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Catheterization and Cardiovascular... Jun 2024Intravascular lithotripsy (IVL) combined with rotational atherectomy (RA), known as Rotatripsy, is used to treat severe coronary artery calcification (CAC), though data...
BACKGROUND
Intravascular lithotripsy (IVL) combined with rotational atherectomy (RA), known as Rotatripsy, is used to treat severe coronary artery calcification (CAC), though data on efficacy, midterm safety and use sequence is limited. We aimed to identify indicators for Rotatripsy use and to assess its safety and success rates, both acutely and at 1-year follow-up.
METHODS
Patients undergoing Rotatripsy for severe CAC across six centers from May 2019 to December 2023 were included. Demographic, clinical, procedural and follow-up data were collected. Efficacy endpoints included device success (delivery of the RA-burr and IVL-balloon across the target lesion and administration of therapy without related complications), technical success (TIMI 3 flow and residual stenosis <30% by quantitative coronary analysis) and procedural success [composite of technical success with absence of in-hospital major adverse cardiovascular events (MACE: cardiac death, myocardial infarction or target vessel revascularization). Safety endpoints comprised Rotatripsy-related complications and MACE at 1-year follow-up.
RESULTS
A total of 114 patients (75 ± 9 years, 78% male) underwent Rotatripsy for 120 lesions. In the majority of procedures RA was followed by IVL, mostly electively (n = 68, 57%) but also for balloon underexpansion (n = 37, 31%) and stent crossing failure (n = 1, 1%). Diverse and complex target lesions were addressed with an average SYNTAX score of 24.6 ± 13.0. Device, technical and procedural success were 97%, 94% and 93%, respectively. Therapy-related complications included two (2%) coronary perforations, one (1%) coronary dissection and one (1%) burr entrapment. At 1-year follow-up(present in 77(67%) patients), MACE occurred in 7(9%) cases.
CONCLUSIONS
Over a 1-year follow-up period, Rotatripsy was safe and effective, predominantly using RA electively before IVL.
PubMed: 38932584
DOI: 10.1002/ccd.31140 -
Progress in Cardiovascular Diseases Jun 2024Calcific coronary artery stenosis is a complex disease associated with adverse outcomes and suboptimal percutaneous treatment. Calcium plaque modification has emerged as... (Review)
Review
Calcific coronary artery stenosis is a complex disease associated with adverse outcomes and suboptimal percutaneous treatment. Calcium plaque modification has emerged as a key strategy to tackle the issues that accompany calcific stenosis - namely reduced device deliverability, unpredictable lesion characteristics, and difficult dilatation. Atherectomy has traditionally been the treatment modality of choice for heavily calcified coronary stenoses. Contemporary technologies have emerged to aid with planning, preparation, and treatment of calcified coronary stenosis in an attempt to improve procedural success and long-term outcomes. In this State Of The Art Review, we synthesize the body of data surrounding the diagnosis, imaging, and treatment of calcific coronary disease, with a focus on i) intravascular imaging, ii) calcific lesion preparation, iii) treatment modalities including atherectomy, and iv) updated treatment algorithms for the management of calcified coronary stenosis.
PubMed: 38925256
DOI: 10.1016/j.pcad.2024.06.007 -
Journal of Cardiovascular Development... Jun 2024Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have been shown to improve the clinical outcomes of percutaneous coronary interventions (PCIs) in...
The Usefulness of Intravascular Ultrasound and Optical Coherence Tomography in Patients Treated with Rotational Atherectomy: An Analysis Based on a Large National Registry.
BACKGROUND
Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have been shown to improve the clinical outcomes of percutaneous coronary interventions (PCIs) in selected subsets of patients.
AIM
The aim was to investigate whether the use of OCT or IVUS during a PCI with rotational atherectomy (RA-PCI) will increase the odds for successful revascularization, defined as thrombolysis in myocardial infarction (TIMI) 3 flow.
METHODS
Data were obtained from the national registry of PCIs (ORPKI) maintained by the Association of Cardiovascular Interventions (AISN) of the Polish Cardiac Society. The dataset includes PCIs spanning from January 2014 to December 2021.
RESULTS
A total of 6522 RA-PCIs were analyzed, out of which 708 (10.9%) were guided by IVUS and 86 (1.3%) by OCT. The postprocedural TIMI 3 flow was achieved significantly more often in RA-PCIs guided by intravascular imaging (98.7% vs. 96.6%, < 0.0001). Multivariable analysis revealed that using IVUS and OCT was independently associated with an increased chance of achieving postprocedural TIMI 3 flow by 67% (odds ratio (OR), 1.67; 95% confidence interval (CI): 1.40-1.99; < 0.0001) and 66% (OR, 1.66; 95% CI: 1.09-2.54; = 0.02), respectively. Other factors associated with successful revascularization were as follows: previous PCI (OR, 1.72; < 0.0001) and coronary artery bypass grafting (OR, 1.09; = 0.002), hypertension (OR, 1.14; < 0.0001), fractional flow reserve assessment during angiogram (OR, 1.47; < 0.0001), bifurcation PCI (OR, 3.06; < 0.0001), and stent implantation (OR, 19.6, < 0.0001).
