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JACC. Cardiovascular Interventions Sep 2022The comparative efficacy of percutaneous techniques for the preparation of calcified lesions before stenting remains poorly studied. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The comparative efficacy of percutaneous techniques for the preparation of calcified lesions before stenting remains poorly studied.
OBJECTIVES
This study sought to compare the performance of up-front rotational atherectomy (RA) or balloon-based techniques before drug-eluting stent implantation in severely calcified coronary lesions as assessed by angiography and optical coherence tomography (OCT).
METHODS
Patient-level data from the PREPARE-CALC (Comparison of Strategies to Prepare Severely Calcified Coronary Lesions) and ISAR-CALC (Comparison of Strategies to Prepare Severely Calcified Coronary Lesions) randomized trials were pooled. The primary endpoint was stent expansion as assessed by OCT imaging. The secondary endpoints included stent eccentricity, stent asymmetry, angiographic acute lumen gain, strategy success and in-hospital occurrence of cardiac death, target vessel myocardial infarction, and repeat revascularization.
RESULTS
Among 274 patients originally randomized, 200 participants with available OCT data after lesion preparation with RA (n = 63), a modified balloon (MB, n = 103), or a super high-pressure balloon (n = 34) before stenting were analyzed. The use of RA versus MB or a super high-pressure balloon led to comparable stent expansion (73.2% ± 11.6% vs 70.8% ± 13.6% vs 71.8% ± 12.2%, P = 0.49) and stent asymmetry (P = 0.83). Compared with RA or MB, a super high-pressure balloon was associated with less stent eccentricity (P = 0.03) with a numerically higher acute lumen gain, albeit not significantly different (P = 0.08). Strategy success was more frequent with RA versus MB (P = 0.002) and numerically more frequent with RA versus a super high-pressure balloon (P = 0.06). Clinical outcomes did not differ between groups.
CONCLUSIONS
In patients with severely calcified lesions undergoing drug-eluting stent implantation, lesion preparation with RA, MB, or a super high-pressure balloon was associated with comparable stent expansion. A super high-pressure balloon is associated with less stent eccentricity, whereas strategy success is more frequent with RA.
Topics: Angioplasty, Balloon, Coronary; Atherectomy, Coronary; Coronary Angiography; Coronary Artery Disease; Drug-Eluting Stents; Humans; Treatment Outcome; Vascular Calcification
PubMed: 36137691
DOI: 10.1016/j.jcin.2022.07.034 -
The Journal of Invasive Cardiology Dec 2019The use of debulking devices improved in the last few years, due to the expanding indications to percutaneous coronary angioplasty, involving an elevated number of... (Review)
Review
The use of debulking devices improved in the last few years, due to the expanding indications to percutaneous coronary angioplasty, involving an elevated number of coronary stenoses with heavy calcification. Rotational atherectomy has become one of the most used devices in this challenging scenario. The aim of this review is to analyze the components and the use of the Rotablator System (Boston Scientific) and to better understand helpful tips and tricks in order to face the most common complications occurring during the procedure.
Topics: Atherectomy, Coronary; Coronary Stenosis; Equipment Design; Humans; Intraoperative Complications; Vascular Calcification
PubMed: 31786529
DOI: No ID Found -
Cardiovascular and Interventional... Jul 2017Traditional percutaneous balloon angioplasty and stent placement is based on mechanical plaque disruption and displacement within the arterial wall. On the contrary,... (Review)
Review
Traditional percutaneous balloon angioplasty and stent placement is based on mechanical plaque disruption and displacement within the arterial wall. On the contrary, transcatheter atherectomy achieves atherosclerotic plaque clearance by means of directional plaque excision or rotational plaque removal or laser plaque ablation. Debulking atherectomy may allow for a more uniform angioplasty result at lower pressures with consequently less vessel barotrauma and improved luminal gain, thereby decreasing the risk of plaque recoil and dissection that may require permanent metal stenting. It has been also argued that atherectomy may disrupt the calcium barrier and optimize drug transfer and delivery in case of drug-coated balloon applications. The authors discuss the various types of atherectomy devices available in clinical practice to date and critically appraise their mode of action as well as relevant published data in each case. Overall, amassed randomized and observational evidence indicates that percutaneous atherectomy of the femoropopliteal and infrapopliteal arteries may achieve high technical success rates and seems to lessen the frequency of bailout stenting, however, at the expense of increased risk of peri-procedural distal embolization. Long-term clinical outcomes reported to date do not support the superiority of percutaneous atherectomy over traditional balloon angioplasty and stent placement in terms of vessel patency or limb salvage. The combination of debulking atherectomy and drug-coated balloons has shown promise in early studies, especially in the treatment of more complex lesions. Unanswered questions and future perspectives of this continuously evolving endovascular technology as part of a broader treatment algorithm are discussed.
Topics: Algorithms; Atherectomy; Cytoreduction Surgical Procedures; Endovascular Procedures; Equipment Design; Femoral Artery; Humans; Limb Salvage; Peripheral Vascular Diseases; Randomized Controlled Trials as Topic; Stents; Vascular Patency
PubMed: 28451812
DOI: 10.1007/s00270-017-1649-6 -
Journal of the American Heart... Nov 2022
Topics: Humans; Atherectomy; Peripheral Arterial Disease; Policy
PubMed: 36373835
DOI: 10.1161/JAHA.122.027422 -
Cardiovascular Revascularization... Jul 2019
Topics: Atherectomy; Atherectomy, Coronary; Humans; Vascular Calcification
PubMed: 31153848
DOI: 10.1016/j.carrev.2019.05.005 -
Catheterization and Cardiovascular... Oct 2021The occurrence of same-day discharge following elective rotational atherectomy cases in England and Wales during 2007-2014 increased from approximately 7 to 36%....
