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Cardiovascular Revascularization... Aug 2023Patients with aortic stenosis (AS) usually have concomitant calcified coronary artery disease (CAD) requiring atherectomy to improve lesion compliance and odds of...
BACKGROUND
Patients with aortic stenosis (AS) usually have concomitant calcified coronary artery disease (CAD) requiring atherectomy to improve lesion compliance and odds of successful percutaneous coronary intervention (PCI). However, there is a paucity of data regarding PCI with or without atherectomy in patients with AS.
METHODS
The National Inpatient Sample (NIS) database was queried from 2016 through 2019 using ICD-10 codes to identify individuals with AS who underwent PCI with or without atherectomy (Orbital Atherectomy [OA], Rotational or Laser Atherectomy [non-OA]). Temporal trends, safety, outcomes, costs, and correlates of major adverse cardiovascular events (MACE) were assessed using discharge weighted data.
RESULTS
Hospitalizations of 45,420 AS patients undergoing PCI with or without atherectomy were identified and of those, 88.6 %, 2.3 %, and 9.1 % were treated with PCI-only, OA, or non-OA, respectively. There was an increase in PCIs (8855 to 10,885), atherectomy [OA (165 to 300) and non-OA (795 to 1255)], and intravascular ultrasound (IVUS) use (625 to 1000). The median cost of admission was higher in the atherectomy cohorts ($34,340.77 in OA, $32,306.2 in non-OA) as compared to the PCI-only cohort ($23,683.98). Patients tend to have decreased odds of MACE with IVUS guided atherectomy and PCI.
CONCLUSIONS
This large database revealed a significant increase in PCI with or without atherectomy in AS patients from 2016 to 2019. Considering the complex comorbidities of AS patients, the overall complication rates were well distributed among the different cohorts, suggesting that IVUS guided PCI with or without atherectomy in patients with AS is feasible and safe.
Topics: Humans; Percutaneous Coronary Intervention; Inpatients; Treatment Outcome; Vascular Calcification; Atherectomy, Coronary; Coronary Artery Disease; Atherectomy; Aortic Valve Stenosis; Coronary Angiography
PubMed: 36997465
DOI: 10.1016/j.carrev.2023.03.008 -
Cardiology in ReviewPeripheral artery disease affects millions of people worldwide, and it is associated with significantly higher morbidity and mortality. In addition, it represents a...
Peripheral artery disease affects millions of people worldwide, and it is associated with significantly higher morbidity and mortality. In addition, it represents a significant challenge for the interventional operators to appropriately and successfully revascularize heavily calcified stenoses. There are several established atherectomy devices with the risk of procedural complications including dissection and perforation, among others. Intravascular lithotripsy (IVL) is a novel tool with relatively less procedural risk compared to the existing modalities. It is a device that emits high-energy ultrasound waves mounted on a balloon catheter that causes fractures on the calcium plaques allowing balloon expansion and luminal gain. Five trials have been published showing the safety and effectiveness of IVL, including one trial evaluating the device in common femoral artery and infrapopliteal arteries. The available data from the limited number of trials are very encouraging and demonstrates minimal risk. Additional studies on a larger scale are needed further to understand the its long-term effects and possible risks.
Topics: Humans; Vascular Calcification; Treatment Outcome; Peripheral Arterial Disease; Constriction, Pathologic; Lithotripsy
PubMed: 36580408
DOI: 10.1097/CRD.0000000000000483 -
Deutsche Medizinische Wochenschrift... Oct 2023In addition to conservative therapy with intensive walking training, endovascular revascularisation and open vascular surgical revascularisation are of high importance...
In addition to conservative therapy with intensive walking training, endovascular revascularisation and open vascular surgical revascularisation are of high importance in the treatment of peripheral arterial disease. Over the past decades, endovascular therapy has developed considerably and is now the treatment of choice for most vascular segments. The use of different devices has been shown to be beneficial for different vessel segments. Primary stent angioplasty has been shown to be superior to balloon angioplasty with secondary stent implantation for the treatment of iliac lesions. Femoropopliteal, the use of paclitaxel-eluting balloon angioplasty is recommended. A mortality signal shown in a meta-analysis was not confirmed. With directional atherectomy and intravascular lithotripsy, different options for plaque modification are available. The cytostatic drug sirolimus as another antirestenotic substance still has to be investigated in large, randomised trials. A final assessment of the effectiveness and safety is not yet possible. Infrapopliteal balloon angioplasty remains the standard treatment. After interventional therapy, regular follow-up is recommended.
Topics: Humans; Peripheral Arterial Disease; Angioplasty, Balloon; Femoral Artery; Atherectomy; Stents; Treatment Outcome; Popliteal Artery; Coated Materials, Biocompatible
PubMed: 37757890
DOI: 10.1055/a-2017-7786 -
Catheterization and Cardiovascular... Nov 2023The safety and efficacy of intravascular lithotripsy (IVL) for the treatment of calcified distal left main (LM) disease remains unclear, especially compared to...
