Adjunctive Balloon Angioplasty Research Articles

Rotational atherectomy with adjunctive balloon angioplasty versus conventional percutaneous transluminal coronary angioplasty in type B2 lesions: Results of a randomized study

A randomized pilot study was performed comparing conventional balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA] group) and rotational atherectomy (RA) with a medium size burr (50% to 70% burr/artery ratio) with systematic adjunctive balloon angioplasty (RA group) in type B2 stenosis. A total of 64 patients were included. Primary success was 93.7% in the RA group and 87.5% in the PTCA group ( p = NS). Technical failure with no complication occurred once in each group. Acute complications occurred in three patients in the PTCA group and in one in the RA group. Angiographic restenosis rates were similar (RA group: 39%, PTCA group: 42%, p = NS) with a follow-up rate of 93%. In type B2 lesions, when compared with conventional angioplasty, RA with systematic balloon angioplasty does not seem to increase procedural success, and the restenosis rate remains comparable. However, these results must be confirmed in a larger series of patients.

Influence of percutaneous transluminal coronary rotational atherectomy with adjunctive percutaneous transluminal coronary angioplasty on coronary blood flow

The purpose of this study was to examine the influence of sequential percutaneous transluminal coronary rotational atherectomy (PTCRA) and coronary angioplasty on coronary blood flow and flow reserve in patients. Rotational coronary atherectomy restores lumen patency by partially ablating fibrocalcific plaque, releasing microparticulate debris into the distal coronary circulation. Adjunctive balloon angioplasty is usually performed to optimize the angiographic luminal dimensions. Serial alterations in coronary physiology have not been reported. Fourteen lesions in 13 patients were treated by sequential rotational atherectomy followed by adjunctive balloon angioplasty. Poststenotic baseline coronary blood flow velocity was measured by using a Doppler flow wire (FloWire, Cardiometrics, Inc., Mountain View, Calif.), and coronary blood flow was calculated by using the distal vessel cross-sectional area obtained by quantitative coronary angiography. Data were acquired at baseline and during hyperemia (12 to 18 μg of intracoronary adenosine), before and after PTCRA, and again after balloon angioplasty. The mean stenosis decreased from 76% ± 12% at baseline to 21% ± 11% at the completion of the procedure ( p < 0.01). The minimal luminal diameter (by quantitative coronary angiography) was 0.7 ± 0.4 mm at baseline, increased to 1.9 ± 0.4 mm after rotational atherectomy ( p < 0.01), and increased to 2.4 ± 0.5 mm after balloon angioplasty ( p < 0.01 versus baseline and PTCRA). Distal (post-stenotic) coronary blood flow at baseline was 47 ± 23 ml/min and 57 ± 38 ml/min during hyperemia. After PTCRA, coronary blood flow increased to 104 ± 59 ml/min and to 132 ± 73 ml/min with hyperemia. After adjunctive angioplasty, coronary blood flow was 84 ± 40 ml/min ( p = not significant [NS] vs PTCRA) and increased to 143 ± 81 ml/min with hyperemia ( p = NS vs PTCRA). The poststenotic coronary flow reserve increased from an initial value of 1.1 ± 0.2 ml/min to 1.3 ± 0.3 ml/min after PTCRA ( p = NS vs baseline) and to 1.6 ± 0.3 ml/min after adjunctive balloon angioplasty ( p < 0.01 vs baseline; p = NS vs PTCRA). PTCRA significantly increased resting coronary blood flow. Adjunctive balloon angioplasty did not significantly augment resting or hyperemic coronary blood flow more than that achieved by rotational atherectomy alone. These data demonstrate that PTCRA alone improves baseline coronary blood flow with minimal additional physiologic change after adjunctive balloon angioplasty.

