Directional Coronary Atherectomy in Takayasu's Disease

A 44-year-old woman with a history of coronary aorta bypass grafting (CABG)for stenosis of the left main trunk (LMT) due to Takayasu's disease underwent directional coronary atherectomy (DCA) to the LMT lesion under percutaneous cardiopulmonary support because she had angina pectoris and heart failure due to occlusion of the grafts. Three and a half years after the catheter intervention, her clinical condition remains good. DCA may be an alternative to CABG in limited cases with LMT disease.     

Rescue and Adjunctive Directional Coronary Atherectomy

Conventional coronary balloon angioplasty is complicated by abrupt arterial occlusion in 4%-8% of cases and remains the most important and feared acute problem with this procedure. This review discusses the significance and various treatment options for abrupt occlusion, focusing particularly on the potential use of directional coronary atherectomy to treat significant coronary arterial dissections complicating conventional angioplasty. The use of adjunctive atherectomy for the treatment of suboptimal coronary angioplasty results without dissection is also discussed. (J Interven Cardiol 1996;9:129–134)     

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.     

Outcomes after Atherectomy Treatment of Severely Calcified Coronary Bifurcation Lesions: A Single Center Experience

BackgroundCoronary bifurcation and calcified lesions account for 15–20% and 6%–20% of percutaneous coronary interventions (PCI), respectively. Treatment of these lesions is associated with high periprocedural complication rates and unfavorable long-term clinical outcomes, including high rates of revascularization. This retrospective, single-center study evaluated the outcomes of atherectomy treatment for heavily calcified coronary bifurcation lesions.MethodsPatients who underwent a coronary atherectomy procedure to treat a heavily calcified lesion between January 2010 and March 2016 at Metropolitan Heart and Vascular Institute (Minneapolis, MN) were included in this retrospective study. Data were stratified to compare atherectomy treatment of coronary bifurcation lesions vs non-bifurcation lesions. Additionally, data were compared based on type of atherectomy utilized during the index procedure, either orbital (OAS) or rotational (RA) atherectomy. Major adverse cardiac events (MACE), defined as a composite of death, myocardial infarction (MI), and target vessel revascularization (TVR), were assessed at 30 days post-procedure.ResultsAmong the 177 patients treated with atherectomy, 72 patients had bifurcation lesions. Compared to patients with non-bifurcation lesions, patients with bifurcation lesions were more likely to have a history of prior PCI or coronary artery bypass grafting. Bifurcation lesions required a higher volume of contrast. There were similar low rates of slow flow/no-reflow (2.8% bifurcations vs 1.0% non-bifurcation; p = 0.355). The 30-day rates of death (1.4% vs 1.9%; p = 0.794), MI (0% vs 0%; p = NA), and TVR (0% vs 1.0%; p = 0.406) were similar in patients with bifurcation lesions versus those without, respectively. An atherectomy sub-analysis (OAS vs RA) of the patients with bifurcation lesions showed that OAS utilization was associated with shorter procedure time (81 min vs 109 min; p = 0.026) and fluoroscopy time (18 min vs 27 min; p = 0.007) compared to RA, respectively—no significant differences in baseline demographic or lesion characteristics were noted in the bifurcation atherectomy sub-groups, except for higher beta/calcium blocker use in RA bifurcation subjects.ConclusionsThe results of this study demonstrated that atherectomy treatment in patients with heavily calcified coronary bifurcation lesions is feasible, resulting in similar low 30-day MACE rates as compared to patients with non-bifurcation lesions. In addition, in this study OAS utilization versus RA in bifurcation lesions was associated with significantly shorter procedure and fluoroscopy time. Further studies are needed to assess the safety and efficacy of atherectomy in patients with severely calcified bifurcation lesions.Summary for annotated table of contentsThis retrospective, single-center study evaluated the outcomes of orbital and rotational atherectomy treatment for heavily calcified coronary bifurcation lesions as compared to non-bifurcation lesions. The results demonstrate that atherectomy treatment in patients with heavily calcified coronary bifurcation lesions is feasible, resulting in similarly low 30-day MACE rates as compared to patients with non-bifurcation lesions. In addition, in this study OAS utilization versus RA in bifurcation lesions was associated with significantly shorter procedure and fluoroscopy time.     

