Trends in Usage and Clinical Outcomes of Coronary Atherectomy: A Report From the National Cardiovascular Data Registry CathPCI Registry.

BACKGROUND: Adjunctive coronary atherectomy (CA) can be utilized in treating severely calcified coronary lesions; however, the temporal trends, patient selection, and variation in use of CA have not been well described. We sought to assess the trends in usage, interhospital variability, and outcomes with CA among patients undergoing percutaneous coronary intervention (PCI). METHODS: All patients undergoing PCI in the National Cardiovascular Data Registry CathPCI Registry from July 1, 2009 to December 31, 2016 (N=3 864 377) were analyzed based on utilization of either rotational or orbital CA. Intervals using date of index CA grouped into 2009 Q3 to 2010, 2011 to 2012, 2013 to 2014, and 2015 to 2016 and hospital-level quartiles based on annual CA volumes were evaluated. The primary outcome measure was in-hospital major adverse cardiac events defined as a composite of all-cause mortality, periprocedural myocardial infarction, or stroke. Independent variables associated with outcomes were determined. RESULTS: CA represented 1.7% (n=65 033) of the total PCI volume. Among hospitals performing PCI (n=1672), 577 (34.5%) did not perform any CA. Patients treated with CA were elderly, more often male, and had a history of diabetes, prior myocardial infarction, PCI, and coronary artery bypass grafting. The utilization of CA increased from 1.1% in Q3 2009 to 3.0% in Q4 of 2016 (5% quarterly increase in odds of CA; OR [95% CI], 1.05 [1.04-1.06], P<0.001). Among patients undergoing CA, there was a temporal decline in major adverse cardiac events (0.98 [0.97-0.99], P<0.001) and myocardial infarction (0.97 [0.96-0.98], P<0.001). In adjusted analyses, increasing hospital CA volume was associated with lower mortality (0.85 [0.76-0.96], P=0.01) and lower rates of PCI failure or complication requiring coronary artery bypass grafting (0.67 [0.56-0.79], P<0.001) but was associated with small increase in coronary perforation (1.18 [1.04-1.35], P<0.01). CONCLUSIONS: Although CA is performed infrequently, its use has increased over time. After accounting for potential confounders, higher CA volume was associated with lower risk of major adverse events counterbalanced by small risk of coronary perforation.

Rotational atherectomy in the drug-eluting stent era: a single-center experience.

BACKGROUND: In heavily calcified lesions, rotational atherectomy (RA) improves procedural success and facilitates stent deployment. Reports on RA in the drug-eluting stent (DES) era are limited. The objective of this study was to determine the presenting characteristics, procedural and in-hospital clinical outcomes of patients who underwent RA at our institution in the DES era. METHODS: Consecutive cases involving RA between January 1, 2004 and December 31, 2009 at a private, tertiary referral hospital were reviewed retrospectively. RESULTS: A total of 158 patients (236 lesions) who underwent RA are described, including 112 patients (158 lesions) with subsequent DES implantation, 19 patients (28 lesions) with bare-metal stent (BMS) implantation, and 27 patients (50 lesions) with no stent. RA was utilized to modify heavily calcified plaque (84%), as bail-out therapy (16%), to preserve the patency of sidebranches (25%) and as debulking therapy for chronic total occlusion (13 lesions) and in-stent restenosis (7 lesions). DES were not placed in 46 patients (23%) due to reference vessel diameter < 2.25 or > 3.75 mm, inability to deliver DES, or desire to avert clopidogrel therapy. Angiographic and procedural success rates were significantly higher in the DES and BMS groups compared with the no stent group (angiographic success: 99.1% for DES versus 95% for BMS versus 63% for no stent; p < 0.05; procedural success: 96.4% for DES versus 95% for BMS versus 63% for no stent; p < 0.05). CONCLUSION: In the DES era, RA remains utilized primarily to modify heavily calcified plaque. In unadjusted analysis, procedural success appears high with subsequent stent placement (DES or BMS) versus RA alone. However, 1 in 4 are not candidates for stent placement, and the lower procedural success rate in this population should be considered prior to embarking on RA.

