Intracoronary thrombolysis followed by directional atherectomy: A combined approach for thrombotic vein graft lesions considered unsuitable for angioplasty

Eccentric complex vein graft lesions with abundant luminal thrombus have been generally considered unfavorable for balloon angioplasty. We present 3 patients in whom such lesions were successfully treated by a combined approach: intracoronary urokinase (1 million units over 1 hr) administered in the catheterization laboratory followed by directional atherectomy of the residual lesions in 2 separate procedures; with the patients maintained on heparin infusion between the 2 stages. No distal embolizations were encountered. Two of the 3 patients developed a groin hematoma without vascular compromise. This combined approach may prove to be an attractive alternative to reoperation in select patients with unfavorable vein graft lesions. © 1992 Wiley-Liss, Inc.     

Brachial approach directional coronary atherectomy of a left coronary artery saphenous vein bypass graft

Directional coronary atherectomy (DCA) of a saphenous vein bypass graft to the left coronary artery was performed percutaneously from the brachial artery approach using a 7F endomyocardial biopsy sheath. Initial positioning was accomplished with a left bypass graft catheter inserted in the sheath. This technique permits use of smaller catheters than usual for DCA in patients in whom larger guides cannot be used. © 1993 Wiiey-Liss, Inc.     

Assessing a strategy of initial stand-alone extractional atherectomy followed by staged stent placement in degenerated saphenous vein graft lesions

To assess whether a staged strategy (initial stand alone transluminal extraction atherectomy and coumadin therapy followed by stenting six weeks later) could reduce ischemic complications in degenerated saphenous vein graft (SVG) interventions, we studied 72 patients undergoing percutaneous interventions of degenerated SVG. Patients were divided into two groups; 28 were treated with a staged strategy (group I) and 44 with similar lesion characteristics were treated with a definitive initial procedure with transluminal extraction atherectomy +/- adjunctive balloon angioplasty and stenting (group II). Procedural success, major in-hospital complications (death, Q-wave myocardial infarction, and emergent coronary bypass surgery), and incidence of distal embolization were compared between the 2 groups. Procedural success was lower (92% vs 100%, p = 0.14) and major in-hospital complications were higher (0% vs 11%, p = 0.14) in group II. Distal embolization occurred in 11% of the patients in group I compared with 23% of the patients in group II (p = 0.19). At 6 week follow-up (group I), 9 patients (33%) had negative symptoms, 11 (41%) underwent stent implantation, 3 (11%) did not require any further therapy (without significant stenosis), and 4 (14%) had total occlusions. We therefore conclude that this staged strategy in degenerated SVG appears to reduce distal embolization but most importantly avoids major in-hospital complications, including any deaths either at the time of initial procedure or during the 6-week follow-up period.     

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.     

Intracoronary separation of a nosecone: an unusual complication of directional atherectomy.

A rare case of coronary separation of nosecone fixed to a 6 Fr GTO cutter catheter after failed directional coronary atherectomy (DCA) is reported. Revascularization was successful using a stent via the subintimal neolumen beside the nosecone. Heavily calcified lesions are relative contraindications to DCA.     

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.     

Early ostial vein graft stenosis: management by atherectomy

During the initial perioperative period (1 mo to 1 yr) after saphenous vein coronary grafting, early stenosis and occlusion occurs in 5-8% of grafts due to intimal hyperplasia. We report a patient who developed ostial stenosis within 4 mo of bypass surgery at the aortotomy site of two vein grafts. Balloon angioplasty of the elastic stenoses did not provide significant luminal enlargement, but successful treatment of the lesions was obtained using directional atherectomy. Histological examination demonstrated intimal hyperplasia. Directional atherectomy may be an excellent technique for treatment of elastic ostial vein graft stenoses in lieu of conventional balloon dilatation.     

Rotational atherectomy followed by drug-eluting stent implantation (Rota-DES): a rational approach for complex calcified coronary lesions

Rotational atherectomy has been regaining interest over the last couple of years after it almost has disappeared from most interventional catheterization laboratories for several years due to failure to prove its original concept of improving long term results of percutaneous coronary interventions (PCI) as was repeatedly shown in studies in the 1990s. Its revival coupled the introduction of drug-eluting stents (DES); these devices have led to treating much more complex lesions and high-risk patients by PCI. However, real-world experience suggested that off-label use of DES is associated with a higher rate of early and late stent thrombosis. Therefore, more attention is now being paid to the initial implantation technique of DES including aggressive lesion preparation to facilitate stent delivery and expansion. The limited studies with rot-ablation and DES showed promising results with no long term safety concerns. In these studies, a subtle observation was made suggesting that rot-ablation prior to DES implantation in such lesions may have an add-on effect on long term outcome compared to DES alone. An ongoing multicenter study is investigating such effect among complex calcified coronary lesions. Even if this additive benefit does not prove true, rot-ablation remains an efficient tool for preparing certain lesions to facilitate effective and safe DES implantation. Therefore, interventional training programs should focus on this difficult technique to bridge the gap of experience which resulted from neglecting it for several years. In this regard, dedicated courses at experienced sites as well as medical simulation may be appropriate.     

