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Journal of Clinical Medicine Apr 2024In-stent restenosis (ISR) remains the primary cause of target lesion failure following percutaneous coronary intervention (PCI), resulting in 10-year incidences of... (Review)
Review
In-stent restenosis (ISR) remains the primary cause of target lesion failure following percutaneous coronary intervention (PCI), resulting in 10-year incidences of target lesion revascularization at a rate of approximately 20%. The treatment of ISR is challenging due to its inherent propensity for recurrence and varying susceptibility to available strategies, influenced by a complex interplay between clinical and lesion-specific conditions. Given the multiple mechanisms contributing to the development of ISR, proper identification of the underlying substrate, especially by using intravascular imaging, becomes pivotal as it can indicate distinct therapeutic requirements. Among standalone treatments, drug-coated balloon (DCB) angioplasty and drug-eluting stent (DES) implantation have been the most effective. The main advantage of a DCB-based approach is the avoidance of an additional metallic layer, which may otherwise enhance neointimal hyperplasia, provide the substratum for developing neoatherosclerosis, and expose the patient to a persistently higher risk of coronary ischemic events. On the other hand, target vessel scaffolding by DES implantation confers relevant mechanical advantages over DCB angioplasty, generally resulting in larger luminal gain, while drug elution from the stent surface ensures the inhibition of neointimal hyperplasia. Nevertheless, repeat stenting with DES also implies an additional permanent metallic layer that may reiterate and promote the mechanisms leading to ISR. Against this background, the selection of either DCB or DES on a patient- and lesion-specific basis as well as the implementation of adjuvant treatments, including cutting/scoring balloons, intravascular lithotripsy, and rotational atherectomy, hold the potential to improve the effectiveness of ISR treatment over time. In this review, we comprehensively assessed the available evidence from randomized trials to define contemporary interventional treatment of ISR and provide insights for future directions.
PubMed: 38673650
DOI: 10.3390/jcm13082377 -
The American Journal of Cardiology Jul 2024
Topics: Humans; Atherectomy, Coronary; Coronary Artery Disease; Postoperative Complications
PubMed: 38761963
DOI: 10.1016/j.amjcard.2024.05.011 -
JACC. Cardiovascular Interventions Sep 2023There are several retrospective studies comparing rotational atherectomy (RA) and orbital atherectomy (OA), but all percutaneous coronary interventions (PCIs) in those... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
There are several retrospective studies comparing rotational atherectomy (RA) and orbital atherectomy (OA), but all percutaneous coronary interventions (PCIs) in those studies were not performed under intracoronary imaging guidance.
OBJECTIVES
This study sought to compare the efficacy and safety of optical coherence tomography (OCT)-guided PCI with RA vs OA.
METHODS
The DIRO (To directly compare RA and OA for calcified lesions, a prospective randomized trial) trial was conducted. We enrolled patients with de novo calcified lesions (arc >180°) assessed by OCT or angiographically moderate or severe calcifications if the OCT catheter could not cross the lesion before any intervention. Eligible patients were randomly 1:1 allocated to lesion preparation with RA vs OA. Stent expansion was defined as the minimum stent area divided by the distal reference area multiplied by 100. Tissue modification was assessed using preatherectomy and postatherectomy OCT images. Procedural outcomes including periprocedural myocardial infarctions were evaluated. Furthermore, clinical events and vascular healing evaluated by OCT at 8 months postprocedure were assessed.
RESULTS
The stent expansion was significantly greater in the RA group vs the OA group (99.5% vs 90.6%; P = 0.02). The maximum atherectomy area was significantly larger in the RA group than in the OA group (1.34 [IQR: 1.02-1.89] mm vs 0.83 [IQR: 0.59-1.11] mm; P = 0.004). The procedural outcomes and clinical events at 8 months did not differ between the groups. The vascular healing was sufficient in both groups.
CONCLUSIONS
The prospective randomized DIRO trial revealed that RA could produce a more favorable tissue modification, which may lead to a larger stent expansion than OA in heavily calcified lesions.
