Comparison of Clinical and Angiographic Outcomes After Bare Metal Stents and Drug-Eluting Stents Following Rotational Atherectomy

Abstract

SummaryFew studies have investigated the clinical outcomes of rotational atherectomy (RA) prior to and during the drugeluting stent (DES) era. The goal of this study was to assess the long-term outcome after RA followed by DES and bare metal stent (BMS) implantation in complex calcified coronary lesions and to compare the outcomes among various DESs.This was a single center retrospective observational study. Consecutive 406 patients who underwent elective RA followed by BMS or DES implantation at our institution from 2001 to 2011 were included. This study compared the long-term outcomes after treatment with RA among BMS and 3 different DESs (sirolimus-eluting stent, paclitaxel-eluting stent, and everolimus-eluting stent) implantation.The mean follow-up period was 4.6 years. Patients with DES were older and exhibited more vessel disease, longer lesion length, and smaller vessel size. Patients with BMS had a significantly higher rate of target lesion revascularization, restenosis, and larger late lumen loss than those with DES. Composite events including mortality, ACS, and target vessel revascularization were significantly higher in the BMS-RA group than in the DES-RA group. After adjustment, BMS remained an independent predictor of MACE and ACS plus death in patients treated with RA. However, there were no significant differences in late lumen loss, restenosis rate, and MACE among the 3 DES.The combination of DES-RA has a favorable effect in both the angiographic and clinical outcomes compared with BMS-RA. However, no significant differences in late loss and events rates were observed among the 3 DES groups. (Int Heart J 2016; 57: 150-157) Key words: Rotablator, Percutaneous coronary intervention, Clinical outcome P revious studies have shown that drug-eluting stents (DES) have reduced revascularization in a wide range of patient and lesion subsets compared to bare-metal stents (BMS).1-3) However, higher event rates are observed when treating complex lesions compared with simple lesions even with DES. [4][5][6] Therefore, the treatment of complex lesions still remains among the few technically challenging fields. One typical example of a complex lesion is diffuse severe calcified lesions. Rotational atherectomy (RA) can facilitate percutaneous coronary intervention (PCI) in calcified lesions through plaque remodeling and increasing its distensibility. 7,8) However, few studies have investigated the clinical outcomes of RA prior to and during the DES era. Multiple types of DES including sirolimus-eluting stents (SES), paclitaxel-eluting stents (PES), and everolimus-eluting stents (EES) were available. The goals of this study were to assess the long-term outcome of DES after RA compared with BMS after RA in complex calcified coronary lesions and to compare the long-term outcomes of SES, PES, and EES after RA.

Rotational atherectomy and new‐generation drug‐eluting stent implantation

“…Recent studies with new‐generation DESs have shown improved outcomes and superior safety profiles compared to that for earlier stents . However, there are limited data regarding the clinical outcomes of RA followed by new‐generation DES implantation . To improve outcomes, adequate lesion preparation before stent implantation is essential for patients with complex anatomy .…”

When a Burr Can Not Penetrate the Calcified Lesion, Increasing Burr Size as Well as Decreasing Burr Size Can Be a Solution in Rotational Atherectomy

“…1,2) While there are several burr sizes such as 1.25 mm, 1.5 mm, 1.75 mm, and ≥ 2.0 mm, it is important to select the appropriate burr size for each lesion because RA has several unique complications regarding burrs such as entrapment or perforation. [3][4][5] Small burrs (1.25 mm or 1.5 mm) are more preferable than large burrs (1.75 mm or 2.0 mm) in current PCI 1,6) because the indication for RA is mostly lesion modification followed by drug-eluting stent (DES) implantation.…”

Difficult Stentablation with an Episode of Stuck and Entrapped Burr within the Underexpanded Stent

“…Several authors have reported that RA followed by stent implantation is a feasible method in terms of high rate of procedural success and favorable long-term outcomes in heavily calcified coronary lesions. [2][3][4][5][6] It is difficult to recognize underexpansion of the balloon and adequate lesion preparation before stenting. IVUS before stenting can help to avoid underexpansion of the stent without sufficient lesion preparation.…”

“…1) If there is a calcified lesion with insufficient expansion after ballooning with non-compliant balloons, rotational atherectomy (RA) is one of the available options for pretreatment of calcified plaques. [2][3][4][5][6] RA might also be used to remove an underexpanded stent. However, there are several problems associated with RA for removal of underexpanded stents.…”