Efficacy of directional coronary atherectomy in cases unsuitable for percutaneous transluminal coronary angioplasty (PTCA) and after unsuccessful PTCA.

Directional coronary atherectomy (DCA) was used in 10 female and 50 male patients with an average age of 58 years. They were categorized into three different groups depending on the indications for atherectomy. Group 1 included all patients who had atherectomy as their primary intervention (n = 20) because they were assumed to be unsuitable for percutaneous transluminal coronary angioplasty (PTCA). Group 2 consisted of patients in whom DCA was used after failed balloon dilatation with unsuccessful but uneventful treatment (n = 17). Group 3 (n = 23) included patients in whom DCA was performed as a "rescue" or "bailout" procedure after unsuccessful PTCA resulting in critical ischemia (ECG changes, chest pain, hypotension, and shock). The target lesions were located in the left main artery in two, left anterior descending artery in 43, right coronary artery in 15, and aortocoronary venous bypass in five. The mean length of the lesions was 8 mm (2 to 25 mm). The overall success rate for 65 lesions was 92%. The mean stenosis was reduced from 87 +/- 12% to 19 +/- 17% in patients with primary success. Presently available follow-up angiograms (30) showed six restenoses. Major complications occurred in seven patients (myocardial infarction in two and coronary artery bypass graft surgery within 24 hours in five); there were no deaths. Our results show that DCA is a safe and effective technique that can extend the use of percutaneous procedures and provide a promising nonsurgical option in cases of unsuccessful PTCA.     

Percutaneous transluminal coronary angioplasty. A report of 100 cases

Percutaneous transluminal coronary angioplasty (PTCA) was performed in 100 coronary heart patients with 122 vessels and 138 lesions dilated. Among these 100 cases, there were 39 complex PTCA performed. The primary success rate was 93% (93/100), was 94.3% (115/122) according to vessel dilated and was 92.1% (127/138) according to lesion dilated. In 4 cases whose lesions were located at the bifurcation of the vessel, kissing balloon technique via a single guiding catheter was applied with success. In 5 cases of total occlusion PTCA was performed with success in 4. PTCA with stent in 1. PTCA was performed in 1 cases of high risk whose LVEF was only 30% and coronary hemoperfusion pump was used during the procedure. Emergency PTCA was performed in 3 AMI patients during the acute phase and elective PTCA in 8 AMI cases after successful thrombolytic therapy. There were complications in 9 cases (9%). Among these 9 cases, 2 developed O-wave MI which recovered after medicinal therapy. One AMI complicated with heart failure was treated by emergency PTCA with success, but the patient died 10 days after PTCA due to pump failure and pulmonary infection. There were no deaths due to PTCA, nor was emergency coronary artery bypass graft (CABG) performed. These cases were followed for 1-30 months on an average of 13 months. Clinical success rate was 91.3%. The clinical success rate was 93.1% by 201Tl perfusion study. Restenosis in 7 cases was confirmed by coronary angiography. For these restenotic cases, PTCA was repeated with success in 4, CABG performed in 1, coronary atherectomy in 1, and medicinal therapy employed in 1 patient.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous transluminal coronary angioplasty in multilesion disease: complete versus incomplete revascularization

We report the results of percutaneous transluminal coronary angioplasty (PTCA) in the first 200 consecutive patients to undergo this procedure for multilesion coronary disease at Dunedin Hospital. In Group I, which consisted of 86 patients (67 men and 19 women, with a mean age of 56 years), complete revascularization of 228 lesions (2.7 lesions per patient) was undertaken. Primary success was achieved in 217 lesions (95%) in 78 patients (91%). There were five major complications, including myocardial infarction in four cases (5%) and emergency coronary artery bypass grafting (CABG) for failed PTCA in one case (1%). In Group II, which comprised 114 patients (82 men and 32 women, with a mean age of 57 years), partial revascularization of 186 lesions (1.6 lesions per patient) was attempted. Primary success was achieved in 165 lesions (89%) in 96 patients (84%). There were nine major complications, including myocardial infarction in two cases (2%), emergency CABG for failed PTCA in four cases (4%), and in-hospital death in three cases (3%). During a follow-up period ranging from 3 to 38 months (mean, 11 months), 16 (20%) of the patients in Group I and 16 (18%) of those in Group II have had recurrent angina and/or restenosis. Twenty-five of these patients have undergone repeat PTCA, with primary success in 24 cases (96%), and six have undergone elective CABG. There has been only one late death (0.6%) after successful PTCA. Complications occurred more frequently in patients with unstable angina (10.0%) and postinfarction angina (19.0%) than in those with stable angina (1.4%). However, the complication rate for multilesion PTCA has become increasingly lower until it now equals that associated with single-vessel PTCA at this institution (about 4% overall).     

