Rotational Atherectomy in the DES Era
Rotational Atherectomy in the DES Era
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.
Introduced in the early 1990s, rotational atherectomy (RA) failed to show consistent clinical benefit and resulted in a restenosis rate of 38% at 6 months. However, RA has found a niche in improving procedural success rates in complex, heavily calcified lesions in which balloon angioplasty and stenting alone often result in failure or suboptimal stent expansion. In heavily calcified lesions, adjuvant RA prior to bare-metal stent (BMS) deployment improved stent expansion, but target lesion revascularization rates remained unacceptably high, ranging from 15–36% at 6–9 months. Reports on RA in the drug-eluting stent (DES) era are limited, but indicate significantly improved target lesion revascularization rates in heavily calcified lesions, ranging from 2–10.6% at 6 months to 3 years. Reports of RA in the DES era used focused inclusion criteria; that is, RA was indicated only for moderate to severe lesion calcification and all patients received a DES (some reports used a historical control group). To our knowledge, no study in the DES era has examined overall use of RA, including patients treated with and without DES implantation and for indications other than severe calcification. Therefore, we sought to analyze patient characteristics, procedural characteristics and in-hospital clinical outcomes of patients who underwent RA between January 1, 2004 and December 31, 2009 to better define the use of RA in the DES era.
Abstract and Introduction
Abstract
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.
Introduction
Introduced in the early 1990s, rotational atherectomy (RA) failed to show consistent clinical benefit and resulted in a restenosis rate of 38% at 6 months. However, RA has found a niche in improving procedural success rates in complex, heavily calcified lesions in which balloon angioplasty and stenting alone often result in failure or suboptimal stent expansion. In heavily calcified lesions, adjuvant RA prior to bare-metal stent (BMS) deployment improved stent expansion, but target lesion revascularization rates remained unacceptably high, ranging from 15–36% at 6–9 months. Reports on RA in the drug-eluting stent (DES) era are limited, but indicate significantly improved target lesion revascularization rates in heavily calcified lesions, ranging from 2–10.6% at 6 months to 3 years. Reports of RA in the DES era used focused inclusion criteria; that is, RA was indicated only for moderate to severe lesion calcification and all patients received a DES (some reports used a historical control group). To our knowledge, no study in the DES era has examined overall use of RA, including patients treated with and without DES implantation and for indications other than severe calcification. Therefore, we sought to analyze patient characteristics, procedural characteristics and in-hospital clinical outcomes of patients who underwent RA between January 1, 2004 and December 31, 2009 to better define the use of RA in the DES era.
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