Brachial approach directional coronary atherectomy of right coronary artery saphenous vein bypass grafts.

We describe here a technique for performing directional coronary atherectomy to right coronary artery saphenous vein bypass grafts from the brachial approach using a long introducer sheath system. This technique has the advantages of 1) avoiding femoral artery trauma and 2) ease of access into the bypass graft, avoiding occasional problems with guide catheter kinking or non-coaxial alignment.     

Reduced distal embolization with transluminal extraction atherectomy compared to balloon angioplasty for saphenous vein graft disease

Extraction atherectomy utilizes suction aspiration as an attempt to limit distal emboll during atherectomy. We sought to test the hypothesis that extraction atherectomy produces less distal embolization than balloon angioplasty when treating saphenous vein grafts. Among 163 consecutive, nonrandomized patients, 103 patients underwent transluminal extraction catheter (TEC)^® atherectomy with or without adjunctive balloon angioplasty, and 60 patients had conventional balloon angioplasty. Both groups showed comparably high procedural success rates (TEC 90.3%, angioplasty 83.3%, P = NS). TEC cases had a significantly lower incidence of angiographic distal embolization, compared with angioplasty (3.9% vs. 16.7%, P = 0.005). In cases with angiographic evidence of thrombus in the grafts, TEC maintained a significantly lower incidence of distal embolization than angioplasty (5.6% vs. 31.8%, P = 0.004). There were no statistical differences between the two groups regarding the incidence of other procedure-related complications, including death, myocardial infarction, or emergency coronary artery bypass grafting. TEC atherectomy appears to have a significantly lower incidence of distal embolization than balloon angioplasty when treating saphenous vein grafts, particularly in the presence of angiographically apparent thrombus. © 1996 Wiley-Liss, Inc.     

Mechanisms of balloon angioplasty and directional coronary atherectomy as assessed by intracoronary ultrasound.

OBJECTIVE. This study was designed to use intracoronary ultrasound imaging to elucidate the physical effects of balloon angioplasty and directional coronary atherectomy in vivo in humans. BACKGROUND. The proposed mechanisms of coronary artery interventions such as balloon angioplasty and directional atherectomy are based on animal studies or pathologic findings and these data may not be applicable to living patients. Intracoronary ultrasound findings correlate highly with pathologic results and may allow in vivo assessment of the mechanisms of such interventions in humans. METHODS. Intracoronary ultrasound imaging was performed in 45 patients after a successful coronary intervention (balloon angioplasty in 30, directional coronary atherectomy in 15). Ultrasound images obtained at the treatment site and at an adjacent angiographically normal references site were analyzed quantitatively for minimal lumen diameter, cross-sectional lumen area, are enclosed by the internal elastic lamina, plaque area (internal elastic lamina area--lumen area) and percent area stenosis (plaque area/internal elastic lamina area). Qualitative analysis included assessment of presence of dissection, plaque composition and plaque topography. RESULTS. The results of the two procedures were similar with respect to minimal lumen diameter (angioplasty 2.6 +/- 0.5 vs. atherectomy 2.6 +/- 0.3 mm, p = NS), lumen area (0.07 +/- 0.03 vs. 0.07 +/- 0.02 cm2, p = NS) and percent area stenosis (59 +/- 14% vs. 51 +/- 21%, p = NS). However, after angioplasty, the internal elastic lamina area was significantly larger at the treated site than at the reference site (delta = +0.03 +/- 0.04 cm2, p = 0.01). There was no significant difference between the two sites after atherectomy (delta = -0.01 +/- 0.05 cm2, p = NS). In addition, dissection was seen significantly more often after balloon angioplasty than after atherectomy (50% vs. 7%, p less than 0.01). The results were similar when stratified for plaque composition and morphology. These data were confirmed in six additional patients who underwent ultrasound imaging before and after the intervention. CONCLUSIONS. Thus, the improvement in lumen dimensions after coronary balloon angioplasty is a result of both vessel stretch, demonstrated by a larger internal elastic lamina area at the treated site, and dissection. Both vessel stretch and dissection are uncommon after atherectomy, a finding consistent with plaque removal as the major mechanism for improved lumen area after this procedure.     

Preliminary experience at a Canadian centre with directional coronary atherectomy for complex lesions.

OBJECTIVE: To evaluate preliminary experience of directional coronary atherectomy for complex coronary artery lesions. DESIGN: Nonrandomized, sequential patients with coronary arterial lesions that were ostial, eccentric, bulky, recurrent or membranous. SETTING: Cardiac catheterization laboratory of a tertiary referral general hospital. PATIENTS: Twenty-three patients with angina pectoris refractory to medical therapy who were suitable candidates for coronary bypass surgery. INTERVENTIONS: Directional coronary atherectomy with associated balloon angioplasty, if required, to reduce lesion stenosis to less than 25%. MAIN RESULTS: Primary success was achieved in 29 of 33 lesions (88%) by atherectomy alone and in 31 of 33 lesions (94%) by additional use of balloon angioplasty. Atherectomy retrieved tissue in 30 of 33 attempts (91%). One patient suffered Q wave myocardial infarction; one had acute occlusion after atherectomy requiring emergency balloon angioplasty; and one required repair of a false aneurysm of the femoral artery. CONCLUSIONS: Directional coronary atherectomy is safe and efficacious for ostial, bulky and eccentric lesions not optimally suited to balloon angioplasty. Lesions which have tortuous segments immediately beyond, restricting movement of the stiff nose-cone, and which are membranous or bandlike, may not be indicated for directional coronary atherectomy.     

