Detailed angiographic analysis of high-speed mechanical rotational atherectomy in human coronary arteries.

Abstract

BACKGROUND Several types of atherectomy devices have been developed recently for treatment of patients with ischemic heart disease. METHODS AND RESULTS Mechanical rotational atherectomy (MRA) using a high-speed rotational burr (Rotablator) was performed on 116 lesions in 104 patients. MRA alone was performed in 27 lesions (23%), and conventional balloon angioplasty (PTCA) was performed after MRA in 89 lesions (77%). Diameter stenosis decreased from 70 +/- 13% before MRA to 54 +/- 23% after MRA, and the final diameter stenosis (after MRA alone or with adjunctive PTCA) was 30 +/- 20% (P < .001). Minimal lumen diameter increased from 1.0 +/- 0.5 mm before MRA to 1.4 +/- 0.7 mm after MRA, and the final minimal lumen diameter was 2.3 +/- 0.7 mm (P < .001). MRA resulted in a decrease in diameter stenosis of 20% or more in 44% of lesions, and the final diameter stenosis (after MRA alone or after PTCA) was less than 50% in 75% of lesions. Considering the small diameter of available burrs, the magnitude of lumen enlargement was equal to 91% of the burr diameter, and only 9% of the burr diameter was "lost" due to elastic recoil or spasm. These angiographic results were obtained despite the presence of complex lesion morphology, including the presence of calcification in 17% of lesions and ostial location in 26% of lesions. Significant angiographic complications included abrupt closure (13 lesions, 11.2%), no reflow (8 lesions, 7%), severe coronary vasospasm (16 lesions, 13.8%), and guide wire fracture (3 lesions, 2.7%). There were no coronary artery perforations. Adjunctive therapy, including salvage PTCA, thrombolytic agents, and vasodilators, was successful in treating angiographic complications in 42 of 49 lesions (86%). Clinical complications included Q-wave myocardial infarction (5 patients, 4.8%), non-Q-wave myocardial infarction (3 patients, 2.9%), femoral vascular injury requiring surgery (3 patients, 2.9%) or blood transfusion (8 patients, 7.7%), abrupt closure requiring emergency bypass graft surgery (2 patients, 1.9%), and in-hospital death (1 patient, 1.0%). Angiographic follow-up (mean follow-up interval, 5.0 +/- 2.0 months) was available in 84% of successfully treated patients and revealed a restenosis rate of 51%, defined as a residual diameter stenosis of more than 50%. There was no significant difference in restenosis rates between de novo lesions (50%) and restenosis (54%) lesions. CONCLUSIONS These data suggest that for the treatment of most coronary stenoses, PTCA is required after MRA to achieve satisfactory lumen enlargement or to salvage complications. Angiographic complications appear to be more common after MRA, and salvage PTCA often is required to manage these device-induced complications. The combination of MRA and PTCA does not prevent restenosis.

Right ventricular infarction following percutaneous coronary rotational atherectomy

“…Safian et al [7] reported Q-wave myocardial infarction following rotational atherectomy to be 4.8% and side branch occlusion to be 2.7% in a series of 116 lesions when both rotational atherectomy and balloon angioplasty were used together, as was done in our patient. Although most would agree that adjunctive balloon angioplasty should be performed following rotational atherectomy to increase immediate patency and treat complications such as dissection [7,8], Safian et al 171 noted that restenosis, which in their study was 51% at 3-6 mo, was not prevented.…”

“…Although most would agree that adjunctive balloon angioplasty should be performed following rotational atherectomy to increase immediate patency and treat complications such as dissection [7,8], Safian et al 171 noted that restenosis, which in their study was 51% at 3-6 mo, was not prevented.…”

Society of cardiac angiography and interventions: Suggested management of the no‐reflow phenomenon in the cardiac catheterization laboratory

“…It occurs frequently following thrombolytic or mechanical reperfusion for acute myocardial infarction and in the setting of unstable angina [3,7,8]. It is most common during use of rotational atherectomy [9,10] and during PCI in saphenous vein grafts [2]. The purpose of this review is to define the angiographic appearance and clinical outcomes of no-reflow and to summarize the various treatment and prevention options currently available to the interventional cardiologist.…”

Effects of technique modification on immediate results of high speed rotational atherectomy in 710 procedures on 656 patients

“…flap, or emboli in affected arteries [5,7,11,13,161. Despite the 5 years of widespread application of this treatment mode, the technique of HSRA is still subject to individual operator variation, both in stand alone and in adjunctive balloon angioplasty procedures.…”