Multicenter clinical experience with rescue atherectomy for failed angioplasty

Directional coronary atherectomy (DCA) has been proposed as a “rescue” technique for failed or suboptimal percutaneous transluminal coronary angioplasty (PICA) in an attempt to avoid myocardial infarction or emergency coronary artery bypass grafting. In this report we review the utilization and outcome of rescue atherectomy from the clinical experience of The Cleveland Clinic Foundation and Medical College of Virginia from November 1988 through January 1993, and from the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) database. This analysis includes 100 patients with 103 treated lesions from 44 patients at the Cleveland Clinic, 36 patients from the Medical College of Virginia, and 20 patients from the CAVEAT database. The etiology of failed PICA was primarily from dissection in 52 lesions (50.5%), “recoil” in 43 lesions (41.8%), and recurrent thrombosis in 8 lesions (7.8%). Complete vessel closure was present in 23 lesions (22.3%). The vessels treated included 51.5% left anterior descending, 24.3% right coronary, and 16.5% circumflex coronary arteries. The average reference vessel diameter in the group was 3.10 ± 0.06 mm (SEM), with an average stenosis of 78.9 ± 1.2 % before PTCA, 55.8 ± 2.4 after PTCA, and 24.1 ± 2.2% after rescue DCA. DCA was successful (Thrombosis in Myocardial Infarction [TIMI] grade 3 flow with >20% stenosis reduction without death, Q-wave myocardial infarction, or coronary artery bypass grafting) in 94 of 103 lesions (91.3%). Complications included 1 patient with perforation (1%), 2 deaths within 24 hours (2.0%), and 6 patients requiring coronary artery bypass grafting (6%). In 33 patients with TIMI grade 0–2 flow or acute closure after PTCA, TIMI grade 3 flow was restored in 30 (90.9%). Rescue atherectomy thus may play a beneficial role in the treatment of acute angioplasty complica tions and/or suboptimal results, although vessel perforation is an uncommon complication.     

Right coronary ostial atherectomy: A really close shave

Percutaneous transluminal coronary balloon angioplasty (PTCA) has had limited success with higher complication and restenosis rates in aorto-ostial lesions. Directional coronary atherectomy (DCA) has been advocated as an alternative to PTCA in such lesions. In this report, we describe a potential complication of DCA in right coronary ostial lesions.     

冠状动脉旋磨术在冠心病钙化病变介入治疗中的应用

目的探讨冠状动脉旋磨术治疗冠状动脉钙化病变的安全性及有效性。方法回顾性分析12例行冠状动脉旋磨术结合冠状动脉球囊成形术和支架植入术的冠状动脉粥样硬化性心脏病(冠心病)患者的临床资料,着重分析手术方法、手术成功率、术后随访主要心血管事件(包括心源性死亡、心肌梗死、靶病变血运重建)的发生率。结果 12例患者共有16处钙化病变,有15处钙化病变行冠状动脉旋磨术,管腔狭窄由术前的87%±10%减少至42%±9%,结合冠状动脉球囊成形术,共植入18枚国产药物支架,手术成功率为93.75%(15/16)。1例因血管严重扭曲,球囊扩张后出现冠状动脉夹层,植入支架失败,建议行外科冠状动脉旁路移植术。术中均无主要并发症(包括心源性死亡、Q波心肌梗死、急诊冠状动脉旁路移植术)发生。所有患者随访(8.4±3.6)个月,有2例再发心绞痛,无主要心血管事件(包括心源性死亡、心肌梗死、靶病变血运重建)发生。5例患者复查冠状动脉造影,有1例出现支架内再狭窄30%。结论冠状动脉旋磨术联合球囊扩张和支架植入术治疗冠状动脉钙化病变可取得很高的手术成功率,是治疗钙化病变安全、有效的方法。     

Comparison of acute elastic recoil after directional coronary atherectomy versus standard balloon angioplasty.

