Plaque excision combined with stent placement. Can a poor "finisher" become a good "starter".

Abstract

In an effort to enhance long-term patency in the coronary circulation, interventional cardiologists have examined the effects of a plethora of devices designed to improve short-term results and reduce the possibility of restenosis. Two disparate techniques, debulking by means of directional coronary atherectomy (DCA) and arterial scaffolding by stent implantation, have been tested separately in prospective randomized trials with respect to angiographic and clinical restenosis. In this issue of Circulation , Moussa et al1 combine plaque excision and slotted-tube stent placement in an attempt to show that the 2 methods are synergistic. DCA has been tested in several well-designed prospective, randomized comparisons with balloon angioplasty. Two early studies, CAVEAT and CCAT, showed that DCA applied to patients with focal lesions in native coronary arteries resulted in only slight reductions in the rate of restenosis. Specifically, in the CAVEAT trial, in which 1012 patients were randomized to DCA or balloon angioplasty,2 angiographic restenosis was only slightly reduced, from 57% in the balloon group to 50% in DCA group; clinical restenosis was unchanged (34% versus 35%). An unexpected and disturbing finding was the excess mortality at 1 year in the DCA group (2.2% for DCA versus 0.6% for PTCA, P =0.035), a finding possibly attributable to the doubling of periprocedural non–Q-wave infarction in patients treated with atherectomy. In the CCAT trial,3 DCA was performed in patients with isolated stenoses in the proximal left anterior descending coronary artery, and results were similar: a nonsignificant reduction in angiographic restenosis (46% versus 43%) and no decrease in clinical restenosis (30.1% versus 30.6%). DCA was further evaluated in CAVEAT II, a trial in which 305 patients with saphenous vein bypass graft stenoses were randomized to either DCA or balloon angioplasty.4 Although initial angiographic success was superior in the DCA arm, there was …