Rotational atherectomy with a new device: Initial clinical experience

The Bard Atherectomy Catheter is a new rotational atherectomy device that consists of a flexible, hollow, thin-walled cutting catheter that, while rotated at 1,500 revolutions per minute, is advanced across the lesion over a special spiral guidewire system. We report the initial clinical experience with this device in 20 peripheral lesions in ten patients. The majority of patients were treated for limb salvage. All lesions were successfully intervened on by atherectomy followed by adjunctive balloon angioplasty. A reduction to less than 50% stenosis was achieved in 13 of the 20 lesions (65%) after atherectomy but in all 20 lesions (100%) after adjunctive angioplasty for all lesions and stenting for dissections in two. Baseline minimal lesion lumen diameter was 0.8 ± 0.7 mm with a reference vessel diameter of 4.2 ± 1.7 mm (75 ± 21% stenosis). The lumen improved to 2.0 ± 0.8 mm (45 ± 19% stenosis) (P < 0.001) following atherectomy and to 3.9 ± 1.9 mm (13 ± 16% stenosis) (P < 0.001) after adjunctive angioplasty. The average weight of removed atheroma was 45 ± 58 mg. All ten patients had initial improvement in symptoms. At 6 months follow-up there was persistent improvement in eight patients and two subjects had undergone amputations. Our early clinical experience with this low profile, flexible atherectomy device, that enables extraction of a large amount of atheroma, suggests that it will become a valuable addition to current atherectomy technologies in small- and medium-sized vessels. The value of this device in coronary vessels is under investigation. © 1996 Wiley-Liss, Inc.

Rotational atherectomy with a new device: Initial clinical experience

The Bard Atherectomy Catheter is a new rotational atherectomy device that consists of a flexible, hollow, thin-walled cutting catheter that, while rotated at 1,500 revolutions per minute, is advanced across the lesion over a special spiral guidewire system. We report the initial clinical experience with this device in 20 peripheral lesions in ten patients. The majority of patients were treated for limb salvage. All lesions were successfully intervened on by atherectomy followed by adjunctive balloon angioplasty. A reduction to less than 50% stenosis was achieved in 13 of the 20 lesions (65%) after atherectomy but in all 20 lesions (100%) after adjunctive angioplasty for all lesions and stenting for dissections in two. Baseline minimal lesion lumen diameter was 0.8 +/- 0.7 mm with a reference vessel diameter of 4.2 +/- 1.7 mm (75 +/- 21% stenosis). The lumen improved to 2.0 +/- 0.8 mm (45 +/- 19% stenosis) (P < 0.001) following atherectomy and to 3.9 +/- 1.9 mm (13 +/- 16% stenosis) (P < 0.001) after adjunctive angioplasty. The average weight of removed atheroma was 45 +/- 58 mg. All ten patients had initial improvement in symptoms. At 6 months follow-up there was persistent improvement in eight patients and two subjects had undergone amputations. Our early clinical experience with this low profile, flexible atherectomy device, that enables extraction of a large amount of atheroma, suggests that it will become a valuable addition to current atherectomy technologies in small- and medium-sized vessels. The value of this device in coronary vessels is under investigation.

Do excimer laser angioplasty and rotational atherectomy facilitate balloon angioplasty? Implications for lesion-specific coronary intervention

Objectives. This study sought to determine whether adjunctive balloon angioplasty after rotational atherectomy and excimer laser angioplasty provides better lumen enlargement (“facilitated angioplasty”) than angioplasty alone.Background. Adjunctive angioplasty is often used immediately after atherectomy and laser angioplasty to further enlarge lumen dimensions, but it is not known whether this practice is superior to angioplasty alone.Methods. Balloon angioplasty was performed in 1,266 native coronary lesions alone (n = 541) or after extraction atherectomy (n = 277) rotational atherectomy (Rotablator) (n = 211) or excimer laser angioplasty (n = 237). Quantitative angiographic analysis included final lumen diameter, final diameter stenosis and efficiency of balloon-mediated lumen enlargement.Results. Compared with angioplasty alone (33 ± 12%) [mean ± SD]), final diameter stenosis was higher for adjunctive angioplasty after extraction atherectomy (37 ± 16%, p < 0.001) and excimer laser angioplasty (37 ± 16%, p < 0.001) and lower after rotational atherectomy (27 ± 15%, p < 0.001). However, there was significant undersizing of balloons after all three devices. To correct for differencs in balloon size, the efficiency index (final lumen diameter/balloon diameter ratio) was calculated and was higher for adjunctive angioplasty after the Rotablator (0.78 ± 0.14, p < 0.001) than after angioplasty alone (0.69 ± 0.12). The efficiency indexes suggested facilitated angioplasty after rotational atherectomy for ostial, eccentric, ulcerated and calcified lesions and lesions >20 mm long. Facilitated angioplasty was also observed after extraction atherectomy and excimer laser angioplasty for ostial lesions, but not for any other lesion subsets.Conclusions. Rotational atherectomy, extraction atherectomy and excimer laser angioplasty can facilitate the results of balloon angioplasty. However, the extent of facilitated angioplasty is dependent on the device and baseline lesion morphology, consistent with the need for lesion-specific coronary intervention.