We evaluated intraprocedural "elastic recoil" in 25 patients (22 men and 3 women) undergoing directional coronary atherectomy (DCA) of left anterior descending stenoses, and compared these with 25 temporally-matched (14 men and 11 women) patients having balloon angioplasties (PTCA). Quantitative arteriography was performed using the Coronary Measurement System (Leiden, The Netherlands), with "elastic recoil" defined as the difference in maximum device or balloon size minus residual minimum diameter. In addition, we determined the effects of relative device size, specific anatomic location (proximal/mid artery), lesion length, eccentricity (symmetry index), and dystrophic calcification on acute "recoil" severity after both procedures. Although initial coronary stenoses were similar (minimum stenotic diameter, DCA = 0.59 +/- 0.20 mm versus PTCA = 0.55 +/- 0.23 mm, p = NS), less "elastic recoil" was observed after atherectomy (DCA = 0.83 +/- 0.57 mm versus PTCA = 1.26 +/- 0.56 mm, p < 0.01), and this was confirmed by absolute recoil/maximum device size ratios (DCA = 23.5 +/- 16.0% versus PTCA = 41.6 +/- 13.8%, p < 0.01). Acute "elastic recoil" was also influenced by maximum device size/"normal" coronary artery ratios [(ratio < 0.9, DCA = 0.26 +/- 0.10 mm versus PTCA = 0.84 +/- 0.13 mm, p < 0.01); (ratio 0.9 to 1.1, DCA = 0.69 +/- 0.41 mm versus PTCA 0.75 +/- 0.32 mm, p = NS); (ratio > 1.1, DCA = 1.09 +/- 0.64 mm versus PTCA = 1.59 +/- 0.48 mm, p < 0.05)].(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary directional atherectomy: rescue for failed balloon angioplasty and treatment of complicated lesions

Balloon angioplasty of the coronaries is still limited by the problems of acute complication and restenosis. Percutaneous directional atherectomy was conceived as a method to remove obstructive material from within the vessel. After encouraging results were obtained in peripheral vessels, coronary atherectomy has been selectively performed in 25 patients with lesions either not well suited for PTCA (n = 11), or as a bail-out after resistant (n = 2) or failed PTCA (n = 12). Twenty-one LAD lesions (4 ostial, 13 proximal, 2 mid, and 2 bifurcation) and four right coronary artery (RCA) lesions with a mean length of 9 ± 6 mm (19 eccentric, and 6 concentric) could be effectively reduced from 90%± 72% to 18%± 22%. Seventy-five percent of rescue cases could be spared emergency bypass operation. At 6 months, angiographic restenosis has been documented in 3 out of 11 patients studied to date (27%). Histologically, rescue procedures resulted in the removal of obstructing plaque material and only minimal thrombus. The occurrence of two perforations during rescue procedures, although clinically insignificant, emphasizes the need for judicious excision. In summary, directional atherectomy appears to be useful to treat lesions not well suited for PTC A, and important as a bail-out method after failed PTCA.     

Acute and long-term outcome of failed percutaneous transluminal coronary angioplasty treated by directional coronary atherectomy

Since its initial performance, balloon percutaneous transluminal coronary angioplasty (PTCA) has been limited by a small but finite incidence of acute coronary dissection. This can result in abrupt vessel closure, usually managed with urgent coronary artery bypass grafting. Despite improvements in equipment, technique, and operator experience, the need for urgent bypass after PTCA has remained relatively stable at 2% to 5%, due in part to the expanding indications of the procedure and its use in patients with more complicated conditions and lesions.₁ Techniques that have been used to stabilize acute coronary dissections and avoid emergency coronary bypass surgery include repeat FTCA balloon inflations, prolonged balloon inflations with perfusion balloons,^2,3 laser balloons,⁴ and permanent and temporary stenting.^5,6 The recent availability of directional coronary atherectomy (DCA) has made possible an additional technique for the acute treatment of coronary dissection.⁷ The purpose of this report is to assess both the acute and long-term efficacy of directional coronary atherectomy for the treatment of failed PTCA due to refractory abrupt closure.     