BACKGROUND
The safety and efficacy of intravascular lithotripsy (IVL) for the treatment of calcified distal left main (LM) disease remains unclear, especially compared to rotational atherectomy (RA).
METHODS
We retrospectively analyzed the baseline clinical, angiographic, intravascular ultrasound (IVUS) characteristics and procedural outcomes of 107 patients who underwent distal LM percutaneous coronary intervention (PCI) with IVL (with or without adjunct atherectomy) versus RA alone for plaque modification before stenting at a single center between 2020 and 2022.
RESULTS
A total of 50 patients underwent calcium modification with IVL with or without adjunct atherectomy and 57 with RA only. The mean age was 73 years and with a high prevalence of diabetes (58.9%), chronic kidney disease (42.1%), prior revascularization (coronary artery bypass graft surgery [36.4%] or prior PCI [32.7%]). Acute coronary syndrome was the primary indication for PCI in over 50% of the patients in both groups. Medina 1-1-1 LM bifurcation disease was identified in 64% and 60% of the IVL and RA groups (p = 0.64) respectively. Final minimum stent area in distal LM (>8.2 mm ), ostial LAD (>6.3 mm ) and ostial LCX (>5.0 mm ) were achieved in 96%, 85% and 89% of cases treated with IVL respectively and 93%, 93% and 100% of cases treated with RA respectively (LM p = 1.00; LAD p = 0.62; LCX; p = 1.00 for difference between the two groups). Procedural success (technical success without in-hospital major adverse events) was achieved in 98% of the IVL group and 86% of the RA-only group (p = 0.04). There were eight procedural complications (flow-limiting dissection, perforation, or slow/no-reflow) in the RA group compared to four in the IVL group (NS), and one patient in the RA required salvaged mechanical support compared to none in the IVL group.
CONCLUSION
Plaque modification with coronary IVL appears to be efficacious and safe for the treatment of severely calcified distal LM lesions compared to RA only. Larger randomized studies are needed to confirm these findings.
Topics: Humans; Aged; Coronary Artery Disease; Atherectomy, Coronary; Percutaneous Coronary Intervention; Retrospective Studies; Coronary Angiography; Treatment Outcome; Vascular Calcification; Lithotripsy; Plaque, Atherosclerotic
PubMed: 37890004
DOI: 10.1002/ccd.30855 -
Zentralblatt Fur Chirurgie Oct 2023Catheter-based atherectomy has been discussed for some years, although the conclusions have been controversial. Recent study data did show the feasibility of...
Catheter-based atherectomy has been discussed for some years, although the conclusions have been controversial. Recent study data did show the feasibility of multifunctional atherectomy devices for complex lesion morphologies, with moderate material use. This is then thus an alternative to bypass surgery, although a direct comparison is lacking.The results of the ByCross approval study were compared to technical and clinical data from various atherectomy systems in terms of range of indication, limitations as defined by the manufacturer, the success and complication rate and the instructions for use. As in many recent studies, a residual stenosis ≤ 50% after atherectomy and ≤ 30% in the completion imaging was defined as the primary endpoint and proof of technical success.Lesions recruited for the ByCross study were more complex than in other studies, with respect to the lesion length (124.7 mm vs. 34 mm in the EASE study and 67.2 mm in the VISION study) and the degree of stenosis (99.4% vs. 88.5% in the EASE and 78,7% in the VISION study). Calcification was also more severe - as defined by the PACSS (Peripheral Artery Calcification Severity Score). ByCross allowed recanalisation of lesions without wire passage prior to atherectomy (26.82%), which is a must for all other systems. The variable tip diameter of the ByCross can achieve a lumen gain of 4.7 mm without tip or wire exchange or run time limits. The 0% rate of embolic events, which is unique for atherectomy device approval studies, can be explained by the working principle and the high aspiration rate. No vessel injuries occurred, and the 6-month follow-up results showed 0% revascularisation rate.New generation atherectomy systems offer safe and effective enlargement of the endovascular portfolio. The ByCross device is an atherectomy, thrombectomy and crossing device free from investment and has a wider range of indications for the iliac and the femorodistal segments, which supports ByCross atherectomy as an alternative for bypass surgery.
Topics: Humans; Treatment Outcome; Constriction, Pathologic; Atherectomy
PubMed: 37699429
DOI: 10.1055/a-2156-5891 -
Cardiovascular Revascularization... May 2024
PubMed: 38744618
DOI: 10.1016/j.carrev.2024.05.015 -
Annals of Vascular Surgery Apr 2024The use of atherectomy for peripheral vascular interventions (PVIs) has increased exponentially and reached 18% of all PVI in the United States. The theoretical benefit...