The occurrence of same-day discharge following elective rotational atherectomy cases in England and Wales during 2007-2014 increased from approximately 7 to 36%. High-volume centers and transradial approach were associated with more likelihood of same-day discharge. As compared with patients who stayed for overnight observation following elective rotational atherectomy, those discharged the same day as the procedure had a similar rate of 30-day mortality (0.35 and 0.50%, respectively; p = 0.409).
Topics: Atherectomy, Coronary; Elective Surgical Procedures; Humans; Pandemics; Patient Discharge; Treatment Outcome
PubMed: 34596334
DOI: 10.1002/ccd.29909 -
Cardiovascular Intervention and... Apr 2023Performing percutaneous coronary intervention (PCI) for calcified lesions is still a major challenge. Calcified lesions are a cause of inadequate dilatation, leading to... (Review)
Review
Performing percutaneous coronary intervention (PCI) for calcified lesions is still a major challenge. Calcified lesions are a cause of inadequate dilatation, leading to poor short- and long-term PCI outcomes. It has been suggested that modification for calcification before stent implantation might improve outcomes by providing adequate dilation. Intravascular lithotripsy (IVL) is available under insurance reimbursement in December 2022 in Japan. IVL is one candidate for a treatment device to modify calcified lesions in addition to atherectomy, such as rotational and orbital atherectomy, and special balloons, such as scoring and cutting balloons. Although the evidence for the indications, of these devices is insufficient, they must be used appropriately in clinical practice. In this report, we propose a method for determining an indication of these devices solely as per the coronary imaging findings with intravascular ultrasound or optical coherent tomography. This consensus document represents the collective opinion of experts on the best current indications and should be changed based on future evidence. However, we believe that it represents the optimal criteria for selecting treatment options in the current situation.
Topics: Humans; Coronary Artery Disease; Percutaneous Coronary Intervention; Atherectomy, Coronary; Treatment Outcome; Vascular Calcification
PubMed: 36780124
DOI: 10.1007/s12928-023-00914-1 -
Cardiology Journal 2019Bifurcating coronary lesions are a very common challenge in interventional cardiology because of the technical complexity in their treatment, the risk of side branch... (Review)
Review
Bifurcating coronary lesions are a very common challenge in interventional cardiology because of the technical complexity in their treatment, the risk of side branch occlusion and an overall worse outcome when compared to non-bifurcating lesions. The presence of calcifications represents further complexity due to the difficulty in device delivery and stent expansion as well as enhanced risk of side branch occlusion. Rotational and orbital atherectomy, scoring and cutting balloons, coronary lithoplasty are available tools which have been introduced over the last three decades to overcome such issue. Nevertheless, their application in different contexts of bifurcations presents specific caveats and the studies directed at comparing such techniques have never been expressly oriented in the subset of the bifurcating lesion. In this paper, we review these devices and their usefulness in bifurcations by analyzing consistent data from clinical trials, and we propose a practical algorithm for the treatment of severely calcified bifurcating lesions according to their anatomical features.
Topics: Atherectomy, Coronary; Coronary Artery Disease; Humans; Lithotripsy; Percutaneous Coronary Intervention; Severity of Illness Index; Stents; Treatment Outcome; Vascular Calcification
PubMed: 31565792
DOI: 10.5603/CJ.a2019.0094 -
EuroIntervention : Journal of EuroPCR... Jul 2020
Topics: Atherectomy, Coronary; Coronary Angiography; Coronary Artery Disease; Humans
PubMed: 32686649
DOI: 10.4244/EIJV16I4A45 -
JACC. Cardiovascular Interventions Apr 2014Rotational atherectomy facilitates percutaneous coronary intervention for complex de novo lesions with severe calcification. A strategy of routine rotational atherectomy... (Review)
Review
Rotational atherectomy facilitates percutaneous coronary intervention for complex de novo lesions with severe calcification. A strategy of routine rotational atherectomy has not, however, conferred reduction in restenosis or major adverse cardiac events. As it is technically demanding, rotational atherectomy is also uncommon. At this 25-year anniversary since the introduction of rotational atherectomy, we sought to review the current state-of-the-art in rotational atherectomy technique, safety, and efficacy data in the modern era of drug-eluting stents, strategies to prevent and manage complications, including slow-flow/no-reflow and burr entrapment, and appropriate use in the context of the broader evolution in the management of stable ischemic heart disease. Fundamental elements of optimal technique include use of a single burr with burr-to-artery ratio of 0.5 to 0.6-rotational speed of 140,000 to 150,000 rpm, gradual burr advancement using a pecking motion, short ablation runs of 15 to 20 s, and avoidance of decelerations >5,000 rpm. Combined with meticulous technique, optimal antiplatelet therapy, vasodilators, flush solution, and provisional use of atropine, temporary pacing, vasopressors, and mechanical support may prevent slow-flow/no-reflow, which in contemporary series is reported in 0.0% to 2.6% of cases. On the basis of the results of recent large clinical trials, a subset of patients with complex coronary artery disease previously assigned to rotational atherectomy may be directed instead to medical therapy alone or bypass surgery. For patients with de novo severely calcified lesions for which rotational atherectomy remains appropriate, referral centers of excellence are required.
Topics: Atherectomy, Coronary; Coronary Artery Disease; Diagnostic Imaging; Humans; Patient Selection; Predictive Value of Tests; Risk Factors; Treatment Outcome; Vascular Calcification
PubMed: 24630879
DOI: 10.1016/j.jcin.2013.12.196