Acute outcome of directional coronary atherectomy vs standard balloon angioplasty in de novo left anterior descending stenoses.

To assess the immediate outcome of directional coronary atherectomy (DCA) versus standard balloon angioplasty (PTCA) in de novo left anterior descending coronary stenoses, 25 consecutive atherectomies (22 men, 3 women) performed at The Toronto Hospital, between July 1990 and March 1991 were compared with 25 (14 men, 11 women) temporally matched successful angioplasties. Coronary stenoses were analyzed by quantitative arteriography, using the Coronary Measurement System (Leiden, The Netherlands), with estimation of transstenotic hemodynamics by fluid dynamic equations. Before and after procedure qualitative blood flow (TIMI criteria) was also evaluated, as was intimal haziness and coronary dissection. In comparison to PTCA, coronary atherectomy produced less residual minimum stenotic diameter (DCA, 2.75 +/- 0.55 vs PTCA, 1.70 +/- 0.44 mm, p < 0.001), and relative percent diameter stenosis (DCA, 17.9 +/- 10.7 vs PTCA, 34.4 +/- 10.7 percent, p < 0.001), with less transstenotic obstructive gradient (DCA, 0.2 +/- 0.2 vs PTCA, 1.0 +/- 1.5 mm Hg, p < 0.05), and greater estimated stenotic flow reserve (DCA, 4.86 +/- 0.15 vs PTCA, 4.50 +/- 0.48 x baseline, p < 0.05). Coronary atherectomy "normalized" TIMI flow patterns in virtually all patients (DCA, 2.96 +/- 0.20 vs PTCA, 2.72 +/- 0.45, p < 0.05), while creating less intimal haziness (DCA, 10/25 [40 percent] vs PTCA, 23/25 [92 percent], p < 0.01), and coronary dissection (DCA, 6/25 [24 percent] vs PTCA, 16/25 [64 percent], p < 0.05). Therefore, when compared with standard balloon angioplasty, DCA produces less residual stenosis, better transstenotic hemodynamics, while decreasing the frequency of coronary artery damage, in de novo left anterior descending stenoses.     

Early Changes in Minimal Luminal Diameter After Balloon Angioplasty and Directional Coronary Atherectomy

Early elastic recoil has been implicated in the pathophysiology of restenosis after balloon coronary angioplasty (PTCA). Directional atherectomy (DCA) may significantly attenuate this vessel wall reaction by altering the vessel wall architecture, specifically by removing or injuring the medial smooth muscle cells. We compared the magnitude of early changes in minimal lumen diameter (MLD) after DCA followed by adjunctive PTCA (group I) in comparison to PTCA alone (group II). In two groups of 30 lesions, matched for vessel size and location, group I cases showed significantly less recoil than group II cases, as assessed by routinely performed 15 minute post-procedure angiograms: mean changes in post-procedure MLD +0.06mm (increase) vs. -0.31mm (decrease) respectively, p = 0.02. In a histopathologic substudy of the DCA treated patients, those without early recoil had significantly higher incidence of media removal compared to patients with recoil (50% vs. 7%, p = 0.03). Therefore, early changes in MLD, presumably related to elastic recoil, are less with DCA and adjunct PTCA in comparison to PTCA alone. Attenuation of early recoil may be an additional mechanism accounting for the acute lumen gain achieved with this technique.     