American Heart Association 68th Scientific Sessions, Anaheim, California, November 13 to 15, 1995.

Dr Elliott Antman, of Harvard Medical School and Brigham and Women’s Hospital in Boston, Massachusetts, presented the results of the Thrombolysis in Myocardial Infarction (TIMI) 9B study at a Satellite Symposium sponsored by George Washington University immediately prior to the American Heart Association Meetings in Anaheim, California, in November 1995. The TIMI 9 trial was a randomized, double-blind study conducted in 150 clinical centers that was designed to compare the efficacy and safety of intravenous heparin versus the direct-acting thrombin inhibitor hirudin in patients with acute myocardial infarction (<12 hours from onset) treated with a thrombolytic agent (streptokinase or tissue-type plasminogen activator [TPA], at the discretion of the treating physician). The TIMI 9A study (n=757) was suspended in April 1994 because of excessive bleeding in both the heparin and hirudin groups. The TIMI 9B trial was restarted in May 1994 with lower doses of both heparin and hirudin; enrollment (n=3002) continued through August 1995. The primary end point of the study was the 30-day incidence of death, myocardial infarction, congestive heart failure, and shock. At 30 days, there was no significant difference in the primary end point between heparin (11.8%) and hirudin (12.8%) and no difference in the incidence of death and myocardial infarction (9.3% in the heparin group, 9.6% in the hirudin group). Similarly, there was no significant difference in major bleeding events (including intracranial hemorrhage) between treatment groups. The TIMI 9 Investigators concluded that hirudin was equally effective as but not superior to heparin with respect to either clinical outcome or bleeding risk in patients with acute myocardial infarction receiving thrombolytic therapy. Also at the George Washington University Satellite Symposium, Dr Eugene Braunwald, of Harvard Medical School and Brigham and Women’s Hospital in Boston, presented the results of the TIMI 10A phase I trial. TIMI 10A is an …

Holmium Laser-Induced Coronary Thrombolysis.

Plaque disruption and thrombosis are determinants for the onset of acute ischemic syndromes. The presence of intracoronary thrombus is associated with an increased risk of complications during revascularization with balloon angioplasty. Thrombi avidly absorb light in the mid-infrared optical spectrum due to their high water content. The potential clinical advantages of the holmium laser as a source of thrombolysis include rapid removal of the target clot, vaporization of procoagulant reactants, elimination of a systemic lytic state, and facilitation of adjunct balloon angioplasty by concomitant plaque vaporization. Notably, while thrombolytic drug therapy treats only the acute cause, that is, thrombus, the laser has the potential for treating both thrombus and its underlying cause, that is, the atherosclerotic plaque. In vitro studies suggest that the effect of the holmium laser is achieved by nonselective, mechanical disruption of the irradiated thrombus, a mechanism unlike selective thrombolysis as induced by pulsed-dye lasers. Further basic and clinical research is needed to explore holmium laser-thrombus interactions and thus lead to optimal clinical application of this technology.

Usefulness of a prototype directional catheter for excimer laser coronary angioplasty in narrowings unfavorable for conventional excimer or balloon angioplasty

We report clinical and angiographic results in 53 patients with 57 significant coronary or saphenous vein graft narrowings treated with directional excimer laser angioplasty. The target vessels were the left main (1%), anterior descending (32%), circumflex (19%), right coronary artery (39%), and vein grafts (9%). Lesions were morphologic class B1 (18%), B2 (79%), or C (3%), with 40 de novo and 17 restenotic lesions. Adjunctive balloon angioplasty was used in 53 lesions (93%). Mean pre- and postprocedural minimal lumen diameters were 0.6 ± 0.3 and 1.9 ± 0.7 mm (p < 0.001), corresponding to a mean diameter stenosis of 72 ± 20% and 27 ± 16%. Procedural success rate was 91%. Cumulative risk of death, Q-wave myocardial infarction, or emergency bypass operation was 9% (5 patients). Of patients who had a successful laser procedure, 28 (60%) with 30 lesions underwent angiographic follow-up at 6 ± 3 months after the procedure. Restenosis rates (>50% diameter restenosis or acute gain loss) were 37% and 23%, respectively. Four patients underwent bypass, 3 angioplasty, and 1 patient died from cancer. This study demonstrates the feasibility of directional application of laser energy to selected unfavorable narrowings for conventional excimer laser or balloon angioplasty. Further evaluation of this device using the now standard saline infusion technique is necessary to establish its ultimate role as a primary interventional device.