CONCLUSIONS
PCIs with rotational atherectomy guided by intravascular imaging modalities (IVUS or OCT) are associated with a higher procedural success rate compared to angio-guided procedures.
PubMed: 38921677
DOI: 10.3390/jcdd11060177 -
Vascular Specialist International Jun 2024Although intravascular atherectomy is widely used for debulking calcified atheromas in peripheral arterial disease, it is associated with complications. Delayed rupture...
Although intravascular atherectomy is widely used for debulking calcified atheromas in peripheral arterial disease, it is associated with complications. Delayed rupture with pseudoaneurysm formation is rare. We report the case of a 73-year-old man who developed a 24 mm×20 mm×27 mm popliteal artery (PA) pseudoaneurysm after rotational atherectomy. Initially, the patient presented with intermittent claudication. Preoperative computed tomographic angiography (CTA) showed a severely calcified atheroma in the PA. Rotational atherectomy was performed using the Jetstream™ device (Boston Scientific). Postoperatively, the ankle-brachial index and symptoms improved. However, 6 days after the atherectomy, the patient complained of calf pain and swelling. Follow-up CTA revealed a pseudoaneurysm and hematoma in the popliteal fossa. Open conversion with removal of the heavily calcified plaque and patch angioplasty were performed via the posterior approach. Delayed PA rupture and pseudoaneurysm formation after rotational atherectomy are rare; however, they require prompt management.
PubMed: 38918946
DOI: 10.5758/vsi.240046 -
Case Reports in Cardiology 2024Rotational atherectomy is an effective procedure for heavily calcified lesions and those that cannot be crossed using conventional percutaneous coronary intervention...
Rotational atherectomy is an effective procedure for heavily calcified lesions and those that cannot be crossed using conventional percutaneous coronary intervention (PCI) devices. Here, we report a rare case of intracoronary burr entrapment in the coronary artery due to burr disconnection from the driveshaft. A 67-year-old man undergoing hemodialysis for nephrosclerosis presented with exertional chest discomfort. Coronary angiography revealed stenotic lesions in the right coronary artery, and PCI was performed using a Rotawire Floppy. During the procedure, the disconnected burr was successfully removed without surgery using the child-in-mother technique with a guide extension catheter. Notably, the patient remained hemodynamically stable throughout the procedure and his recovery was uncomplicated. He was discharged on the second postprocedural day. At the 6-month follow-up, the patient remained asymptomatic with no evidence of myocardial ischemia. This report informs clinicians of the possibility of burr disconnection and the non-surgical intervention used for its removal.
PubMed: 38915476
DOI: 10.1155/2024/5482922 -
Giornale Italiano Di Cardiologia (2006) Jun 2024Coronary calcific disease represents one of the main challenges for the interventional cardiologist, for whom optimal lesion preparation and percutaneous coronary... (Review)
Review
Coronary calcific disease represents one of the main challenges for the interventional cardiologist, for whom optimal lesion preparation and percutaneous coronary intervention optimization are paramount for correct management. In this perspective, intravascular imaging using optical coherence tomography (OCT) is becoming an increasingly indispensable tool. This work aims to provide a detailed overview of the complexity of calcified lesions, first analyzing their various morphologies and their clinical impact: spotty calcium seems to be more present in plaques at higher risk of destabilization, while diffuse calcification is typical of stable coronary stenosis; the eruptive calcific nodule is one of the three culprit lesion phenotypes responsible for acute coronary syndromes.In the second part of this review, the available technologies for the treatment of calcified lesions are described, with the aid of illustrative OCT images. Intravascular lithotripsy causes fractures at various levels of the calcified plaque, both circumferentially and longitudinally, with an improvement in vessel compliance; atherectomy acts by modifying the composition of the plaque with selective action on the hard calcific component. OCT, providing a comprehensive overview of lesion characteristics, can guide in the selection of the most appropriate therapeutic strategy, while also offering important information on the effectiveness of the chosen treatment.