Directional atherectomy of left main stenoses

Balloon angioplasty (PTCA) of left main (LM) stenoses is limited by frequent clinical restenosis. Directional coronary atherectomy (DCA) may be an effective alternative to PTCA due to its ability to achieve a greater postprocedural luminal diameter when treating bulky, eccentric plaques and aorto-ostial lesions. We analyzed the acute and long-term results following 24 DCA procedures in 22 patients with “protected” LM lesions. Acute success (residual stenosis ≤ 40%, no major ischemic complications) was 88% overall, 100% in 13 planned procedures, and 73% in 11 adjunctive DCA procedures that followed suboptimal PTCA. Mean LM stenosis was reduced from 86% to 13% (P < 0.01). There were no procedural complications directly attributed to DCA. At a mean of 24 ± 3 months, the clinical restenosis rate was 16%, survival was 100%, and event-free survival (freedom from death, MI, or repeat lesion-related interventions) was 89%. We conclude that DCA in protected LM lesions (1) can achieved excellent angiographic results with low procedural complication rates, (2) may succeed where PTCA yields subopitimal results, and (3) may provide late clinical outcomes superior to those of balloon angioplasty. © Wiley-Liss, Inc.     

One hundred and thirteen attempts at directional coronary atherectomy: the early and combined experience of two European centres using quantitative angiography to assess their results.

Directional coronary atherectomy has been introduced as an alternative to conventional balloon angioplasty when treating coronary artery stenoses with complex lesion morphology. To determine the immediate efficacy of coronary atherectomy in patients with such lesions, the first 113 attempts at directional atherectomy in two centres using quantitative angiography were reviewed in 105 patients. The lesions were classified as complex stenosis since 95% had a symmetry index less than 1.0, a length of 6.83 +/- 2.55 mm on average and an area of plaque of 9.77 +/- 6.69 mm2. Procedural success defined as a residual stenosis less than or equal to 50% after tissue retrieval was obtained in 90 (85.7%) of 105 patients. The primary angioplastic success rate, combining atherectomy and balloon angioplasty in case of failed attempt of atherectomy was 95.2%. Coronary atherectomy was unsuccessful in five patients; three were referred for emergency coronary artery bypass grafting. Major complications (death, emergency surgery and transmural infarction) were encountered in 5.7% of the patients. Assessed by quantitative coronary analysis, a residual minimal luminal diameter of 2.42 +/- 0.52 mm and a diameter stenosis of 26 +/- 12% were obtained immediately after directional coronary atherectomy. We conclude that directional coronary atherectomy is particularly suitable for the treatment of stenosis with complex lesion morphology and is associated with acceptable complication rates. Randomized trials comparing atherectomy with balloon angioplasty are warranted to clarify the role of atherectomy in the treatment of lesions in the proximal part of the three major epicardial coronary arteries.     

Probe angioplasty of total coronary occlusion using an intracoronary Probing Catheter

Coronary angioplasty (PTCA) of total coronary occlusion is limited by the inability of guidewires and conventional dilating catheters to cross all such lesions. We have therefore developed a technique for PTCA of chronic total coronary occlusions using the ultralow profile "balloon-on-a-wire" Probe. An intracoronary Probing Catheter is used to facilitate crossing the stenosis with a guidewire and then to deliver a Probe into the obstruction for balloon dilatation. This technique was used in 13 patients including six in whom other dilating systems had failed to cross the occlusion. Successful dilatation was performed in nine patients (67%). Among the six patients in whom other dilating systems had failed, dilatation was performed in five using the Probing Catheter technique with a successful outcome achieved in four (67%). The Probing Catheter technique offers a promising new method to apply "balloon-on-a-wire" technology to the dilatation of chronic total coronary occlusions. This method may allow successful dilatation when other dilating systems fail.     

Indication for coronary revascularization for angina pectoris: correlation with prognosis of medically-treated patients

