Abstract
Objective Patients with advanced renal insufficiency are at high risk of coronary artery disease (CAD) and complex lesions. Treating complex calcified lesion with rotational atherectomy (RA) in these patients might be associated with higher risks and poorer outcomes. This study was set to evaluate features and outcomes of RA in these patients. Method Consecutive patients who received coronary RA from April 2010 to April 2018 were queried from the Cath Lab database. The procedural details, angiography, and clinical information were reviewed in detail. Results A total of 411 patients were enrolled and divided into Group A (baseline serum creatinine <5 mg/dl, n = 338) and Group B (baseline serum creatinine ≥ 5 mg/dl through ESRD, n = 73). Most patients had high-risk features (65.7% of acute coronary syndrome (ACS), 14.1% of ischemic cardiomyopathy, and 5.1% of cardiogenic shock). Group B patients were significantly younger (66.8 ± 11.4 vs. 75.2 ± 10.7 years, p < 0.001) and had more RCA and LCX but less LAD treated with RA. No difference was found in lesion location, vessel tortuosity, bifurcation lesions, chronic total occlusion, total lesion length, or total lesion numbers between the two groups. Less patients in Group B obtained completion of RA (95.9% vs 99.1%, p=0.037). There was no difference in the incidence of procedural complication or acute contrast-induced nephropathy. Group B patients had more deaths and MACE while in the hospital. The MACE and CV MACE were also higher in Group B patients at 180 days and one year, mostly due to TLR and TVR. Multivariate regression analysis showed that ACS, age, peripheral artery disease (PAD), advanced renal insufficiency, ischemic cardiomyopathy/shock, and high residual SYNTAX score were independent risk factors for in-hospital MACE, whereas ACS, advanced renal insufficiency, ischemic cardiomyopathy/shock, triple-vessel disease, and PAD independently predicted MACE at 6 months. Conclusions Rotablation is feasible, safe, and could be carried out with very high success rate in very-high-risk patients with advanced renal dysfunction through ESRD without an increase in procedural complication.
Highlights
Coronary artery calcifications are common in coronary artery disease (CAD), with approximately 38% of lesions calcified as shown in coronary angiography [1]
Consecutive patients who received Rotablation atherectomy (RA) therapy for coronary lesions from April 2010 to April 2018 at our Cath Labs were interrogated from the Cath Lab database and identified by manual inspection. e indications for Percutaneous coronary intervention (PCI) and RA, procedural details, and complications at the time of index PCI were retrieved. e admission CAD diagnosis for coronary intervention was divided into stable angina, unstable angina, NSTEMI, STEMI, and ischemic cardiomyopathy. e first four diagnoses were made according to the commonly used ESC guidelines [16, 17]. e diagnosis of ischemic CM was made if the patients presented with no chest pain but clinical heart failure or acute pulmonary edema without or without respiratory failure
Most patients had highrisk features (65.7% of acute coronary syndrome (ACS), 14.1% of ischemic cardiomyopathy, and 5.1% of cardiogenic shock), and only 20.2% of patients had stable angina. 73.5% of patients presented with hypertension, 58.6% with diabetes, and 10.7% with peripheral artery disease (PAD)
Summary
Coronary artery calcifications are common in coronary artery disease (CAD), with approximately 38% of lesions calcified as shown in coronary angiography [1]. In addition to the increasing incidence of CAD, patients with renal impairment have an increased risk of severe coronary calcifications and it could reach 60% in patients with chronic kidney disease (CKD) [2, 3]. Percutaneous coronary intervention (PCI) for calcified coronary lesions is associated with remarkably worse outcomes compared with noncalcified lesions, even in the drug-eluting stent (DES) era [4, 5]. Severely calcified lesions are difficult to be crossed or dilated with balloon or stent and are associated. To mitigate the poor results associated with coronary calcifications, lesion preparation in PCI is necessary to facilitate balloon and stent delivery, and full vessel expansion. Using RA accounted for 1–3% of PCI in the UK, Europe, and the USA [13]
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