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PubMed1995

Peripheral vascular complications in the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-I).

OBJECTIVES: In-hospital peripheral vascular complications of balloon angioplasty were compared with those of directional atherectomy in the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-I) to identify patients at risk and evaluate costs and outcomes. BACKGROUND: The incidence, costs and outcomes of peripheral vascular complications after coronary intervention have not been fully characterized as a function of randomly assigned therapy. METHODS: At 35 sites in the United States and Europe, 1,012 patients were randomized. Peripheral vascular complications were defined as the composite of pulse loss, pseudoaneurysm, hematoma > 4 cm in diameter or groin hemorrhage necessitating blood transfusion. Logistic models were derived to 1) predict these complications from baseline and procedural characteristics, 2) test the relevance of randomization assignment, and 3) assess their impact on hospital costs and long-term outcomes. RESULTS: Sixty-seven patients (6.6%) developed peripheral vascular complications, of whom 15 (22.4%) required a blood transfusion, 14 (20.9%) underwent vascular surgery, and 2 (3.0%) died. Both in-hospital deaths occurred in patients with peripheral vascular complications. There was no difference in composite peripheral vascular complication rates among patients randomized to angioplasty or atherectomy. Greater age, female gender, postprocedural heparin and intraaortic balloon counterpulsation were predictive of increased risk. In a representative 60% subset, mean hospital costs increased from $9,583 in patients without to $18,350 in those with peripheral vascular complications (p = 0.0001). The unadjusted mortality rate at 1 year was 7.5% for patients with peripheral vascular complications compared with 1.1% for all others (p = 0.0001). These complications identified patients at greater risk of death, myocardial infarction or repeat revascularization at 30 days and 1 year. The atherectomy group had a trend toward more frequent deaths and myocardial infarction. CONCLUSIONS: Directional atherectomy and balloon angioplasty had similar in-hospital peripheral vascular complication rates. Female gender, greater age, postprocedural heparin and intraaortic balloon counterpulsation were predictive of higher risk. The twofold increase in cost and sevenfold increase in long-term deaths highlight the need to prevent these periprocedural events and monitor patients closely.

Angioplasty, Balloon, Coronary↗
PubMed1995

Role of intraaortic balloon pump counterpulsation in high risk coronary rotational atherectomy.

OBJECTIVES: This study sought to evaluate the role of intraaortic balloon pump counterpulsation in preventing hemodynamic instability and promoting a successful outcome during percutaneous transluminal coronary rotational atherectomy in high risk patients. BACKGROUND: The application of rotational atherectomy has widened to include patients with complex lesions and left ventricular dysfunction. Although intraaortic balloon pumping has been successfully used to provide hemodynamic support during balloon angioplasty, its role in high risk rotational atherectomy has not yet been defined. METHODS: In a retrospective review of 159 consecutive high risk patients who underwent rotational atherectomy, 28 had an intraaortic balloon pump placed electively before the procedure (Group 1) whereas 131 did not (Group 2). RESULTS: Group 1 was older and more likely to have multivessel disease and left ventricular dysfunction. Augmented diastolic pressure was maintained > 90 mm Hg in all Group 1 patients, and significant procedure-related hypotension was encountered in nine Group 2 patients, requiring an emergency intraaortic balloon pump in five. Procedural success was achieved in all 28 patients in Group 1 and in 118 in Group 2 (p = 0.07). Slow flow occurred in 18% and 17% of Group 1 and 2 patients, respectively. Among patients with slow flow, non-Q wave myocardial infarction occurred only in Group 2 (0% vs. 27%). On multivariate analysis, elective intraaortic balloon pump placement was the only variable to correlate with a successful procedure uncomplicated by hypotension (p < 0.05). Hospital stay and vascular complications were similar in both groups. CONCLUSIONS: Elective placement of an intraaortic balloon pump before coronary rotational atherectomy in selected high risk patients promotes both procedural hemodynamic stability and a successful outcome.

Aged↗
PubMed1996

Influence of percutaneous transluminal coronary rotational atherectomy with adjunctive percutaneous transluminal coronary angioplasty on coronary blood flow.