Quantitative Coronary Dimensions and Restenosis After Directional Atherectomy or Balloon Angioplasty

Coronary artery dimensions were evaluated in 42 patients (52 lesions) undergoing directional atherectomy of primary atheromatous lesions in native coronary arteries between October 1989 and April 1991, Dimensions were compared with a cohort of 162 patients (213 lesions) undergoing percutaneous transluminal coronary angioplasty of similar lesions between March 1984 and April 1988. Computer-assisted quantitative angiography was performed for paired near-orthogonal views (captured during diastole) of each treated lesion; image pairs taken prior to, immediately following, and 6 months after coronary intervention were studied. Although coronary dimensions were equivalent for the two treatment groups before therapy, the immediate posttreatment minimal lumen diameter was significantly larger after atherectomy than angioplasty (2.24 ± 0.53 mm vs 1.52 ± 0.34 mm, P < 0.01). Despite this, coronary dimensions were similar in the two groups at follow-up angiography. Several dichotomous definitions of restenosis were tested using these quantitative data. Restenosis rates were similar for the two treatments using most definitions, but those definitions based on loss of relative or absolute lumen dimensions resulted in higher rates of restenosis following atherectomy. These data demonstrate that: (1) directional coronary atherectomy can achieve greater initial gain in luminal dimensions than angioplasty; (2) the loss in vessel dimensions within 6 months (late loss) is greater after atherectomy than after angioplasty; and (3) restenosis definitions rely on relative or absolute loss of initial luminal gain favor of angioplasty. (J Interven Cardiol 1996;9:121–127)     

Coronary Flow Velocity Reserve After Successful Balloon Angioplasty and Directional Atherectomy

Background: To ascertain whether transesophageal echocardiography (TEE) allows for measurement of coronary flow velocity "reserve" in patients with disease of the left anterior descending artery (LAD), and to establish the flow velocity response following angiographically successful angioplasty and atherectomy. Methods: Four groups of patients were studied: normal controls (n = 15) consisted of patients without obstructive coronary artery disease, a LAD stenosis group (n = 15) consisted of patients with > 70% stenosis, an LAD postangiographically successful balloon angioplasty group (n = 12), and an LAD postangiographically successful directional atherectomy group (n = 6). Two-dimensional horizontal plane TEE was used to image the proximal left coronary arterial system. Pulsed Doppler recordings were made of proximal LAD flow velocities at rest, and following an infusion of 0.56 mg/kg IV dipyridamole. Results: The peak diastolic flow velocity ratio (hyperemic flow/baseline flow) for normal controls was 3.46 ± 0.48 (mean ± standard deviation), for the LAD stenosis group was 1.35 ± 0.26, for the balloon angioplasty group was 2.08 ± 0.45, and for the directional atherectomy group was 2.10 ± 0.82. Conclusions: We conclude that: (1) it is feasible to record with TEE Doppler, flow velocity and flow reserve in normals, in obstructive coronary artery disease, and following revascularization; (2) coronary flow velocity ratio (CFVR) is decreased in patients with LAD stenosis; (3) CFVR remains subnormal in patients with angiographically successful directional atherectomy and balloon angioplasty; and (4) that flow velocity ratios following directional atherectomy were not significantly different from those following balloon angioplasty .     

Successful Stent Implantation in Acute Myocardial Infarction and Successful Directional Coronary Atherectomy of a Stenotic Lesion Involving an Aneurysm in a Woman with Kawasaki Disease of Adult Onset

Our patient was a woman who suffered from Kawasaki disease at the age of 20. Coronary aneurysms were confirmed in the left main trunk and proximal sites of the left anterior descending artery and the circumflex artery by coronary angiography at the age of 21. When she suffered an inferior acute myocardial infarction at the age of 24, two Palmaz-Schatz stents were successfully implanted in the right coronary lesion in order to prevent acute closure. One month later, directional coronary atherectomy was successfully performed to the left anterior descending artery lesion which had a rapid progression of the stenosis, and the pathological examination revealed that the cause of the stenosis was thrombus. She has remained well during the following 2 years.     

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.     