Influence of adjunctive balloon angioplasty on coronary blood flow after rotational atherectomy

Rotational atherectomy is being performed with increasing frequency in a distinct subset of patients whose lesion characteristics are unfavorable for conventional balloon angioplasty. Although satisfactory luminal enlargement can be accomplished with the use of rotational atherectomy alone in some patients, adjunctive balloon angioplasty is necessary in most patients, to obtain a minimal residual angiographic result. To demonstrate responses associated with rotational atherectomy results, serial coronary blood flow measurements were obtained in a patient undergoing rotational atherectomy for unstable angina. Adjunctive balloon angioplasty resulted in normalization of post-stenotic coronary flow reserve. Recanalization by rotablator alone may not normalize coronary flow despite a satisfactory angiographic result.

Mechanism of high-speed rotational atherectomy and adjunctive balloon angioplasty revisited by quantitative coronary angiography: Edge detection versus videodensitometry

High-speed rotational coronary atherectomy (RA) is primarily used to treat complex lesions. Quantitative angiographic analysis of such complex lesions by edge detection is often unsuitable, whereas videodensitometry, measuring vessel dimensions independently of the target stenosis contours, may offer potential advantages. To gain insight into the operative mechanism of RA and to study the agreement between the two quantitative angiographic methods in measuring the minimal luminal cross-sectional area, the edge detection and videodensitometry techniques were applied to coronary angiograms of 21 lesions in 19 patients with symptoms who underwent successful RA and balloon angioplasty (BA). Obstruction diameter as determined by edge detection increased from 1.00 ± 0.31 mm before intervention to 1.35 ± 0.29 mm after RA ( p < 0.001) and further increased to 1.74 ± 0.33 mm after adjunctive BA ( p < 0.001). The mean between-method difference (edge detection minus videodensitometry) was 0.34 mm 2 before intervention, 0.13 mm 2 after RA, and 0.09 mm 2 after adjunctive BA (not significant). The standard deviation of the differences decreased from ±0.87 mm 2 before intervention to ±0.80 mm 2 after RA (not significant) and increased after BA significantly to ±1.21 mm 2 ( p < 0.05). Thus edge detection and videodensitometry provided equivalent immediate angiographic results after RA and adjunctive BA. The good agreement after RA may reflect the operative mechanism of RA, which by ablation of noncompliant plaque material yields a circular symmetric lumen with smooth surface. The increased dispersion of the between-method differences observed after adjunctive BA presumably results from dissections, plaque ruptures, and loss of luminal smoothness after balloon dilatation.

Atherectomy (directional, rotational, extractional) and its role in percutaneous revascularization

After an initial wave of enthusiasm, atherectomy devices face a number of difficult issues today. The first two randomized studies comparing balloon angioplasty with directional atherectomy, the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) and the Canadian Coronary Atherectomy Trial (CCAT), showed no clinical benefit for atherectomy. Data from these trials, as well as other studies, suggest that the mechanism of lumen enlargement with atherectomy may be less beneficial than expected. A number of investigations are currently evaluating the benefit of even more aggressive debulking with directional coronary atherectomy, but in view of the increased incidence of acute complications, it is unlikely that this technique will increase its share in routine coronary angioplasty in the near future. Clinical evaluation of rotational and extractional atherectomy has not reached a conclusive phase yet, but results from registries and single-center observations show that these devices require adjunctive balloon angioplasty in a large proportion of cases, on the one hand, and that they do not solve the issue of restenosis, on the other. The difficulty in delineating the rationale for use of these devices highlights the urgent need for controlled and carefully designed device trials.