The purpose of this study was to examine the influence of sequential percutaneous transluminal coronary rotational atherectomy (PTCRA) and coronary angioplasty on coronary blood flow reserve in patients. Rotational coronary atherectomy restores lumen patency by partially ablating fibrocalcific plaque, releasing microparticulate debris into the distal coronary circulation. Adjunctive balloon angioplasty is usually performed to optimize the angiographic luminal dimensions. Serial alterations in coronary physiology have not been reported. Fourteen lesions in 13 patients were treated by sequential rotational atherectomy followed by adjunctive balloon angioplasty. Poststenotic baseline coronary blood flow velocity was measured by using a Doppler flow wire (FloWire, Cardiometrics, Inc., Mountain View, Calif.), and coronary blood flow was calculated by using the distal vessel cross-sectional area obtained by quantitative coronary angiography. Data were acquired at baseline and during hyperemia (12 to 18 microg of intracoronary adenosine), before and after PTCRA, and again after balloon angioplasty. The mean stenosis decreased from 76 percent +/- 12 percent at baseline to 21 percent +/- 11 percent at the completion of the procedure (p<0.01). The minimal luminal diameter (by quantitative coronary angiography) was 0.7 +/- 0.4 mm at baseline, increased to 1.9 +/- 0.4 mm after rotational atherectomy (p<0.01), and increased to 2.4 +/- 0.5 mm after balloon angioplasty (p<0.01 versus baseline and PTCRA). Distal (poststenotic) coronary blood flow at baseline was 47 +/- 23 ml/min and 57 +/- 38 ml/min during hyperemia. After PTCRA, coronary blood flow increased to 104 +/- 59 ml/min and to 132 +/- 73 ml/min with hyperemia. After adjunctive angioplasty, coronary blood flow was 84 +/- 40 ml/min (p=not significant [NS] vs PTCRA) and increased to 143 +/- 81 ml/min with hyperemia (p=NS vs PTCRA). The poststenotic coronary flow reserve increased from an initial value of 1.1 +/- 0.2 ml/min to 1.3 +/- 0.3 ml/min after PTCRA (p=NS vs baseline) and to 1.6 +/- 0.3 ml/min after adjunctive balloon angioplasty (p<0.01 vs p=NS vs PTCRA). PTCRA significantly increased resting coronary blood flow. Adjunctive balloon angioplasty did not significantly augment resting or hyperemic coronary blood flow more than that achieved by rotational atherectomy alone. These data demonstrate that PTCRA alone improves baseline coronary blood flow with minimal additional physiologic change after adjunctive balloon angioplasty.

Aged↗
PubMed1999

Comparative analysis of early and late angiographic outcomes using two quantitative algorithms in the Balloon versus Optimal Atherectomy Trial (BOAT).

Although substantial intersystem variability has been shown among several commercially available quantitative angiographic (QA) analysis algorithms, no previous study has compared the angiographic findings using 2 different QA systems performed at the same central angiographic laboratory. The purpose of this study was to compare the early and late QA results obtained with the CMS (MEDIS) and ARTREK (ImageComm) QA systems in the Balloon versus Optimal Atherectomy Trial. Directional atherectomy (n = 496) or balloon angioplasty (n = 490) was performed in 986 patients; late QA follow-up was available in 767 patients (77.7%). QA analysis was performed by 2 independent observers using the CMS and ARTREK systems. Correlation between the 2 QA systems for baseline measurements was good (Pearson's R = 0.78), although the CMS system resulted in larger baseline reference diameter (RD) (3.22 +/- 0.45 vs 3.07 +/- 0.40 mm; p <0.0001) and baseline minimal lumen diameters (MLD) (1.05 +/- 0.35 vs 0.92 +/- 0.32; mm p <0.0001) than the ARTREK system. The final and follow-up RD (+0.17 and +0.11 mm, respectively) were also larger using the CMS system. In contrast, the final and follow-up measurements of MLD and percent diameter stenosis were not significantly different using the 2 QA systems. The QA system did not affect the ability to detect a difference in restenosis rates (>50% follow-up diameter stenosis) between the 2 treatment groups (CMS, directional atherectomy [31.8%]; balloon angioplasty [40.5%]; p = 0.013 and ARTREK, directional atherectomy [33.9%], balloon angioplasty [41.3%]; p = 0.036). Only lesion irregularity contributed to the difference in baseline measurements of MLD and percent diameter stenosis. We conclude that important differences in measurements of RD, baseline MLD, and percent diameter stenosis were noted using the CMS and ARTREK systems. Both systems, however, were able to detect a treatment benefit associated with directional atherectomy in BOAT. The comparability of other angiographic systems will require similar evaluation in other studies.