To assess the indication for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG), we studied 93 patients with angina pectoris but without myocardial infarction. All patients had significant stenosis (greater than 50%) in at least one coronary artery, including the left anterior descending artery. Fifty-eight patients received medical treatment (Group I), 12 had PTCA (Group II) and 23 had CABG (Group III). Findings of coronary angiography, treadmill exercise tests and dipyridamole perfusion scintigraphy as well as the frequency of cardiac events during follow-up were assessed in each group. 1. Coronary angiography revealed 1 vessel disease in 38% of the patients in Group I, 58% in Group II, and 13% in Group III; 2 vessel disease in 33%, 25% and 61%; and 3 vessel disease in 29%, 17% and 26%, respectively. 2. Exercise duration with the treadmill test was 4.7 min in Group I, 4.0 min in Group II and 3.7 min in Group III. ST depression (greater than or equal to 1 mm) was induced in 75%, 83% and 95%, respectively. Exercise duration improved from 4.0 to 6.0 min after PTCA and from 3.7 to 4.5 min after CABG. Exercise-induced ST depression also became less frequent; from 83% to 25% after PTCA and from 95% to 32% after CABG. Dipyridamole perfusion scintigraphy showed reversible defects in 86% of the patients in Group I and in all patients in Groups II and III. Reversible defects were observed in 17% of the patients after PTCA and in 21% after CABG. 3. During a mean follow-up period of 26 months, cardiac deaths occurred in one patient (2%) in Group I and 2 (7%) in Group III. Nonfatal cardiac events (myocardial infarction and unstable angina or those necessitating revascularization--late PTCA or CABG) were observed in 12 patients (21%) in Group I, 4 (24%) in Group II and 10 (36%) in Group III. Anginal attacks at least once weekly remained in 12% of the patients in Group I, 19% in Group II and 14% in Group III at the last follow-up. In conclusion, PTCA and CABG appear to be effective methods for improving ischemia and exercise tolerance. However, preventive PTCA and CABG may not be indicated in patients with mild angina, because the prognosis is also excellent in medically-treated patients with angina but without myocardial infarction or left main coronary artery disease.     

Present status and perspective of percutaneous transluminal coronary angioplasty from the viewpoint of short and long term results: comparative study of the results of PTCA and CABG procedure

Balloon technology has advanced to incorporate the skills of angioplasters while efforts to enhance their skills continue. These factors have contributed to the expansion of percutaneous transluminal coronary angioplasty (PTCA) indications. We have analyzed the comparison of short and long term results between PTCA and CABG revascularization procedures. In the development of revascularization procedures, one graft surgery has significantly declined in use since 1983 (2 years after the start of PTCA) while there has been an increase of multi graft surgery (more than 2 grafts). On the other hand, PTCA has showed a linear increase since 1982 and reached 160 cases in 1985. The growth of complex angioplasty other than PTCA for single discrete lesions is parallel to that of PTCA and has been used in 44% of overall cases. The growth curve of angioplasty crossed over that of revascularization surgery in 1983. PTCA was successful in 246 patients out of 300 overall cases representing 88% success rate and in 340 lesions representing an 81% success. For CABG the patency rate was 89.5% which means a out of 638 grafts were successful. PTCA was conducted in 137 cases with multiple lesion. That data could be interpreted as mean patient success of 120/137, lesion success was 196/265 with a success rate of 88% and 73%, respectively. Primary results in 284 multi CABG cases were good with a patency rate of 91% (487 patent grafts out of 536 anastomoses). However, in-hospital deaths were 3.5% higher (10 cases with CABG group). The effective dilatation of high-grade organic lesion was found to be closely related to the improvement of clinical symptoms and a marked decrease in incidence of ergonovine induced spasms at the angioplasty site in patients with vasospastic angina (VSA). Thus PTCA can be accepted as an alternative therapy to CABG in VSA. In the long term follow up, work load response parameters such as exercise time, % predicted HR, PRP, Mets and the modified treadmill exercise scores improved significantly after the successful PTCA.     

Our experience with percutaneous transluminal coronary angioplasty--two years follow-up study

The results of 130 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures carried out in 112 patients between November, 1986 and October, 1988 are reported. The follow-up period ranged from 1 month to 24 months. Eighty-four patients (75%) had single vessel disease, and 28 (25%) had multivessel disease. Two-vessel dilatation was done in 23 patients. The primary success rate was 92%. In successful cases, the diameter of stenosis was changed on an average from an initial 85% to 23%. Acute occlusion of the vessel occurred on 9 occasions (6.8%). Emergency coronary bypass surgery (CABG) was done in 3 (2.7%), 2 patients (1.8%) were subjected to immediate re-dilatation. One patient who underwent CABG died (case fatality 0.8%). Occlusion of the dilated vessels did not occur after the patients were discharged from hospital. Follow-up data revealed that long-term clinical success (class I status) was seen in 78 patients who had a successful primary dilatation. Of the 25 patients who were studied by a repeat coronary arteriography, 7 had developed restenosis. Five of these patients have been successfully redilated. It is concluded that PTCA is an effective and safe method of treatment in selected patients with coronary artery disease in our setting.     