Potent Stent-Less Procedure Using Rotational Atherectomy and Drug-Coated Balloon to Right Coronary Ostial Lesion

BackgroundEven in the drug-eluting stent era, ostial lesion of the right coronary artery (RCA) still remains therapeutic challenge for interventional cardiologists. Case Series Case 1 (76 y.o. male) with angina on effort underwent transradial stent-less percutaneous coronary intervention (PCI) using rotational atherectomy (RA) followed by drug-coated balloon (DCB) dilation alone (RA/DCB) against a calcified de novo RCA ostial lesion. Case 2 (86 y.o. female) with recurrent unstable angina and hemodialysis underwent transfemoral RA/DCB against a severe repeat in-stent restenosis probably due to calcified nodule in the RCA ostium. In the both patients, PCI was successfully completed under intravascular ultrasound imaging (IVUS) guidance without complications. Follow-up CAG performed 4–5 months after the procedure revealed no significant lumen narrowing in the both RCA ostial lesions.ConclusionsThe both cases suggest that stent-less PCI using RA/DCB under IVUS might be an alternative revascularization therapy of choice for calcified RCA ostial lesions.     

Outcomes in Elderly Patients With Severely Calcified Coronary Lesions Undergoing Orbital Atherectomy

Objectives

We evaluated the clinical outcomes of elderly patients who underwent orbital atherectomy for the treatment of severe coronary artery calcification (CAC) prior to stenting.

Background

Percutaneous coronary intervention (PCI) of severe CAC is associated with worse clinical outcomes including death, myocardial infarction (MI), and target vessel revascularization (TVR). The elderly represents a high‐risk group of patients, often have more comorbid conditions, and have worse outcomes after PCI compared to younger patients. Clinical trials and a large multicenter registry have demonstrated the safety and efficacy of orbital atherectomy for the treatment of severe CAC. Clinical outcomes of elderly patients who undergo orbital atherectomy are unknown.

Methods

Of the 458 patients, 229 were ≥75 years old (elderly) and 229 were <75 years old (younger). The primary endpoint was rate of 30‐day major adverse cardiac and cerebrovascular events (MACCE), comprised of cardiac death, MI, TVR, and stroke.

Results

The primary endpoint was similar in the elderly and younger groups (2.2% vs. 2.2%, P = 1), as were the individual endpoints of death (2.2% vs. 0.4%, P = 0.1), MI (0.9% vs. 1.3%, P = 0.65), TVR (0% vs. 0%, P = 1), and stroke (0% vs. 0.4%, P = 0.32). The rates of angiographic complications and stent thrombosis were similarly low in both groups.

Conclusions

The elderly represented a sizeable number of patients who underwent orbital atherectomy. It is a safe and effective treatment strategy for elderly patients with severe CAC as the clinical outcomes were similar to their younger counterparts. A randomized trial should further clarify the role of orbital atherectomy in these patients.

     

Optimal Treatment Strategies in Patients with Chronic Kidney Disease and Coronary Artery Disease

Background

Chronic kidney disease is an independent risk factor for coronary artery disease and is associated with an increase in adverse outcomes. However, the optimal treatment strategies for patients with chronic kidney disease and coronary artery disease are yet to be defined.

Methods

MEDLINE, EMBASE, and CENTRAL were searched for studies including at least 100 patients with chronic kidney disease (defined as estimated glomerular filtration rate ≤60 mL/min/1.73 m² or on dialysis) and coronary artery disease treated with medical therapy, percutaneous coronary intervention, or coronary artery bypass surgery and followed for at least 1 month and reporting outcomes. The outcome evaluated was all-cause mortality. Meta-analysis was performed to evaluate the outcomes with revascularization (percutaneous coronary intervention or coronary artery bypass surgery) when compared with medical therapy alone. In addition, outcomes with percutaneous coronary intervention vs coronary artery bypass surgery were evaluated.

Results

The search yielded 38 nonrandomized studies that enrolled 85,731 patients. Revascularization (percutaneous coronary intervention or coronary artery bypass surgery) was associated with lower long-term mortality (mean 4.0 years) when compared with medical therapy alone (relative risk [RR] 0.73; 95% confidence interval [CI], 0.62-0.87), driven by lower mortality with percutaneous coronary intervention vs medical therapy and coronary artery bypass surgery vs medical therapy. Coronary artery bypass surgery was associated with a higher upfront risk of death (RR 1.81; 95% CI, 1.47-2.24) but a lower long-term risk of death (RR 0.94; 95% CI, 0.89-0.98) when compared with percutaneous coronary intervention.