Algorithms↗
PubMed2001

Treatment of diffuse in-stent restenosis with rotational atherectomy followed by radiation therapy with a rhenium-188-mercaptoacetyltriglycine-filled balloon.

OBJECTIVES: This study was done to evaluate the feasibility and efficacy of beta-radiation therapy with a rhenium-188-mercaptoacetyltriglycine ((188)Re-MAG(3))-filled balloon after rotational atherectomy for diffuse in-stent restenosis (ISR). BACKGROUND: Rotational atherectomy has been shown to be safe and efficient for the treatment of ISR, but the recurrence rate is still high. Intracoronary beta-irradiation after rotational atherectomy may be a reasonable approach to prevent recurrent ISR. METHODS: Fifty consecutive patients with diffuse ISR (length >10 mm) in native coronary arteries underwent rotational atherectomy and adjunctive balloon angioplasty, followed by beta-irradiation using a (188)Re-MAG(3)-filled balloon catheter. The radiation dose was 15 Gy at a depth of 1.0 mm into the vessel wall. RESULTS: The mean lengths of the lesion and irradiated segment were 25.6 +/- 12.7 mm and 37.6 +/- 11.2 mm, respectively. Radiation was delivered successfully to all patients, with a mean irradiation time of 201.8 +/- 61.7 s. No adverse event, including myocardial infarction, death or stent thrombosis, occurred during the follow-up period (mean 10.3 +/- 3.7 months), and nontarget vessel revascularization was needed in one patient. The six-month binary angiographic restenosis rate was 10.4%, and the loss index was 0.17 +/- 0.31. CONCLUSIONS: Beta-irradiation using a (188)Re-MAG(3)-filled balloon after rotational atherectomy is safe and feasible in patients with diffuse ISR, and it may improve their clinical and angiographic outcomes. Further prospective, randomized trials are warranted to evaluate the synergistic effect of debulking and irradiation in patients with diffuse ISR.

Atherectomy, Coronary↗
PubMed1998

Adjunctive stent implantation following directional coronary atherectomy in patients with coronary artery disease.

OBJECTIVES: This prospective case-control study evaluated the acute and long-term results of stent implantation preceded by debulking of the plaque by means of directional coronary atherectomy. BACKGROUND: In comparison with balloon angioplasty, intracoronary stenting produces a larger luminal diameter, maintains artery patency and reduces the incidence of restenosis. Optimal stent deployment is a pivotal factor for achieving the best results, but the bulk of the atherosclerotic plaque opposes stent expansion and may limit the success of the procedure. Debulking of the plaque may provide a better milieu for optimal stent deployment. METHODS: Directional coronary atherectomy followed by a single Palmaz-Schatz stent implantation was attempted in 100 patients. The successes, complications and angiographic results of the combined procedure were evaluated both acutely and during follow-up. Matched patients undergoing successful Palmaz-Schatz stent implantation alone during the same period served as controls. RESULTS: Atherectomy followed by stent implantation was performed in 94 patients with 98 lesions; periprocedural complications were observed in four cases. The stenosis diameter decreased from 76+/-9% at baseline to 30+/-13% after atherectomy (p < 0.0001), and 5+/-9% after stent implantation (p < 0.0001); it increased to 27+/-15% at 6-month angiography (p < 0.0001). During the 14+/-10 months of follow-up, none of the patients died or experienced myocardial infarction, but three patients underwent target lesion revascularization. The patients undergoing stent implantation alone achieved smaller acute gains, tended to have a higher late lumen loss, had a higher restenosis rate (30.5% vs. 6.8%, p < 0.0001) and showed a greater incidence of clinical events during follow-up (p < 0.0001). CONCLUSIONS: Debulking atherosclerotic lesions by means of directional coronary atherectomy before stent implantation is a safe procedure with a high success rate and a low incidence of restenosis at follow-up.