Coronary artery morphologic features after coronary rotational atherectomy: Insights into mechanisms of lumen enlargement and embolization

The coronary arteries and myocardium from two patients who died after coronary rotational atherectomy were analyzed to gain insights into the mechanisms of lumen enlargement and to document embolization of calcified plaque. Rotational atherectomy resulted in sharp cuts in plaque, producing a relatively smooth luminal surface. When extensive nodular calcific atherosclerosis was present, the luminal surface was focally uneven with exposure of jagged calcified plaque to blood flow. Deep plaque fissures and medial dissections were also seen. These fissures may have been created by the rotoblator or by adjunctive balloon angioplasty. Multiple calcific atheroemboli were present after rotoblator use in plaques containing extensive nodular calcification; in moderately calcified plaque only one small atheroembolus was found. Thus embolization of calcified plaque can occur after rotational atherectomy and may correlate with the severity of plaque calcification. Rotational atherectomy produces a focally smooth, sharp-edged, luminal surface, a lumen enlargement mechanism different from balloon angioplasty.

760-4 Initial Multicenter Experience with Therapeutic Ultrasonic Coronary Angioplasty in Patients

Therapeutic ultrasonic (195 kHz) catheters with 1.2 or 1.7 mm ball tips for coronary angioplasty have recently been developed. During the first phase of a multi-center European trial (CRUSADE) this system was evaluated in 100 patients (86% male, mean age 57 years) with symptomatic coronary artery disease or acute myocardial infarction. Lesions were located in the LAD (n = 61), CX (n = 17), and RCA (n = 22); 62% were type B or C; 11 lesions were restenotic, 19 occlusive, 9 longer than 20 mm, 37 calcified, 18 thrombotic, and 15 collateralised. The ultrasound catheter crossed 82/100 lesions, adjunctive balloon angioplastywas needed in 98 lesions. There was no death and myocardial infarction, or CABG in the first 24 hours. There was no perforation, but 2 acute vessel closures; intimal cleft or dissection was seen in 17 lesions of which 1 required stenting. Procedural success was obtained in 93%. At 24 hours 11/100 vessels were reoccluded. At 6 months angiographic follow-up in 51 patients restenosis (&gt;50% stenosis) occured in 33%. Therapeutic ultrasound angioplasty is a feasible and safe new treatment modality. Adjunctive balloon angioplasty is regularly necessary. Preliminary experience suggests usefulness in lesions with visible thrombus, and undilatable or uncrossable lesions.

980-85 Percutaneous Aspiration Thrombectomy: A Novel Way to Recannalize Thrombosed Hemodialysis Access Grafts

Hemodialysis access thrombosis is the leading cause of hospitalization in the dialysis population. Thrombosis of polytetrafluoroethylene (PTFE) grafts can be treated either with surgical thrombectomy or percutaneous thrombolysis. Percutaneous aspiration thrombectomy (AT) is a new technique of rapidly recannalizing occluded PTFE grafts as an outpatient which utilizes standard 8 Fr catheters and vacuum aspiration without the need for surgery or the cost and risk of thrombolysis. Nineteen P with thrombosed PTFE grafts underwent AT with adjunctive balloon angioplasty (PTA). AT success was defined as successful declotting without the need for surgical declotting or thrombolysis. Angiographic success was defined as &lt;30% stenosis after PTA with brisk graft flow. Clinical success was defined as immediate resumption of dialysis without need for hospitalization for anticoagulation. Acute results in 19 patients: N(%) AT success 19 (100) Adjunctive PTA 19 (100) Adjunctive stenting 2 (11) Angiographic success 17 (90) Clinical success 17 (90) Procedure time &lt;30 minutes 12 (71) Complications 0 (0) All 17 clinically successful patients were dialyzed immediately after the procedure without difficulty. No patient required hospitalization. The 2 patients who were clinical and angiographic failures after PTA required placement of a new dialysis access. Percutaneous aspiration thrombectomy appears to be a simple yet effective alternative to the conventional treatment of thrombosed PTFE dialysis grafts.