Intervencionismo coronario en lesiones severamente calcificadas mediante aterectomía rotacional y stent liberador de paclitaxel: resultados tras un año de seguimiento / Percutaneous coronary intervention in heavily calcified lesions using rotational atherectomy and paclitaxel-eluting stents: outcomes at one year

Las lesiones severamente calcificadas dificultan el intervencionismo coronario. La aterectomía rotacional permite tratar estas lesiones y los stents liberadores de paclitaxel (SLP) reducen la reestenosis a largo plazo. Se evaluó retrospectivamente el resultado de la aterectomía rotacional y los SLP en lesiones severamente calcificadas en 50 pacientes consecutivos. Se estudió la mortalidad y la revascularización de la lesión tratada tras 1 año (mediana, 14 meses; intervalo intercuartílico, 8,75-25,5). El 52% eran mayores de 70 años; el 68%, varones; el 52% tenía síndrome coronario agudo; el 80%, enfermedad multivaso y un 44% recibió abciximab. Hubo 2 muertes intrahospitalarias, 3 en el seguimiento (una cardiaca) y 3 (6%) casos de revascularización de la lesión tratada. A 1 año, la supervivencia libre de muerte cardiaca fue del 94% y la supervivencia libre de revascularización de la lesión tratada, del 94%; esto muestra que la estrategia de SLP y aterectomía rotacional en lesiones severamente calcificadas proporciona excelentes resultados (AU)

Heavily calcified lesions present a challenge for percutaneous coronary intervention. With rotational atherectomy, it is possible to treat these lesions and paclitaxel-eluting stents (PESs) reduce the risk of restenosis over the long term. This retrospective study investigated clinical outcomes with rotational atherectomy and PESs in 50 consecutive patients with heavily calcified lesions. Mortality and target lesion revascularization at 1 year (median, 14 months; interquartile range, 8.75-25.5 months) were recorded. Some 52% of patients were aged over 70 years, 68% were male, 52% had acute coronary syndrome, 80% had multivessel disease and 44% were receiving abciximab. Two patients died in hospital, three died during follow-up (one cardiac death) and 3 (6%) underwent target lesion revascularization. At 1 year, the survival rate free of cardiac death was 94% and the survival rate free of target lesion revascularization was 94%. These findings demonstrate that the combination of rotational atherectomy and PESs gives excellent results in heavily calcified lesions (AU)

Management of calcified lesions in 2004.

Calcified lesions are encountered with increasing frequency in the catheterization laboratory. Percutaneous coronary interventions of calcified lesions are associated with a higher complication rate than percutaneous intervention on non-calcified lesions. The review focuses on current management strategies in the drug eluting stent era of this complex lesion subset. Evidence based approaches to treat calcified coronary lesions with balloon based and atherectomy devices as adjunctive modalities in the drug eluting stent era are discussed in this article.

Directional coronary atherectomy in 2005.

The original aim of atherectomy was to reduce restenosis by means of aggressive plaque debulking, and the failure of large randomized trials to show any advantage of atherectomy over balloon angioplasty restricted its wider application. However, single-center registries in which aggressive debulking was performed by experienced operators have reported favorable results in terms of reduced restenosis and improved clinical outcomes when atherectomy was performed before stenting. Plaque debulking reduces the potential for plaque shift and facilitates subsequent high-pressure stent expansion, smoothes the internal vessel surface, scaffolds intimal flaps, and prevents elastic recoil. It has also been demonstrated that atherectomy can play a role in the treatment of complex lesions (ostial left anterior descending coronary artery lesions, left main lesions, and bifurcations), in which plaque shift may compromise the result of the procedure. New-generation devices have shown that atherectomy can be safely and effectively used to treat even relatively small vessels. In the current era of drug-eluting stents characterized by a considerable reduction in restenosis rates, optimal stent geometry and final luminal diameter are still important predictors of restenosis. Given the possible role of plaque shifting at the edges of a stent in causing restenosis, debulking could be added to the local drug effect in complex lesions.

Contemporary trends in coronary intervention: a report from the Registry of the Society for Cardiac Angiography and Interventions.

This report of the Registry for the Society for Cardiac Angiography and Interventions provides data on the trends in coronary interventional procedures from the time period June 1966 through December 1998. A total of 19,510 consecutive coronary interventional procedures were recorded. Over this time period, significant trends in coronary stent implantation were recorded along with a decreasing reliance on balloon angioplasty as sole therapy. Patients with acute myocardial infarction comprised an increased fraction of all procedures. Almost half of all interventions were performed in patients with multivessel disease. Finally, decreasing rates of in-hospital death and emergent bypass surgery compared to prior reports from the registry characterize the current practice of interventional cardiology. Cathet. Cardiovasc. Intervent. 49:19-22, 2000.

Evolving trends in interventional device use and outcomes: results from the National Cardiovascular Network Database.