Topics: Humans; Tomography, Optical Coherence; Coronary Artery Disease; Vascular Calcification; Atherectomy, Coronary; Lithotripsy; Percutaneous Coronary Intervention; Plaque, Atherosclerotic
PubMed: 38912742
DOI: 10.1714/4287.42688 -
Journal of Vascular Surgery Jun 2024Within the past decade, Medicare Part B reimbursements for various surgical procedures have been declining, whereas health care expenses continue to increase. As a...
OBJECTIVE
Within the past decade, Medicare Part B reimbursements for various surgical procedures have been declining, whereas health care expenses continue to increase. As a result, hospitals may increase service charges to offset losses in revenue, which may disproportionately affect underinsured patients. Our analysis aimed to characterize Medicare billing and utilization trends across common vascular surgical procedures.
METHODS
The 2017 to 2021 Medicare Physician and Other Practitioners by Provider and Service dataset was queried for Current Procedural Terminology (CPT) codes for common vascular surgery procedures. The average charges, reimbursements, charge-to-reimbursement ratios, and service counts were calculated for the most common interventions performed by vascular surgeons. Data was stratified by care setting, facility (inpatient and outpatient hospital) vs non-facility locations. All monetary values were adjusted to the 2021 United States dollars to account for inflation.
RESULTS
For facility settings, the mean charge billed to Medicare Part B increased from $3708 to $3952 (6.6%) from 2017 to 2021, with the average charge-to-reimbursement ratio increasing from 7.2 to 8.6. There were 17 of the 19 facility procedures that had a decline in reimbursements, decreasing from an average of $558 to $499 (-10.4%). Stab phlebectomy had the largest individual decrease in facility reimbursement (-53.5%), followed by above-knee amputation (-11.3%) and below-knee amputation (-11.0%). Both non-facility charges (-10.8%) and reimbursements (-12.2%) declined over the study period. Procedural utilization remained stable from 2017 to 2019. Tibial and femoral-popliteal atherectomy had increases of 45.9% and 33.7%, respectively, in overall procedural utilization when performed in non-facility settings from 2017 to 2019.
CONCLUSIONS
Our analysis of vascular surgery procedures billed to Medicare Part B from 2017 to 2021 demonstrates an increase in charges, a decline in reimbursements, and a resultant increase in charge-to-reimbursement ratios for facility care settings. In contrast, non-facility charges have decreased in the face of declining reimbursements. These markups in submitted charges in facility locations may serve as an additional barrier to accessing care for patients who are underinsured.
PubMed: 38909918
DOI: 10.1016/j.jvs.2024.05.042 -
Journal of Vascular Surgery Jun 2024Controversy exists regarding the value and limitations of different sites of service for peripheral artery disease (PAD) treatment. We aimed to examine practice patterns...
OBJECTIVE
Controversy exists regarding the value and limitations of different sites of service for peripheral artery disease (PAD) treatment. We aimed to examine practice patterns associated with peripheral vascular interventions (PVI) performed in the office-based laboratory (OBL) vs. outpatient hospital site of service using a nationally representative database.
METHODS
Using 100% Medicare fee-for-service claims data, we identified all patients undergoing PVI for claudication or chronic limb-threatening ischemia (CLTI) between 01/2017 and 12/2022. We evaluated the associations of patient and procedure characteristics with site of service using multivariable hierarchical logistic regression. We used multinomial regression models to estimate the relative risk ratios (RRR) of site of service and intervention type (angioplasty, stent, atherectomy) and intervention level (iliac, femoropopliteal, tibial) after adjusting for baseline patient characteristics and clustering by physician.
RESULTS
Of 848,526 PVI, 485,942 (57.3%) were performed in an OBL. OBL use increased significantly over time from 48.3% in 2017 to 65.5% in 2022 (P<0.001). Patients treated in OBLs were more likely to be Black (aOR 1.14, 95%CI 1.11-1.18) or other non-white race (aOR 1.13, 95%CI 1.08-1.18), have fewer comorbidities, and receive treatment for claudication vs. CLTI (aOR 1.30, 95%CI 1.26-1.33) compared to patients treated in outpatient hospital settings. Physicians with majority practice (>50% procedures) in an OBL were more likely to practice in urban settings (aOR 21.58, 95%CI 9.31-50.02), specialize in radiology (aOR 18.15, 95%CI 8.92- 36.92), and have high-volume PVI practices (aOR 2.15, 95%CI 2.10-2.29). The median time from diagnosis to treatment was shorter in OBLs, particularly for patients with CLTI (29 vs. 39 days, P<0.001). The OBL setting was the strongest predictor of patients receiving an atherectomy alone (aRRR 6.67, 95%CI 6.59-6.76) or atherectomy+stent (aRRR 10.84, 95%CI 10.64-11.05), and these findings were consistent in subgroup analyses stratified by PVI indication. OBL setting was also associated with higher risk of tibial interventions for both claudication (aRRR 3.18, 95%CI 3.11-3.25) and CLTI (aRRR 1.89, 95%CI 1.86-1.92). Average reimbursement (including procedure and facility fees) was slightly higher for OBLs compared to the hospital ($8,742/case vs. $8,459/case; P<0.001). However, in a simulated cohort resetting the OBL's intervention type distribution to that of the hospital, OBLs were associated with a hypothetical cost savings of $221,219,803 overall and $2,602 per case.