Atherectomy, Coronary↗
PubMed1999

Mechanisms of acute lumen gain and recurrent restenosis after rotational atherectomy of diffuse in-stent restenosis: a quantitative angiographic and intravascular ultrasound study.

OBJECTIVES: This quantitative angiographic and intravascular ultrasound study determined the mechanisms of acute lumen enlargement and recurrent restenosis after rotational atherectomy (RA) with adjunct percutaneous transluminal coronary angioplasty in the treatment of diffuse in-stent restenosis (ISR). BACKGROUND: In-stent restenosis remains a significant clinical problem for which optimal treatment is under debate. Rotational atherectomy has become an alternative therapeutic approach for the treatment of diffuse ISR based on the concept of "tissue-debulking." METHODS: Rotational atherectomy with adjunct angioplasty of ISR was used in 45 patients with diffuse lesions. Quantitative coronary angiographic (QCA) analysis and sequential intravascular ultrasound (IVUS) measurements were performed in all patients. Forty patients (89%) underwent angiographic six-month follow-up. RESULTS: Rotational atherectomy lead to a decrease in maximal area of stenosis from 80+/-32% before intervention to 54+/-21% after RA (p < 0.0001) as a result of a significant decrease in intimal hyperplasia cross-sectional area (CSA). The minimal lumen diameter after RA remained 15+/-4% smaller than the burr diameter used, indicating acute neointimal recoil. Additional angioplasty led to a further decrease in area of stenosis to 38+/-12% due to a significant increase in stent CSA. At six-month angiographic follow-up, recurrent restenosis rate was 45%. Lesion and stent length, preinterventional diameter stenosis and amount of acute neointimal recoil were associated with a higher rate of recurrent restenosis. CONCLUSIONS: Rotational atherectomy of ISR leads to acute lumen gain by effective plaque removal. Adjunct angioplasty results in additional lumen gain by further stent expansion and tissue extrusion. Stent and lesion length, severity of ISR and acute neointimal recoil are predictors of recurrent restenosis.

Aged↗
PubMedDate not supplied

Rotational atherectomy.

Rotational atherectomy is used most often to treat stenoses that are calcified, located at an arterial ostium or at the site of a bifurcation, or resulting from in-stent restenosis. The atherectomy device debulks soft and calcified plaque while minimizing injury to adjacent normal arterial segments. In a randomized comparison with excimer laser and balloon angioplasty, rotational atherectomy achieved a statistically higher procedural success rate without an increased incidence of major complications. Patients with lesions that were more complex derived the greatest benefit from rotational atherectomy. To date, rotational atherectomy usually is performed in conjunction with a) the intracoronary infusion of a "cocktail" containing verapamil, heparin, and nitroglycerin; b) the intravenous infusion of a glycoprotein IIb/IIIa receptor antagonist, such as abciximab; c) a stepped burr approach, leading to a burr:artery ratio of 0.8; d) burr rotations <30 seconds in duration; e) avoidance of burr deceleration; and f) low-pressure balloon angioplasty. Under these circumstances, it has a procedural success rate of 98% and a major complication rate of <2%.

Animals↗
PubMed1993

The Bard Rotary Atherectomy System (BRAS): initial experience in patients with peripheral vascular disease.

