibial artery in 3 (11%). Six (22%) of the lesions were in-stent stenoses. The mean diameter stenosis was 87%+/-9%, and the mean lesion length was 34+/-24 mm. RESULTS: All but 2 (7%) of the lesions could be treated successfully (residual stenosis <30%) with the atherectomy catheter (93% technical success) using an average of 5+/-2 (range 1-10) passes of the device. Six lesions (22%) were treated after predilation and 21 (78%) with primary atherectomy. In 8 (30%) lesions, additional balloon angioplasty was performed. The 2 failures were in heavily calcified lesions through which the device could not pass despite predilation. The mean diameter stenosis after atherectomy was 14%+/-22% (range 0%-90%); after additional balloon angioplasty, the mean residual stenoses reduced to 12%+/-21% (range 0%-100%). One (6%) of the 2 patients who failed atherectomy sustained a thrombotic occlusion of the target vessel. This complication was treated successfully with local lysis, but the vessel reoccluded 3 days later; a stent was implanted. The mean ankle-brachial index increased from 0.50+/-0.27 to 0.86+/-0.40 before discharge. CONCLUSIONS: Below-the-knee native vessel lesions and in-stent restenoses with a diameter of at least 2.5 mm can be treated successfully and safely with this new atherectomy catheter. Additional balloon angioplasty was necessary in only a few cases.

Aged↗