Combination therapy for evolving myocardial infarction: Intracoronary thrombolysis and percutaneous transluminal angioplasty

Nonsurgical coronary reperfusion for evolving myocardial infarction is a promising new technique for the salvage of jeopardized myocardium. Successful reperfusion can be established by intracoronary infusion of streptokinase in approximately 75 percent of patients within the first 6 hours of transmural infarction [1,2]. Following recanalization, most patients are left with high grade fixed coronary stenoses which are potential sites for recurrent thrombus formation. Since the underlying site for coronary thrombosis is still present, reocclusion may occur. Indeed, early experience suggests that recurrence of thrombosis is not uncommon [3,4]. Therapy for evolving myocardial infarction should, in some patients, involve not only thrombolysis, but also an attack on the fixed coronary lesion. We describe a patient with evolving myocardial infarction who was treated successfully with combination therapy consisting of intracoronary streptokinase followed by percutaneous transluminal coronary angioplasty [5].     

Revascularization of a thrombosed,previously stented aorto-renal graft using combined directional atherectomy and AngioJet thrombectomy

We report an interesting case with bilateral PTFE aorto-renal grafts of which one graft underwent balloon angioplasty and stenting for proximal stenosis. Combined debulking by AngioJet thrombectomy and Simpsons directional atherectomy was performed within the stent following reocclusion of the graft 9 months later. Cathet. Cardiovasc. Intervent. 46:85–88, 1999. © 1999 Wiley-Liss, Inc.     

Results of directional atherectomy of primary atheromatous and restenosis lesions in coronary arteries and saphenous vein grafts.

Directional coronary atherectomy (DCA) was performed in 158 patients over a 2-year period at the Mayo Clinic. Primary atheromatous lesions were treated in 92 patients (group 1) and restenosis lesions were treated in 66 (group 2). Technical success (recovery of tissue and greater than or equal to 40% luminal enlargement with a residual stenosis of less than 50%) was achieved in 152 lesions (92%); clinical success (technical success and no in-hospital death, Q-wave myocardial infarction or coronary bypass surgery) was achieved in 143 patients (91%). Adjunctive balloon angioplasty was used in 41 patients. DCA was successful less often in group 1 than in group 2 (86 vs 97%; p = 0.038). A major complication occurred in 7% of patients; in-hospital death, Q-wave myocardial infarction and emergency coronary bypass surgery occurred in 3, 1 and 4% of patients, respectively. Major complications were more frequent in group 1 than in group 2 (10 vs 1; p = 0.02). During a follow-up period of 14 +/- 8 months, no difference between the groups was found in the incidence of late death (4%), Q-wave myocardial infarction (1%), recurrent severe angina (29%), bypass surgery (15%) or repeat interventional procedure of the same vascular segment (24%). Vein graft and restenosis lesions tended to have greater success and fewer complications. Angiographic restenosis (increase of greater than or equal to 30% in stenosis severity by visual assessment) occurred in 62% of patients and 58% of lesions with successful DCA, and was similar in the 2 groups; a tendency toward higher restenosis rates was seen in patients with vein graft DCA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Membrane-covered stents: a new treatment strategy for saphenous vein graft lesions.

The restenosis rate after stenting of lesions in aortocoronary venous bypass grafts still has to be considered unsatisfactorily high. We investigated a new stent design characterized by an expandable polytetrafluorethylene (PTFE) membrane in between two layers of struts. Five consecutive male patients (age 70 +/- 6 years) were followed prospectively who presented with at least two de novo lesions in different grafts 13 +/- 3 years after bypass surgery. A total of 11 lesions were treated located in grafts anastomosed to the circumflex (n = 3), to the LAD (n = 7), and to the right coronary artery (n = 1). Within the same procedure, every patient received membrane-covered stents (n = 6) and conventional stents (n = 5) in either of their lesions. All patients underwent successful interventions. The minimal luminal diameter increased from 1.0 +/- 0.5 to 2.9 +/- 0.6 mm in lesions treated by the membrane-covered stents and from 0.8 +/- 0.4 to 2.4 +/- 0.7 mm in the lesions treated by conventional stents. During follow-up, four out of five patients required angioplasty for in-stent restenosis of lesions covered by a conventional stent, whereas no patient underwent revascularization for a lesion treated by a membrane-covered device. The mean minimal luminal diameter of lesions covered by a conventional stent decreased by 42% to 1.4 +/- 0.6 mm; the mean minimal luminal diameter of the lesions treated by a stent graft declined by 9% to 2.8 +/- 0.6 mm (P < 0.05). This series of intraindividual comparisons suggests that membrane-covered stents may have the power to reduce in-stent restenosis in obstructed aortocoronary venous bypass grafts.