Coronary perforation complicating rotational ablation: the U.S. multicenter experience.

This study retrospectively analyzed the data within the U.S. Multicenter Registry for Rotational Ablation to determine the incidence of coronary perforation during rotational ablation, its angiographic predictors and clinical outcomes during 2953 consecutive patients, 3717 lesions. Patients were categorized into Group A (without perforation, N = 2931) and Group B (with perforation, N = 22 patients). Perforation occurred in 0.7% of procedures, and in 0.6% of lesions treated and was more frequent within the right (12/ 1105, 1.1%) and circumflex (9/761, 1.2%) arteries than the left anterior descending artery [1/1727, 0.06%; (P < 0.001)]. Morphologic features associated with increased perforation rates were eccentricity, tortuousity, and lesion length > 10 mm. Group B was assessed with regard to major complications, including death, surgery, myocardial infarction, or tamponade (type I); and minor complications; sealing with balloon angioplasty and without clinical sequelae (type II). There were 15 type I: emergency surgery in nine, of whom two died, and six infarctions (5 non-Q wave and one Q wave); and 7 type II patients. Coronary perforation, although a rare complication of rotational ablation, is seen more frequently in the right and circumflex coronary arteries than the left anterior descending artery, and occurs more frequently with lesion eccentricity, tortuousity, and length > 10 mm.

Cocktail attenuation of rotational ablation flow effects (CARAFE) study: pilot.

Although rotational ablation has been successful in the treatment of complex coronary lesions, periprocedural complications of microvascular-mediated ischemia (slow flow or no reflow) and coronary vasospasm may occur. In an attempt to reduce such complications, a drug cocktail consisting of a combination of verapamil 10 micrograms/ml, nitroglycerin 4 micrograms/ml, and heparin 20 U/ml was infused in 21 consecutive patients with AHA/ACC Type B2 and C lesion morphology. A total of 27 lesions were treated, with a procedural success rate of 95%. One patient required emergency bypass surgery. Coronary vasospasm occurred in 7% (2/27 lesions). Only one lesion (3.7%) was associated with a transient reduction in TIMI flow that resolved within 5 min, and none had classical no-reflow. No patient developed intraluminal thrombus, and none had hypotension requiring inotropic support. All patients had prophylactic temporary pacemakers inserted. All RCA and circumflex lesions and 50% of LAD stenoses required transient pacing. A "cocktail" infusion of verapamil, nitroglycerin, and heparin mixed in pressurized saline delivered through the 4-French Teflon sheath of the Rotablator system during rotational ablation is associated with high success and low complication rates. Transient AV block is frequent, especially when treating RCA and circumflex arteries; therefore, prophylactic pacing is indicated.

Percutaneous coronary rotational atherectomy: New Jersey experience.

Complex coronary lesions can be approached percutaneously with rotational atherectomy. The first 70 procedures were performed at Newark Beth Israel Medical Center with a success rate of 94 percent. Despite treating a high-risk patient population, the complication rate was low.

Restenosis following transluminal angioplasty in experimental atherosclerosis.

Percutaneous transluminal angioplasty has received considerable attention in the treatment of obstructive atherosclerotic lesions in humans. However, restenosis frequently occurs and has limited the long-term effectiveness of this procedure. To study restenosis, a model of atherosclerosis was developed in 16 New Zealand rabbits. Atherosclerosis was induced in one or both iliac vessels by balloon deendothelialization followed by a 2% cholesterol diet for 6 weeks. Angiographic lesions were demonstrable in all animals. Fourteen iliac vessels served as controls, and nine underwent successful angioplasty with an increase in luminal diameter from 1.0 +/- 0.2 to 1.9 +/- 0.4 mm (p less than 0.01). After 4 weeks on a high cholesterol diet, all animals had another angiogram, which documented significant progression of disease in only six of 14 control iliac vessels, but in all nine dilated vessels. The average decrease in luminal diameter was 0.2 +/- 0.3 mm for the control group compared with 1.6 +/- 0.5 mm for the dilated group (p less than 0.01). Histopathological correlates revealed further remodeling of at various stages of organization and recanalization. In summary, this study demonstrates that restenosis occurs following transluminal angioplasty and is significantly more frequent than the natural progression of disease in a rabbit model of atherosclerosis. The mechanism of this restenosis appears to be related to intraluminal thrombosis and acceleration of atherosclerosis. Evaluation of antiplatelet drugs in the prevention of restenosis seems warranted.

Acute effects of transluminal angioplasty in three experimental models of atherosclerosis.

Transluminal angioplasty has shown promise as a nonoperative treatment of atherosclerotic obstruction. Despite its increasing clinical use and potential importance, little is known of its mechanism and acute effects. To evaluate transluminal angioplasty, three rabbit models of experimental atherosclerosis were developed: Group 1 (n = 20) = high cholesterol diet plus balloon de-endothelialization; Group 2A (n = 12) = high cholesterol diet plus an indwelling catheter; Group 2B (n = 10) = normal diet plus an indwelling catheter. After 6 weeks or 8 weeks, distinct angiographic and pathological lesions in the iliac artery were evident in all groups. Group 1 showed predominant foam cell lesions, while Group 2 showed eccentric mixed fibrous and foam cell or only fibrous lesions. Significant angiographic stenosis was present in 78% of the animals. Angioplasty of the highest grade iliac stenosis resulted in at least a 20% reduction in luminal diameter narrowing in 26 of 37 animals (70%). Histopathological examination 1 day following angioplasty in 17 animals showed two patterns. In Group 1 animals, neointimal fracture and dissection were evident, while in Group 2 animals thinning and stretching of the nonatherosclerotic portion of the vessel walls could be demonstrated. This study demonstrates that the New Zealand rabbit can be used to produce a spectrum of morphologically distinct atherosclerotic lesions that lend themselves to the study of transluminal angioplasty. The immediate consequences of angioplasty, which appear to depend upon the underlying histopathology and widening of the narrowed lumen, are frequently concurrent with intimal fracture, dissection, or thinning of the nonatherosclerotic portion of the vessel wall.