Sixteen patients with a mean age of 65.4 +/- 9.8 years and suffering from peripheral vascular disease underwent peripheral atherectomy using a new mechanical device--the BARD Rotary Atherectomy System (BRAS). The BRAS is an "over the wire" system that consists of a spiral guidewire and a handheld motor drive unit, which rotates at 1,500 rpm. Prior to the procedure angiography demonstrated the presence of 18 obstructions (1 tibial, 2 popliteal, 15 superficial femoral arteries) with a mean stenosis of 95.7 +/- 8%. Successful atherectomy was achieved in 16 of 18 lesions and resulted in an 89% immediate success rate and a significant (P less than 0.01) reduction of stenosis to 37.8 +/- 12.5%. There were no significant complications. The excised and removed material embedded over the spiral guidewire demonstrated the presence of fibrotic tissue, fatty lesions, and calcium deposits. Medial or adventitial layers were not present in the removed atherosclerotic material. Mean ABI was significantly (P less than 0.01) increased from 0.38 +/- 0.17 to 0.55 +/- 0.21 following atherectomy. Angiographic follow-up obtained in ten patients 8.8 +/- 5.2 months following the procedure demonstrated restenosis in six of those ten patients. The ABI at this time remained unchanged. These results demonstrated that the new BRAS mechanical atherectomy system is feasible and safe for recanalization of severely stenosed arteries in patients with peripheral vascular disease.

Aged↗
PubMed1995

Influence of plaque morphology on the mechanism of luminal enlargement after directional coronary atherectomy and balloon angioplasty.

OBJECTIVE: To relate the mechanism of luminal gain after directional atherectomy and balloon angioplasty to the morphological characteristics of the coronary lesions, assessed by intravascular ultrasound imaging. DESIGN: Intravascular ultrasound imaging was performed before and after the revascularisation procedure to assess the contribution of wall stretching and plaque reduction in luminal gain. SUBJECTS: 32 patients undergoing balloon angioplasty and 29 undergoing directional coronary atherectomy. MAIN RESULTS: The main luminal area in vessels treated by balloon angioplasty increased from 1.51 (SD 0.30) to 3.91 (1.09) mm2 (P < 0.0001) with a concomitant increase in total vessel area from 11.44 (2.73) to 13.07 (2.83) mm2 (P < 0.0001). Therefore stretching of the vessel wall accounted for 68% of the luminal gain while plaque reduction accounted for the remaining 32%. This mechanism ranged from 45% in non-calcific plaques to 81% in echogenic plaques. The main luminal area in vessels treated by directional atherectomy increased from 1.49 (0.32) to 4.68 (1.73) mm2 (P < 0.0001), with a concomitant increase of total vessel area from 13.61 (4.67) to 15.2 (4.04) mm2 (P = 0.006). Thus stretching of the vessel wall accounted for 49% of the luminal area gain and plaque reduction for the remaining 51%. The presence of calcium influenced the relative contribution of these two mechanisms to the final luminal gain after directional atherectomy, since in calcific plaques stretching of the vessel wall accounted for only 9% of the luminal gain as compared to 56% in non-calcific plaques. After balloon angioplasty there was greater evidence of coronary dissections (32% v 3% after directional atherectomy, P < 0.01) and plaque fissure (60% v 0%, P < 0.01). Plaque fissure was more frequently seen in echolucent and concentric lesions, whereas dissections prevailed in echogenic and eccentric lesions. CONCLUSIONS: Intravascular ultrasound imaging may allow the assessment of acute changes in lumen and vessel wall after revascularisation procedures, and help in evaluating the potential effect of the structure and morphology of coronary lesions on the mechanism of luminal enlargement.

Adult↗
PubMed1998

Histopathological correlates of early arterial recoil following directional coronary atherectomy.