Conclusions

In chronic kidney disease patients with coronary artery disease, the current data from nonrandomized studies indicate lower mortality with revascularization, via either coronary artery bypass surgery or percutaneous coronary intervention, when compared with medical therapy. These associations should be tested in future randomized trials.     

Successful Directional Atherectomy of De Novo Coronary Lesions Assessed With Three-Dimensional Intravascular Ultrasound and Angiographic Follow-Up

Recent histopathologic and intravascular ultrasound (IVUS) data indicate that inadequate compensatory enlargement of atherosclerotic lesions contributes to the development of significant arterial stenoses. Such lesions may contain less plaque, which may have implications for atheroablative interventions. In this study, we compared lesions with (group A, n = 16) and without inadequate compensatory enlargement (group B, n = 30) as determined by IVUS. The acute results and the follow-up lumen dimensions of angiographically successful directional coronary atherectomy procedures were compared. Inadequate compensatory enlargement was considered present when the preintervention arterial cross-sectional area at the target lesion site was smaller than that at the (distal) reference site. Three-dimensional IVUS analysis and quantitative angiography were performed in 46 patients before and after intervention. IVUS measurements included the arterial, lumen, and plaque (arterial minus lumen) cross-sectional areas at the target lesion site (i.e., smallest lumen site) and the (distal) reference site. Angiographic follow-up was performed in 42 patients. Preintervention and postintervention angiographic measurements and IVUS lumen cross-sectional area measurements were similar in both groups. However, at follow-up, the angiographic minimum lumen and reference diameters were significantly smaller in group A compared with group B (1.71 ± 0.47 mm vs 2.14 ± 0.73 mm, p <0.03, and 2.97 ± 0.29 mm vs 3.39 ± 0.76 mm, p <0.02; group A vs B). The data of this observational study suggest that lesions with inadequate compensatory enlargement, as determined by IVUS before intervention, may have less favorable long-term lumen dimensions after directional coronary atherectomy procedures.     

Long-Term Outcomes After PCI or CABG for Left Main Coronary Artery Disease According to Lesion Location

ObjectivesThe aim of this study was to investigate the impact of lesion site (ostial or shaft vs. distal bifurcation) on long-term outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease.BackgroundLong-term comparative data after PCI and CABG for LMCA disease according to lesion site are limited.MethodsPatients from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry were analyzed, comparing adverse outcomes (all-cause mortality [a composite outcome of death, Q-wave myocardial infarction, or stroke] and target vessel revascularization) between PCI and CABG according to LMCA lesion location during a median follow-up period of 12.0 years.ResultsIn overall population, the adjusted risks for death and serious composite outcome were higher after PCI than after CABG for distal bifurcation disease, which was mainly separated beyond 5 years. These outcomes were not different for ostial or shaft disease. When comparing drug-eluting stents (DES) and CABG, the adjusted risks for death and serious composite outcome progressively diverged beyond 5 years after DES compared with CABG for distal bifurcation disease (death: hazard ratio: 1.78; 95% confidence interval: 1.22 to 2.59; composite outcome: hazard ratio: 1.94; 95% confidence interval: 1.35 to 2.79). This difference was driven mainly by PCI with a 2-stent technique for distal bifurcation. In contrast, the adjusted risks for these outcomes were similar between DES and CABG for ostial or shaft disease.ConclusionsAmong patients with distal LMCA bifurcation disease, CABG showed lower mortality and serious composite outcome rates compared with DES beyond 5 years. However, there were no between-group differences in these outcomes among patients with ostial or shaft LMCA disease.     

冠状动脉CT血管成像对冠心病预后预测价值及治疗策略的指导意义

冠状动脉CT血管成像是筛查和诊断冠状动脉粥样硬化性心脏病的无创检查手段,但指南对于冠状动脉CT血管成像结果用于临床决策方面并无明确推荐,治疗方案的选择仍多根据临床经验决定.现从冠状动脉狭窄程度、冠状动脉钙化积分和斑块类型等的预后价值及治疗策略进行综述.