Feasibility and safety of orbital atherectomy for the treatment of in‐stent restenosis secondary to stent under‐expansion

Abstract

Background: Debulking and ablative techniques are sometimes used for the treatment of in-stent restenosis (ISR) secondary to resistant stent under-expansion (SU). The safety and effectiveness of orbital atherectomy (OA) in this cohort of patients has not been reported. Methods: We retrospectively evaluated consecutive patients treated with OA for ISR secondary to balloon undilatable SU at two academic tertiary care centers between October 2016 and June 2019. Angiographic or intravascular imaging identified SU. Technical success was defined as residual 0% stenosis with TIMI III flow. Results: A total of 41 patients were included in the study. Patients had an average age of 65 ± 12 years; 73% male, 61% diabetic, 41% with prior coronary artery bypass grafting, 61% with a prior incident of ISR, 51% presented with stable angina, 17% unstable angina, and 32% non-ST elevation myocardial infarction (MI). Implantation of the under-expanded stents occurred between 2 months and 22 years prior to the index procedure. A total of 27% of patients had multiple layers of stents in the target lesion and 32% of patients had in-stent chronic total occlusion. Technical success was achieved in 40 (98%) patients. There were 2 (5%) major adverse cardiovascular events; both of them were periprocedural MI from the no-reflow phenomenon. There were 2 (5%) Ellis type II coronary perforations that required no intervention. Conclusions: OA can be effectively performed as an adjunctive tool in the treatment of ISR with balloon undilatable SU. The use of OA for SU is not approved by the U.S. Food and Drug Administration and is "off label" and caution must be used to limit any device/stent interaction.

Procedural and 1‐year clinical outcomes of orbital atherectomy for treatment of coronary in‐stent restenosis: A single‐center, retrospective study

“…Cutting balloon angioplasty, rotational atherectomy, laser atherectomy with contrast medium and coronary lithoplasty have been used as treatment of ISR due to underexpanded stents 24‐27 . A recent report on OA for ISR secondary to stent underexpansion demonstrated that OA can be performed in these cases and warned about a possibility of device/stent interaction 9 . Our included case of OCT‐guided OA demonstrated that the ISR was caused by both stent underexpansion and concentric neointimal hyperplasia.…”

“…We have described the use of OA for the treatment of calcified bifurcation lesions 8 . Recently feasibility and safety of OA for treatment of ISR secondary to stent underexpansion is reported, however the use of OA for ISR is still off‐label and long‐time clinical outcomes have not been described 9 . In the present study we retrospectively assessed the procedural and 1‐year clinical outcomes of OA in 87 ISR lesions.…”

Shockwave intravascular lithotripsy in the treatment of under‐expanded coronary stent: Case Series

“…Orbital atherectomy can be effectively performed as an adjunctive tool in the treatment of under‐expanded stent, as shown in a retrospective study. 18 …”

Between a rock and a hard place: Orbital atherectomy for under‐expanded stents

“…In this issue of CCI, Neupane et al describe a series of 41 patients treated with OA for ISR due to stent under-expansion. 4 The majority of patients were diabetic, had prior ISR and in 32% of patients the ISR resulted in a chronic total occlusion. No data were provided on the duration of procedure or number of OA runs, however, at least one high-speed run was performed in all cases.…”

“…In this issue of CCI, Neupane et al describe a series of 41 patients treated with OA for ISR due to stent under‐expansion 4 . The majority of patients were diabetic, had prior ISR and in 32% of patients the ISR resulted in a chronic total occlusion.…”