Topics: Humans; Tomography, Optical Coherence; Percutaneous Coronary Intervention; Prospective Studies; Retrospective Studies; Treatment Outcome; Atherectomy
PubMed: 37704299
DOI: 10.1016/j.jcin.2023.06.016 -
Journal of Clinical Medicine Jul 2023Present research on the influence of gender on the treatment of coronary artery disease (CAD) and the outcome after percutaneous coronary intervention (PCI) is...
Present research on the influence of gender on the treatment of coronary artery disease (CAD) and the outcome after percutaneous coronary intervention (PCI) is inconsistent. Sex differences in the presentation of CAD and the success after treatment have been described. We intend to compare the male and female sex in the procedure and the long-term outcome of Rotational Atherectomy (RA). A total of 597 consecutive patients (20.3% female and 79.7% male, mean age 75.3 ± 8.9 years vs. 72.7 ± 9 years, < 0.001) undergoing Rotational Atherectomy between 2015 and 2020 were enrolled in the analysis. Demographic and clinical data were registered. In-hospital, 1-year, and 3-year MACCEs (major adverse cardiac and cerebrovascular events) were calculated. Women presented more often with myocardial infarction (23.9% vs. 14.9%, = 0.017). The intervention was mainly performed via femoral access compared to radial access (65.4% vs. 33.6%, = 0.002). Women had a smaller diameter of the balloon predilatation compared to men (2.8 ± 0.5 mm vs. 3.15 ± 2.4 mm, < 0.05) and a smaller maximum diameter of the implanted stent (3.5 ± 1.2 mm vs. 4.10 ± 6.5 mm, = 0.01). In-hospital, 1-year-, and 3-year MACCEs did not differ between the sexes. After a multivariate analysis, no difference between men and women could be detected. In conclusion, this analysis shows differences between women and men in periprocedural characteristics but does not show any differences after RA regarding in-hospital, 1-year-, and 3-year MACCEs.
PubMed: 37568447
DOI: 10.3390/jcm12155044 -
EuroIntervention : Journal of EuroPCR... Dec 2023There is a paucity of real-world data on the in-hospital (IH) and post-discharge outcomes in patients undergoing lower extremity peripheral vascular intervention (PVI)...
BACKGROUND
There is a paucity of real-world data on the in-hospital (IH) and post-discharge outcomes in patients undergoing lower extremity peripheral vascular intervention (PVI) with adjunctive atherectomy.
AIMS
In this retrospective, registry-based study, we evaluated IH and post-discharge outcomes among patients undergoing PVI, treated with or without atherectomy, in the National Cardiovascular Data Registry PVI Registry.
METHODS
The IH composite endpoint included procedural complications, bleeding or thrombosis. The primary out-of-hospital endpoint was major amputation at 1 year. Secondary endpoints included repeat endovascular or surgical revascularisation and death. Multivariable regression was used to identify predictors of atherectomy use and its association with clinical endpoints.
RESULTS
A total of 30,847 patients underwent PVI from 2014 to 2019, including 10,971 (35.6%) treated with atherectomy. The unadjusted rate of the IH endpoint occurred in 524 (4.8%) of the procedures involving atherectomy and 1,041 (5.3%) of non-atherectomy procedures (p=0.07). After adjustment, the use of atherectomy was not associated with an increased risk of the combined IH endpoint (p=0.68). In the 6,889 (22.4%) patients with out-of-hospital data, atherectomy was associated with a reduced risk of amputation (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI]: 0.51-0.85; p<0.01) and surgical revascularisation (aHR 0.63, 95% CI: 0.44-0.89; p=0.017), no difference in death rates (p=0.10), but an increased risk of endovascular revascularisation (aHR 1.21, 95% CI: 1.06-1.39; p<0.01) at 1 year.
CONCLUSIONS
The use of atherectomy during PVI is common and is not associated with an increase in IH adverse events. Longitudinally, patients treated with atherectomy undergo repeat endovascular reintervention more frequently but experience a reduced risk of amputation and surgical revascularisation.