919-10 Coronary Hemodynamics After Rotational Atherectomy

The effects of Rotational Athereclomy (PTCRA) and adjunctive balloon angioplasty on the coronary microcirculation were studied with a Doppler-Flow wire in 10 patients (Pts) with single discrete subtotal stenoses in one coronary artery (LAD = 5, RCA = 4, LCX = 1). TIMI-grade Flow was determined for each vessel. Using a cine proyeclor equipped with fra me counter, the number of cineframes required from initiation of the contrast injection 10 opacification of a specified distal landmark were recorded before and after PTCRA. Doppler measurements were made before and after PTCRA and adjunctive balloon. Average Peak Velocity (APV) and Diastolic/Systolic Velocity ratio (DSVR) were measured distal to the lesion. Coronary Flow Reserve (CFRI was assessed with adenosine (24 to 30 JLg i.c.). Estimated coronary blood flow (CBF) and coronary vascular resistances were calculated by standard formulae. Resu/ts: Before PTCRA, all Pts had TIMI-III Flow. Immediately after PTCRA, 2 Pts had TIM I-I Flow, 4 Pts had TIMI-II Flow, and 4 Pts had TIMI-III Flow. In all Pts however, the frame to opacification increased significantly from 49 ± 12 to 118 ± 47 frames (p &lt; 0.05). After the administration of nitroglycerin i.e. (10/10 Pts) and verapamil. i.e. (2/10 Ptsl. TIMI-III Flow was restored in all Pts and the frame to opacification returned to baseline (50 ± 9 frames). The following are the coronary hemodynamics after PTCRA + adjunctive balloon + nitroglycerin + verapamil. Results (mean ± semi):Empty CellBeforeAfterp valueMAP (mmHg)101 ± 594 ± 4nsHR (bts/min)72 ± 274 ± 3nsProx. Lumen Diam (mm)3.44 ± 013.50 ± 0.2nsMinimal Lumen Diam (mm)1.3 ± 012.6 ± 02005APV(cm/s)20 ± 336 ± 50.05DSVR (ratio)1.8 ± 0.815 ± 0.6nsCSF (ml/min)81 ± 14154 ± 180.05CVR (mmhg/ml/min)1.74 ± 0.40.74 ± 0.4005CFR (ratio)1.24 ± 011.6 ± 0.1ns 1) Immediately after PTCRA, the reduction in CBF is likely due to coronary spasm since this spasm was rapidly reversed by of coronary vasodilators. 2) Immediately after PTCRA + adjunctive balloon, there is an increase in APV, estimated CBF and a fall in CVR. Despite this beneficial hemodynamic profile, the CFR remained abnormal. suggesting either ischemic reactive hyperemia or a persistent abnormality in the microcirculatuion.

919-9 Comparative Angioscopic Findings After Rotational Atherectomy and Balloon Angioplasty

Angioscopy has shown to be superior to angiography in detecting intraluminal post-PTCA changes. This randomized study was conducted to compare angioscopic results of rotational alherectomy (RA) vs balloon angioplasty (BA) in 43 patients with stable angina. Forty five lesions were randomly assigned to RA (n = 23) or BA (n = 22). We included lesions located 2 cm distal from the ostium of the vessel and in a straight segment. Restenotic or graft lesions were excluded from the study. RA consisted in rotablation with a single burr (75% of coronary diameter) followed by adjunctive BA (mean total inflation duration = 275 ± 145 sec, mean maximal inflation pressure = 5 ± 2 Atm). BA consisted in 2 to 5 balloon inflations Imean lotal inflalion duration = 356 ± 168 sec, mean maximal inflation pressure: 8 ± 2 Atm). Balloon size was chosen for a ratio: artery diameter/balloon diameter close to one. Angioscopy (4.5F lmagecath angioscope) was performed immediately after the procedure. Abnormal angioscopic findings included the presence of: 1) flaps, graded from 1 to 3(1: intimal: 2: protruding into ≤50% of the lumen: 3: protruding into &gt;50% of the lumen). 2) Ihrombi, graded from 1 to 3 (1: flat deposits; 2: protruding but non-occlusive: 3: occlusive), 3) subintimal hemorrhage. The 2 groups were comparable for clinical data and angiographic lesion appearance. Angiography showed comparable results in the 2 groups. Success rate (residual % diameler stenosis &lt;50%): 91% vs 92% and final % diameter stenosis using Philips DCI automated OCA: 33 ± 13% vs 30 ± 10% were similar in RA and BA groups respeclively, as well as rate of dissections (NHLBI classification): 3 in the RA group (grade A in 1, grade B in 2) compared with 7 in the BA group (grade A in 1, grade B in 5, grade C in 1), (p = NS). Nevertheless, on angioscopy, flaps were observed less frequently after RA(n = 6, 26%lthan afler BA(n = 13, 59%)and were also less severe (grade 1 in 4, grade 2 in 2 and grade 3 in none) than after BA (grade 1 in 4, grade 2 in 4 and grade 3 in 5), (p &lt; 0.05). There was no difference in the incidence of angioscopic thrombi (4 after RA, 7 after BA) or subintimal hemorrhage (4 after RA. 3 after BA) between the 2 groups. There was no angioscopy-related complicalions. On angioscopy, rotational atherectomy wilh adjunctive balloon augioplasty leads to less frequent and less severe intra-luminal abnormalities than balloon angioplasty, with less intra-luminal flaps. Whelherthese findings are of clinical significance remains under invesligation.

