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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 -
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 -
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 -
Revista Portuguesa de Cardiologia :... Apr 2015Percutaneous coronary intervention is currently the most common form of revascularization for symptomatic coronary artery disease. In elderly, diabetic and renal... (Review)
Review
Percutaneous coronary intervention is currently the most common form of revascularization for symptomatic coronary artery disease. In elderly, diabetic and renal patients, there is an increased prevalence of calcified coronary disease. Rotational atherectomy (RA) can be useful in the treatment of these lesions. Plaque removal was initially proposed as an alternative to balloon angioplasty, hence RA required high-velocity protocols with large-sized burrs (over 2.0 mm). With a high incidence of acute complications and disappointing restenosis rates, the use of RA dwindled. However, the advent of drug-eluting stents, which significantly decreased the rate of restenosis, led to the repositioning of RA as an adjunctive technique in the preparation of densely calcified lesions, improving stent delivery and expansion. In recent years, a better understanding of the mechanism of action of RA has changed it from a plaque debulking to a compliance modifying technique. As a result, RA has become less aggressive, using smaller size burrs and lower rotational speeds. This conservative approach has improved immediate results, with increased safety and better long-term outcomes. In this review paper, the technique of RA is explained in the light of current knowledge.
Topics: Atherectomy, Coronary; Coronary Artery Disease; Equipment Design; Humans
PubMed: 25843308
DOI: 10.1016/j.repc.2014.11.011 -
The Journal of Invasive Cardiology May 2014A number of atherectomy devices were developed in the last few years. Among them, the DiamondBack 360° Peripheral Orbital Atherectomy System (Cardiovascular Systems,... (Review)
Review
A number of atherectomy devices were developed in the last few years. Among them, the DiamondBack 360° Peripheral Orbital Atherectomy System (Cardiovascular Systems, Inc) was specifically designed to work in severely calcified plaque. This article reviews the history, mechanism of action, evolution, clinical data, and future applications of this particular atherectomy device.
Topics: Angioplasty, Balloon; Atherectomy; Endovascular Procedures; Equipment Design; Humans; Plaque, Atherosclerotic; Stents
PubMed: 24791720
DOI: No ID Found -
Journal of the American Heart... Nov 2022Background Atherectomy has become the fastest growing catheter-based peripheral vascular intervention performed in the United States, and overuse has been linked to...
Background Atherectomy has become the fastest growing catheter-based peripheral vascular intervention performed in the United States, and overuse has been linked to increased reimbursement, but the patterns of use have not been well characterized. Methods and Results We used Blue Cross Blue Shield of Michigan Preferred Provider Organization and Medicare fee-for-service professional claims data from the Michigan Value Collaborative for patients undergoing office-based laboratory atherectomy in 2019 to calculate provider-specific rates of atherectomy use, reimbursement, number of vessels treated, and number of atherectomies per patient. We also calculated the rate that each provider converted a new patient visit to an endovascular procedure within 90 days. Correlations between parameters were assessed with simple linear regression. Providers completing ≥20 office-based laboratory atherectomies and ≥20 new patient evaluations during the study period were included. A total of 59 providers performing 4060 office-based laboratory atherectomies were included. Median professional reimbursement per procedure was $4671.56 (interquartile range [IQR], $2403.09-$7723.19) from Blue Cross Blue Shield of Michigan and $14 854.49 (IQR, $9414.80-$18 816.33) from Medicare, whereas total professional reimbursement from both payers ranged from $2452 to $6 880 402 per year. Median 90-day conversion rate was 5.0% (IQR, 2.5%-10.0%), whereas the median provider-level average number of vessels treated per patient was 1.20 (IQR, 1.13-1.31) and the median provider-level average number of treatments per patient was 1.38 (IQR, 1.26-1.63). Total annual reimbursement for each provider was directly correlated with new patient-procedure conversion rate (=0.47; <0.001), mean number of vessels treated per patient (=0.31; <0.001), and mean number of treatments per patient (=0.33; <0.001). Conclusions A minority of providers perform most procedures and are reimbursed substantially more per procedure compared with most providers. Procedural conversion rate, number of vessels, and number of treatments per patient represent potential policy levers to curb overuse.
Topics: Humans; Aged; United States; Medicare; Atherectomy; Fee-for-Service Plans; Endovascular Procedures; Michigan
PubMed: 36300666
DOI: 10.1161/JAHA.121.023356