Topics: Humans; Retrospective Studies; Peripheral Arterial Disease; Aftercare; Endovascular Procedures; Risk Factors; Treatment Outcome; Patient Discharge; Atherectomy; Lower Extremity
PubMed: 37750241
DOI: 10.4244/EIJ-D-23-00432 -
Cardiovascular Revascularization... Jan 2024
Topics: Humans; Atherectomy, Coronary; Atherectomy
PubMed: 37537102
DOI: 10.1016/j.carrev.2023.07.021 -
Journal of Vascular Surgery Apr 2024We evaluated the midterm results of atherectomy-assisted angioplasty for the treatment of femoropopliteal lesions and the identification of possible subgroups of...
OBJECTIVE
We evaluated the midterm results of atherectomy-assisted angioplasty for the treatment of femoropopliteal lesions and the identification of possible subgroups of patients with superior outcomes.
METHODS
We conducted a single-center, physician-initiated, nonindustry-sponsored retrospective analysis of patients with Rutherford category ranging from II to V and de novo occlusive or stenotic lesions of the superficial femoral (SFA) and/or popliteal arteries treated with atherectomy-assisted angioplasty (Jetstream rotational atherectomy + drug-eluting ballooning). In cases of subintimal recanalization or patients without an SFA stamp, with previous ipsilateral bypass surgery, systemic coagulopathy, end-stage renal disease requiring hemodialysis, life expectancy of <12 months, and intolerance to aspirin, clopidogrel, and/or heparin were excluded.
RESULTS
In a total of 103 enrolled patients, the median SFA and/or popliteal lesion length was 80 mm (interquartile range, 61.2 mm) with 73 lesions being occlusive (70.9%) and 84 (81.5%) classified as Fanelli calcification score 3 and 4. Technical success was met in 96.1% of cases (n = 99) at a median operative time of 108 minutes. Adjunctive stenting was needed in 10 patients (9.8%). At a median follow-up of 18.0 ± 10.8 months, Rutherford class clinical improvement was present in 77 patients (74.8%), and 7 patients (6.79%) presented target lesion occlusion needing reintervention in 6 cases (5.82%). The primary patency rates were 97% at 12 months and 83% at 24 months with secondary patency rates of 99% at 12 months and 91% at 24 months of follow-up. There were no significant differences when treating differently located lesions, diabetic vs nondiabetic patients, or comparing experienced vs nonexperienced operators.
CONCLUSIONS
The use of rotational atherectomy and drug-eluting balloons for the treatment of severe femoropopliteal disease showed relatively low need for bailout stenting and good midterm primary patency rates. The influence of lesion location, diabetes mellitus, or operator experience did not show statistically different results in terms of patency. Longer term outcomes and comparative analysis are needed to consolidate further clinical evidence.
Topics: Humans; Femoral Artery; Atherectomy, Coronary; Retrospective Studies; Treatment Outcome; Angioplasty, Balloon; Peripheral Arterial Disease; Popliteal Artery; Atherectomy; Vascular Patency
PubMed: 38128846
DOI: 10.1016/j.jvs.2023.12.030 -
Thrombosis Journal Aug 2023Takayasu's arteritis (TAK) is a rare chronic granulomatous arteritis that mainly affects the aorta and its major branches. Coronary artery (CA) involvement can be...
Takayasu's arteritis (TAK) is a rare chronic granulomatous arteritis that mainly affects the aorta and its major branches. Coronary artery (CA) involvement can be observed in 10-25% of TAK patients. We report a 21-year-old young female who was previously diagnosed with TAK and severe left main coronary artery (LMCA) stenosis and underwent numerous percutaneous coronary interventions (PCIs) in our hospital due to in-stent restenosis (ISR). This time, an excimer laser coronary atherectomy (ELCA) and drug-coated balloon (DCB) dilation was taken at the LMCA for the ISR. The blood flow was smooth after the operation, and she was symptom-free after discharge. Unfortunately, 5 months later, severe intimal hyperplasia was still seen in the stent of LMCA and left anterior descending (LAD) coronary artery. A coronary artery bypass graft surgery (CABG) was performed, and she has been symptom-free ever since. ELCA plus DCB is one of the novel ways we first reported. However, ensuring long-term inflammation control is equally important to restore blood flow. The combination of revascularization and anti-inflammation/immunosuppression is recommended to improve the outcomes of TAK patients with CA involvements.
PubMed: 37563604
DOI: 10.1186/s12959-023-00529-9