Elastic recoil has been implicated in the pathophysiology of restenosis after conventional balloon angioplasty alone. Directional atherectomy may attenuate arterial recoil by removing the internal elastic lamina and medial smooth muscle cells and altering the vessel wall architecture. This study sought to evaluate early recoil after directional atherectomy and its relation with excision of deep arterial wall structures. We prospectively evaluated the correlation of the histopathologic evidence of media or adventitia as assessed in the atheroma retrieved during the procedure with the early changes in minimal lumen diameter after directional atherectomy followed by adjunct balloon dilatation in 50 consecutive cases. Recoil was assessed by routinely performed 1- and 15-min postprocedure angiograms, and patients were divided into two groups according to the absence (group I, n = 26) or presence (group II, n = 24) of recoil. The mean changes in minimal luminal diameter between 1 and 15 min was +0.22 mm in group I and -0.14 mm in group II. The absence of recoil was strongly associated with evidence of media tissue in the pathologic analysis as compared with cases with recoil (42 vs. 18%, respectively; p = 0.02). Similarly, retrieval of adventitia was seen exclusively in the group without recoil (15 vs. 0%; p = 0.06). Vessels that underwent recoil had significantly larger reference and immediate postprocedure minimal luminal diameters (3.62 +/- 0.57 and 3.02 +/- 0.45 mm, respectively) as compared with arteries with no recoil (3.28 +/- 0.35 and 2.75 +/- 0. 43 mm, respectively; p < 0.05 for both). Therefore, early luminal changes, likely related to elastic recoil, correlated with excision of deep wall structures during directional atherectomy. Arteries that showed recoil were larger, possibly due to thicker muscular layer and/or larger plaque burden as compared with arteries that did not recoil. Thus, optimal tissue debulking during directional atherectomy appears to attenuate recoil, providing an additional insight into the mechanism of action of this percutaneous revascularization device.

Angioplasty, Balloon, Coronary↗
PubMed1992

Intravascular ultrasound evaluation of the effect of rotational atherectomy in obstructive atherosclerotic coronary artery disease.

BACKGROUND: High-speed rotational atherectomy uses a diamond-coated, elliptical burr to abrade occlusive atherosclerosis, especially noncompliant calcified plaque. METHODS AND RESULTS: Intravascular ultrasound (IVUS) was used to analyze 28 patients after atherectomy. Arteries treated and imaged were left main (three), left anterior descending (12), left circumflex (five), right coronary (seven), and saphenous vein graft (one). Twenty patients had adjunct balloon angioplasty. Twenty-two (79%) target lesions were calcified; the intimal arc of calcium was 160 +/- 126 degrees (range, 0-360 degrees). After atherectomy, the intima-lumen interface was unusually distinct and circular. The lumen was larger than the largest burr used for both stand-alone (1.19 +/- 0.19-fold the largest burr size) and adjunct balloon procedures (1.30 +/- 0.15-fold the largest burr). Three-dimensional reconstruction of the ultrasound images showed a smooth lumen, especially in calcified plaque. Deviations from cylindrical geometry occurred only in areas of soft plaque or superficial tissue disruption of calcified plaque. Five patients were studied before and after rotational atherectomy. IVUS showed an increase in lumen size, a decrease in plaque-plus-media area and in arc of target lesion calcification, and no change in target lesion external elastic membrane cross-sectional area. CONCLUSIONS: Rotational atherectomy causes atheroablation with only moderate evidence of barotrauma in heavily calcified arteries, even after adjunct balloon angioplasty. The lumen is cylindrical, especially in areas of calcified plaque, and somewhat larger than the largest burr tip used.

Angioplasty, Balloon, Coronary↗
PubMed1992

Restenosis after directional coronary atherectomy. Effects of luminal diameter and deep wall excision.