The use of atherectomy for peripheral vascular interventions (PVIs) has increased exponentially and reached 18% of all PVI in the United States. The theoretical benefit on extensive arterial calcification relies on the concept of plaque modification and removal instead of displacement, as with other endovascular techniques. To date, there are no prospective studies comparing the different atherectomy technologies (directional, rotational, orbital, and laser). Moreover, most related prospective comparative studies have a small number of patients, and larger studies are single arm in patients with relatively mild to moderate disease burden. While available literature shows lower dissection risk and reduced bailout stenting, the superiority of this technology compared to other endovascular techniques has yet to be proven. Despite the lack of level 1 evidence to support its superiority, the lucrative reimbursement fueled the overuse of this technology as first-line therapy, particularly in office-based laboratories and ambulatory surgery centers. The use of atherectomy ought to be selective and complementary to other endovascular technologies, and individualized patient-level decision-making based on the practitioner's preference and expertise is essential to selectively incorporate atherectomy in managing complex atherosclerotic lesions.
PubMed: 38583766
DOI: 10.1016/j.avsg.2023.12.104 -
Catheterization and Cardiovascular... Oct 2023The effectiveness of combined atherectomy and stenting relative to use of each procedure alone for the treatment of lower extremity peripheral artery disease has not...
BACKGROUND
The effectiveness of combined atherectomy and stenting relative to use of each procedure alone for the treatment of lower extremity peripheral artery disease has not been evaluated.
AIMS
The objective of this study was to evaluate the short- and long-term major adverse limb event (MALE) following the receipt of stenting, atherectomy, and the combination of stent and atherectomy.
METHODS
A retrospective cohort of patients undergoing atherectomy, stent, and combination stent atherectomy for lower extremity peripheral artery disease was derived from the Vascular Quality Initiative (VQI) data set. The primary outcome was MALE and was assessed in the short-term and long-term. Short-term MALE was assessed immediately following the procedure to discharge and estimated using logistic regression. Long-term MALE was assessed after discharge to end of follow-up and estimated using the Fine-Gray subdistribution hazard model.
RESULTS
Among the 46,108 included patients, 6896 (14.95%) underwent atherectomy alone, 35,774 (77.59%) received a stent, and 3438 (7.5%) underwent a combination of stenting and atherectomy. The adjusted model indicated a significantly higher odds of short-term MALE in the atherectomy group (OR = 1.35; 95% confidence interval [CI]:1.16-1.57), and not significantly different odds (OR = 0.93; 95% CI:0.77-1.13) in the combination stent and atherectomy group when compared to stenting alone. With regard to long-term MALE, the model indicated that the likelihood of experiencing the outcome was slightly lower (HR = 0.90; 95% CI:0.82-0.98) in the atherectomy group, and not significantly different (HR = 0.92; 95% CI:0.82-1.04) in the combination stent and atherectomy group when compared to the stent group.
CONCLUSIONS
Patients in the VQI data set who received combination stenting and atherectomy did not experience significantly different rates of MALE when compared with stenting alone. It is crucial to consider and further evaluate the influence of anatomical characteristics on treatment strategies and potential differential effects of comorbidities and other demographic factors on the short and long-term MALE risks.
Topics: Humans; Retrospective Studies; Femoral Artery; Treatment Outcome; Risk Factors; Atherectomy; Peripheral Arterial Disease; Lower Extremity; Stents
PubMed: 37560820
DOI: 10.1002/ccd.30799 -
International Journal of Cardiology Nov 2023Coronary calcification is common and increases the difficulty of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
BACKGROUND
Coronary calcification is common and increases the difficulty of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
METHODS
We examined the impact of calcium on procedural outcomes of 13,079 CTO PCIs performed in 12,799 patients at 46 US and non-US centers between 2012 and 2023.
RESULTS
Moderate or severe calcification was present in 46.6% of CTO lesions. Patients whose lesions were calcified were older and more likely to have had prior coronary artery bypass graft surgery. Calcified lesions were more complex with higher J-CTO score (3.0 ± 1.1 vs. 1.9 ± 1.2; p < 0.001) and lower technical (83.0% vs. 89.9%; p < 0.001) and procedural (81.0% vs. 89.1%; p < 0.001) success rates compared with mildly calcified or non-calcified CTO lesions. The retrograde approach was more commonly used among cases with moderate/severe calcification (40.3% vs. 23.5%; p < 0.001). Balloon angioplasty (76.6%) was the most common lesion preparation technique for calcified lesions, followed by rotational atherectomy (7.3%), laser atherectomy (3.4%) and, intravascular lithotripsy (3.4%). The incidence of major adverse cardiovascular events (MACE) was higher in cases with moderate or severe calcification (3.0% vs. 1.2%; p < 0.001), as was the incidence of perforation (6.5% vs. 3.4%; p < 0.001). On multivariable analysis, the presence of moderate/severe calcification was independently associated with lower technical success (odds ratio, OR = 0.73, 95% CI: 0.63-0.84) and higher MACE (OR = 2.33, 95% CI: 1.66-3.27).
CONCLUSIONS
Moderate/severe calcification was present in nearly half of CTO lesions, and was associated with higher utilization of the retrograde approach, lower technical and procedural success rates, and higher incidence of in-hospital MACE.
Topics: Humans; Percutaneous Coronary Intervention; Calcium; Risk Factors; Coronary Occlusion; Coronary Angiography; Calcinosis; Chronic Disease; Treatment Outcome; Registries
PubMed: 37562751
DOI: 10.1016/j.ijcard.2023.131254