Directional coronary atherectomy in intermediate sized vessels: final results of the intermediate vessel atherectomy trial (IVAT).

Revascularization options for intermediate sized vessels (2.5-2.9 mm) have historically been limited. IVAT is a pilot study to assess the efficacy and safety of debulking intermediate sized vessels using directional coronary atherectomy (DCA). Between March 1996 and June 1997, 50 patients were enrolled at seven hospitals in the United States. Of those patients, 70% presented with unstable angina and 52% had single vessel disease. Of the lesions treated, 96% were de novo. Adjunctive PTCA after DCA was performed in 90% of cases at the discretion of the investigator to maximize luminal diameter. The GTO DCA device was used in 90% of cases. Procedural success (residual stenosis <50% without major complications) was 94%. Stents were placed in 12% of patients. The only complications were three non-Q wave MIs. Mean reference vessel diameter increased from 2.49 mm pre-procedure to 2.57 mm after DCA and 2.61 post-procedure; mean MLD increased from 0.76 mm to 2.03 mm to 2.31 mm; and mean stenosis decreased from 70% to 21% post DCA and to 11% post procedure. At six months follow-up, 18.0% of target lesions required revascularization. Total revascularization, including non-target vessels, was 32%. These results suggest that DCA has a high procedural success rate and a low target lesion revascularization rate in intermediate sized vessels.     

Directional Coronary Atherectomy of In-stent Restenosis: A Two-Center Experience

Background: Tissue proliferation is the major cause of in-stent restenosis (ISR). Thus, debulking of material should be the most favorable method to treat ISR. The present study was performed to test the clinical and angiographic outcome of directional coronary atherectomy (DCA) in the treatment of restenosis within different stents. Methods and Results: Fifty patients with ISR in single stents (12 Palrnaz-Schatz stents, 8 Pura stents, 10 Multilink stents, 10 NIR stents, 8 Wallstents, and 2 Microstents) underwent DCA with adjunctive balloon angioplasty in 38 patients. Primary success was achieved in 48 patients (96%). Two patients developed CK-MB elevations, one with a Q-wave infarction. Some minor technical problems occurred with respect to the different stent types. The percent diameter stenosis decreased from 76 ± 7% at baseline to 29 ± 6% after atherectomy (P < 0.0001) and 20 ± 4% after adjunctive PTCA, and it increased to 45 ± 19% at 4-month angiography (P < 0.0001). Angiographic restenosis occurred in 14 (29.2%) of 48 patients who were reevaluated after 4 months. Conclusion: While DCA is able to remove u significant amount of intimal tissue in selected patients with in-stent restenosis, new atherectomy catheter designs are required to make this a feasible and safe procedure.     

Directional coronary atherectomy in acute myocardial infarction

To date, application of directional coronary atherectomy (DCA) in acute myocardial infarction (AMI) has had limited reports. In eleven patients with AMI, DCA was applied. In three of these patients, DCA was used as a stand-alone procedure without use of thrombolytic agents. In each case a guidewire was placed across the stenosis, and in eight patients balloon angioplasty was utilized as a predilating modality prior to DCA. The thrombolytic agent urokinase was utilized in five of these eight patients, either before, during, or after angioplasty and/or DCA. DCA success (defined as ability to cross the lesion, reduction of less than or equal to 20% in stenosis and thrombolysis--when a thrombus is present) was achieved in 10 of 11 patients. One patient had persistent abrupt reclosure of an LAD lesion, accompanied by hemodynamic compromise, necessitating intra-aortic balloon pump insertion and subsequent emergent coronary artery bypass graft surgery. Final angiograms revealed residual stenoses less than or equal to 20%, and adequate thrombolysis. Significant cardiac events were limited to one emergent CABG, Q wave MI in four patients, and non-Q wave MI in two patients. Clinically all eleven patients improved, survived the AMI/CABG, and were discharged. This clinical experience demonstrates the feasibility and safety of DCA application in selected patients who experience acute myocardial infarction.