CONCLUSION
The OBL site of service was associated with greater access to care for non-white patients and shorter time from diagnosis to treatment, but more frequently performed high-cost interventions compared to the outpatient hospital setting. The benefit to patients from improved access to PAD care in OBL settings must be balanced with the potential limitations of receiving differential care.
PubMed: 38908807
DOI: 10.1016/j.jvs.2024.06.006 -
Angiology Jun 2024We investigated the safety and efficacy of debulking infrainguinal lesions in patients with peripheral artery disease (PAD) undergoing endovascular revascularization...
Safety and Effectiveness of Debulking for the Treatment of Infrainguinal Peripheral Artery Disease. Data From the Recording Courses of vascular Diseases Registry in 2910 Patients.
We investigated the safety and efficacy of debulking infrainguinal lesions in patients with peripheral artery disease (PAD) undergoing endovascular revascularization (EVR) as part of the RECording Courses of vascular Diseases (RECCORD) registry. Patient and lesion specific characteristics, including the lesion complexity score (LCS) were analyzed. The primary endpoint encompassed: (i) clinical improvement in Rutherford categories, (ii) index limb re-interventions, and (iii) major amputations during follow-up. The secondary endpoint included the need for bail-out stenting. Overall, 2910 patients were analyzed; 2552 without and 358 with debulking-assisted EVR. Patients were 72 (interquartile range (IQR) = 15) years old and 1027 (35.3%) had diabetes. Overall complication rates were similarly low in the debulking vs the non-debulking group (4.7 vs 3.2%, = .18). However, peripheral embolizations rates were low but more frequent with debulking vs. non-debulking procedures (3.9 vs 1.1%, < .001). After adjustment for clinical and lesion-specific parameters, including LCS, no differences were noted for the primary endpoint (odds ration (OR) = 0.99, 95%CI = 0.69-1.41, = .94). Bail-out stenting was less frequently performed in patients with debulking-assisted EVR (OR = 0.5, 95%CI = 0.38-0.65, < .0001). Debulking-assisted EVR is currently used in ∼12% of EVR with infrainguinal lesions and is associated with lower bail-out stent rates but higher peripheral embolization rates; no differences were found regarding index limb re-intervention and amputation rates.
PubMed: 38904281
DOI: 10.1177/00033197241263381 -
BMC Cardiovascular Disorders Jun 2024Calcified lesions are one of the most challenging cases for PCI, where optimal angiographic results and satisfying outcomes are hard to achieve. (Comparative Study)
Comparative Study
BACKGROUND
Calcified lesions are one of the most challenging cases for PCI, where optimal angiographic results and satisfying outcomes are hard to achieve.
METHODS
We evaluated the baseline clinical, procedures characteristics and outcomes of patients with severe coronary artery calcification (CAC) who underwent coronary intravascular lithotripsy (IVL) and rotational atherectomy (RA).
RESULTS
Respectively 152 and 238 patients who underwent IVL and RA are enrolled from January 2023 to November 2023. Regarding demographic characteristics, the gender proportion, medical history of PCI and smoke history among groups reach statistical significance. Left anterior descending and right coronary artery were the main vessels treated in both groups. The 2.5 and 3.0 mm IVL balloons and 1.5 mm burr were the most commonly used. 99.3% cases were successfully implanted drug-eluting stents after IVL balloon pre-treatment, which was higher than in the group treated with RA. During hospitalization, there were no serious adverse events in the IVL group, but there were two adverse events in the RA group. Procedural complications were higher in the RA group than the IVL group (5.5% vs. 0.7%, P = 0.027).
CONCLUSIONS
IVL appears to be safe and effective for the treatment of severe CAC lesions compared to RA.
Topics: Humans; Atherectomy, Coronary; Male; Female; Lithotripsy; Vascular Calcification; Coronary Artery Disease; Aged; Treatment Outcome; Severity of Illness Index; Middle Aged; Retrospective Studies; Risk Factors; Time Factors; Drug-Eluting Stents; Coronary Angiography; Angioplasty, Balloon, Coronary; Aged, 80 and over
PubMed: 38898393
DOI: 10.1186/s12872-024-03965-1