BACKGROUND: Deep wall excision during directional atherectomy has been reported in one study to increase the risk of subsequent restenosis. On the other hand, we have observed that the probability of late (6-month) restenosis is reduced by maximizing postprocedure luminal diameter. Although such maximal luminal enlargement by directional atherectomy has not increased procedural complications in our experience, it might well increase the incidence of subintimal (deep wall component) recovery. We performed this study to evaluate the relative influences of luminal enlargement and deep wall component excision on postatherectomy restenosis. METHODS AND RESULTS: Atherectomy resulted in a 7 +/- 15% residual stenosis with < 0.5% incidence of angiographic vessel perforation. The minimal luminal diameter of each lesion was measured before and after intervention in 413 lesions, 389 (94%) of which had histological analysis of the excised specimens. Specimens were categorized by the deepest layer retrieved: type I (recovery of intima alone, n = 141), type II (recovery of media, n = 79), and type III (recovery of adventitia, n = 65). Repeat angiographic measurement of minimal luminal diameter was available for 329 (80%) segments 6 months after atherectomy. Compared with the 32% restenosis rate for type I excision, there was no increase in restenosis (stenosis > 50%) for type II, type III, or types II+III (p = 0.86). Stratification by vessel characteristics also failed to show any association between restenosis and deep wall component recovery in any subgroup, including native coronary (p = 0.85), left anterior descending coronary artery (p = 0.70), right coronary artery (p = 0.51), saphenous graft (p = 0.78), or prior restenosis lesions (p = 0.98). Paradoxically, the recovery of adventitia (type III excision) was associated with a lower late percent stenosis (p = 0.03) and a trend toward less restenosis (p = 0.11) compared with type I excisions. A multiple logistic regression model was constructed that demonstrated immediate postprocedure luminal diameter (p = 0.02) to be an independent determinant of restenosis. In this model, the presence of deep wall components (type II+III) did not adversely affect (p = 0.86) restenosis, but the recovery of adventitia was associated with an independent trend toward reduced restenosis (p = 0.06). CONCLUSIONS: The immediate goal of directional atherectomy should be to safely provide the largest lumen possible in order to reduce restenosis. The recovery of deep wall components does not appear to jeopardize the beneficial effect that obtaining a large immediate postprocedure lumen diameter has on reducing the incidence of late restenosis.

Atherectomy, Coronary↗
PubMed1997

Randomized comparison of angioplasty of complex coronary lesions at a single center. Excimer Laser, Rotational Atherectomy, and Balloon Angioplasty Comparison (ERBAC) Study.

BACKGROUND: The purpose of this study was to test whether coronary revascularization with ablation of either excimer laser or rotational atherectomy can improve the initial angiographic and clinical outcomes compared with dilatation (balloon angioplasty) alone. METHODS AND RESULTS: At a single center, a total of 685 patients with symptomatic coronary disease warranting elective percutaneous revascularization for a complex lesion were randomly assigned to balloon angioplasty (n = 222), excimer laser angioplasty (n = 232), or rotational atherectomy (n = 231). The primary end point was procedural success (diameter stenosis < 50%, absence of death, Q-wave myocardial infarction, or coronary artery bypass surgery). The patients who underwent rotational atherectomy had a higher rate of procedural success than those who underwent excimer laser angioplasty or conventional balloon angioplasty (89% versus 77% and 80%, P = .0019), but no difference was observed in major in-hospital complications (3.2% versus 4.3% versus 3.1%, P = .71). At the 6-month follow-up, revascularization of the original target lesion was performed more frequently in the rotational atherectomy group (42.4%) and the excimer laser group (46.0%) than in the angioplasty group (31.9%, P = .013). CONCLUSIONS: Procedural success of rotational atherectomy is superior to laser angioplasty and balloon angioplasty; however, it does not result in better late outcomes. The role of plaque debulking before balloon dilatation in percutaneous coronary revascularization remains to be fully defined.

Adult↗
PubMed1992

Directional coronary atherectomy at the Toronto and Mount Sinai Hospitals: report of the initial 120 procedures.

OBJECTIVE: To assess the procedural success and complication rates of the first 120 directional coronary atherectomy cases performed at two Toronto hospitals. DESIGN AND SETTING: Case series in tertiary referral centres. PATIENTS: One hundred and thirteen patients in whom 120 atherectomy procedures were attempted between July 1990 and April 1992. INTERVENTION: Directional coronary atherectomy. MAIN RESULTS: Angiographic success was obtained in 115 of 120 procedures (96%) involving 117 of 123 lesions (95%). Procedural success (angiographic success without death, myocardial infarction or coronary bypass surgery) was obtained in 110 of 120 procedures (92%). Adjunctive balloon angioplasty was required in 20 procedures (17%). There was one death at 36 h in an elderly patient who underwent an emergency procedure while in cardiogenic shock. Periprocedural non-Q wave myocardial infarction occurred in five patients. There were no Q wave myocardial infarctions. Three patients required coronary bypass surgery prior to discharge and vascular complications occurred in five patients. CONCLUSIONS: Directional coronary atherectomy can be performed with procedural success and complication rates comparable to conventional balloon angioplasty. Randomized trials are underway to determine if atherectomy results in a lower restenosis rate.