BACKGROUND: Although multiple new coronary interventional devices have been approved for marketing in the United States, use of these technologies in general clinical practice and their associated outcomes have not been reported. METHODS AND RESULTS: Using the National Cardiovascular Network's Coronary Interventional Database, we examined temporal trends in the use and outcomes of coronary stents, lasers, directional atherectomy, and rotational atherectomy devices at 12 US hospitals between January 1994 and December 1997 (n = 76,904). Over this period, the percentage of cases involving coronary stents rose more than 12-fold (from 5.4% in 1994 to 69.0% in 1997). In contrast, use of atherectomy-type devices declined significantly. Device selection was strongly influenced by the patient's coronary anatomy and procedural indication, but less by age, sex, or race. Device use also varied significantly among individual centers (4-fold variation among sites in stent use and 6-fold variation in atherectomy use) even after adjusting for patient characteristics. Although overall mortality rates were unchanged during this 4-year period, procedural success rates have improved and complication rates have declined significantly. Lengths of postprocedure hospital stay also fell significantly for all patients undergoing coronary intervention in this time period. CONCLUSIONS: Percutaneous interventional strategies are rapidly changing with the explosive growth of coronary stent use and the decline in use of atherectomy devices. Patient outcomes, including complication rates and postprocedure lengths of stay, have also improved as the new interventional strategies have been refined in clinical practice.

Directional coronary atherectomy: from therapeutic device to research tool in coronary artery disease.

Directional coronary atherectomy (DCA) was introduced as a new percutaneous revascularization modality in 1990, and was initially applied to large vessels without tortuosity or calcification, with overall results including a 95% procedural success, 94% clinical success and 4.6% major complications (urgent bypass surgery in 3.8%, Q wave myocardial infarction in 1.7%, and hospital mortality in 0.3% of patients). In addition to its established efficacy for eccentric lesions, newer applications emerged such as treatment of saphenous vein grafts, thrombus-associated lesions, aorto-ostial lesions, failed or suboptional coronary angioplasty results, bifurcation lesions and use as a part of multi-vessel intervention. Comparative studies with coronary angioplasty such as CAVEAT I and II and CCAT showed better success rates with DCA vs coronary angioplasty, but failed to demonstrate benefit in restenosis rates. OARS and BOAT studies helped define optimal atherectomy techniques, which led to better acute angiographic results and to the "debulking plus stenting" concept. A spin-off of those clinical applications has been the opportunity to study the histology of tissue excised by DCA in vivo in different clinical settings. Such studies, investigating plaque ulceration, thrombosis and inflammation are reviewed, with special emphasis on new insights into unstable angina; the future of atherectomy research is also outlined with a categorization of various possible protocols to be applied utilizing coronary atherectomy specimens from live patients.

Coronary interventions approaching the year 2000.

Interventional cardiology is only 22 years old, but its successes at the end of this century stand heavily on the shoulders of innovative pioneers who labored earlier in the century. Balloon angioplasty gradually developed and eventually achieved great success in treating America's greatest health risk, coronary artery disease, through the 1980s. Both mortality benefit and symptom improvement have been demonstrated for coronary angioplasty, making it one of the most frequently performed procedures in the world today. In an effort to overcome acute complications and late restenosis, atherectomy devices and stents became useful tools over the past decade. As the generation of baby boomers begins to swell the ranks of the middle aged and elderly in the early 21st century, it is with great hope that molecular biology and the continued development of the technology of interventional cardiology will allow even greater successes in decreasing death and disability from ischemic heart disease.

[Rationale for coronary recanalization using transluminal atherectomy]. / Razionale della ricanalizzazione coronarica mediante aterectomia transluminale.

Although balloon angioplasty represented a significant advance in the treatment of coronary artery disease, this procedure is limited by acute occlusion and late restenosis. Among the new devices proposed to overcome the limitations of balloon catheters, Simpson's atherocath has the unique property of removing the atherosclerotic plaques from the coronary wall. Size and stiffness of the terminal portion limit the use of the atherocath to the proximal, non tortuous portion of coronary vessels more than 2.5 mm in size. Studies comparing atherectomy with balloon angioplasty have demonstrated a greater acute luminal gain with atherectomy but have failed to prove a clinical advantage from this better initial results. Atherectomy however is a rapidly evolving technology: better devices and more aggressive dilating strategies could significantly modify the conclusions of the earlier studies. In the meantime atherectomy is providing a unique opportunity to study vascular wall pathology.