Adult↗
PubMed1992

Directional coronary atherectomy in lesions unfavourable for balloon angioplasty: initial Green Lane and Mercy Hospitals experience.

AIMS: directional coronary atherectomy is a new percutaneous interventional technique in which coronary arterial stenotic material is shaved off to alleviate stenosis. This study presents the initial outcome of coronary atherectomy at Green Lane and Mercy hospitals where the major indications for atherectomy are lesions with angiographic appearances unfavourable for balloon angioplasty or where balloon angioplasty had been unsuccessful. METHODS: data on patients undergoing coronary atherectomy between February 1990 and December 1991 were analysed. No patient or procedure was excluded. RESULTS: for the first 28 lesions in 25 patients, procedural success, improvement in lumen diameter to less than 50% diameter loss stenosis, but freedom from myocardial infarction, death or emergency bypass surgery, was achieved in 27 of 28 lesions. In one patient there was acute thrombotic coronary arterial closure treated successfully by balloon angioplasty. Another patient developed an asymptomatic fistulous connection with an adjacent coronary vein which resolved spontaneously. CONCLUSIONS: although technically more difficult than balloon angioplasty, directional coronary atherectomy can be carried out in selected patients with a high initial success rate and low complication rate. The technique has allowed percutaneous treatment of a number of selected patients unsuitable for balloon angioplasty, and has turned an unsuccessful angioplasty into an initial procedural success in others.

Adult↗
PubMed2005

Directional coronary atherectomy in 2005.

The original aim of atherectomy was to reduce restenosis by means of aggressive plaque debulking, and the failure of large randomized trials to show any advantage of atherectomy over balloon angioplasty restricted its wider application. However, single-center registries in which aggressive debulking was performed by experienced operators have reported favorable results in terms of reduced restenosis and improved clinical outcomes when atherectomy was performed before stenting. Plaque debulking reduces the potential for plaque shift and facilitates subsequent high-pressure stent expansion, smoothes the internal vessel surface, scaffolds intimal flaps, and prevents elastic recoil. It has also been demonstrated that atherectomy can play a role in the treatment of complex lesions (ostial left anterior descending coronary artery lesions, left main lesions, and bifurcations), in which plaque shift may compromise the result of the procedure. New-generation devices have shown that atherectomy can be safely and effectively used to treat even relatively small vessels. In the current era of drug-eluting stents characterized by a considerable reduction in restenosis rates, optimal stent geometry and final luminal diameter are still important predictors of restenosis. Given the possible role of plaque shifting at the edges of a stent in causing restenosis, debulking could be added to the local drug effect in complex lesions.

Atherectomy, Coronary↗
PubMed1994

[Transluminal atherectomy for occlusive peripheral vascular disease: preliminary results].

We studied the preliminary results of atherectomy of atherosclerotic lesions involving the lower extremities in 10 patients. Fifteen arterial stenotic lesions, five iliac, eight superficial femoral, one popliteal, and one anterior tibial, were treated. Five lesions were re-stenoses after balloon angioplasty, while the remaining lesions were previously untreated primary stenoses. For atherectomy, over-the-wire atherectomy catheters ranging in size from 7 to 10-F were used. Balloon angioplasty was also performed in cases 3, 6 and 9. Atherectomy was considered a success in all patients based on angiographic and clinical criteria. Complications occurred in three patients: intimal dissection, distal embolism and arterial spasm. In the patients with distal embolism, a surgical approach was required to remove the embolus. The internal elastic lamina or media was resected in 10 lesions on the histopathologic specimens. Although further assessment of complications and long-term results is required, these results suggest that atherectomy is useful for treating occlusive peripheral vascular disease.

Aged↗