919-12 Transient Wall Motion Abnormalities Following Rotational Coronary Atherectomy are Reflective of Myocardial Stunning More than Microinfarction

Transient wall motion abnormalities (WMA) have been found following rotational coronary atherectomy (ROTA) in the majority of patients assessed by serial echocardiography. A possible mechanism of transient WMA in this setting is myocardial stunning secondary to distal embolization of atherosclerotic debris from the ROTA site as defined by regional transient dysynergy resolving completely by 24 hours post ROTA. Microinfarction in the setting of myocardial stunning is an additional explanation for this phenomena, and the prevalence of microinfarction in the setting of stunning has not been determined. We screened selected patients with transient WMA post-ROTA for troponin I, myoglobin and CKMB release as a screening for myocardial necrosis. We studied 9 patients: 8/9 male, 7/9 LAD lesion, 2/9 RCA lesion. All patients had adjunctive post ROTA balloon angioplasty except one who required a 3.0 mm Cook stent. In this welect patient group wall motion was normal in all patients before intervention and within 24 hours following ROTA. Following ROTA peak onset of WMA ranged from 5–27 min, mean maximal %WMA 28.3% ± 11.89%, and median time to full recovery of wall motion was 88 min ± 655 min. Evidence of myocardial necrosis (positive markers) was present in 3/9 patients following ROTA with the evolution of transient ECG T wave abnormalitics 3/3, increased CKMB &gt; 7.5 ng/ml (range 25–72) 2/3, increased myoglobin level 2/3 and increased troponin I &gt; 1.35 ng/ml (range 3.88–15.9) in 3/3 patients. None of the remaining patients developed any indicator of myocardial necrosis. max%WMA Median Time to Recovery p Positive Markers n = 3 28.3% (16–35%) 63 min (24–180 min) NS Negative Markers n = 6 28.0% (12–44%) 88 min (24–270 min) NS Despite prolonged recovery times and extensive transient %WMA, reflective of myocardial stunning, these factors were not predictive of troponin I release following successful ROTA. Thus microinfarction may occur in the context of myocardial stunning, yet the dominant mechanism transient WMA is likely to be myocardial stunning.

Angiographic follow-up of patients after transluminal coronary extraction atherectomy

The transluminal coronary extraction-endarterectomy catheter (TEC) consists of a torquing tube with a distal, conical rotating blade. We successfully treated 26 patients (27 lesions) using this catheter with adjunctive balloon angioplasty. Twenty-five patients (26 lesions) had serial angiography before, 1 day after, and 3 months after the procedure. All 17 patients without restenosis 3 months after the procedure had angiography at 6 months. Restenosis, defined as >50% diameter stenosis, was noted in nine lesions at 3 months (early restenosis) and in five lesions at 6 months (late restenosis). Between vessels with and without early restenosis, the percentage of diameter stenosis seen 1 day after the procedure and the luminal diameter were significantly different (38% ± 14% vs 22% ± 12%, respectively, p < 0.01; 2.3 vs 2.9 mm, p < 0.01, respectively). However, between vessels with and without late restensis, these variables were not significantly different. The overall restenosis rate was 54% (native vessels 50%; grafts 80%). This observational study suggests that very early diameter narrowing seen 1 day after the procedure has greater contribution to early restenosis than to late restenosis after successful TEC atherectomy with adjunctive balloon angioplasty.

Peripheral arterial angioplasty balloons as adjuncts to percutaneous coronary revascularization

Although PTCA balloon technology has improved dramatically since the first catheters were introduced over a decade ago, some limitations remain. The largest conventional balloon size available is 4.0 mm diameter. Larger size balloons are sometimes necessary for saphenous vein graft dilatation or in very large native coronary arteries. Also, adjunctive balloon angioplasty is used frequently after atherectomy and other coronary device therapy. Current generation balloons are not always necessary in this setting, since a large lumen has already been established. Thus, it has become useful in our laboratory to use peripheral arterial angioplasty balloons for both large coronary vessel dilatation, and also for adjunctive dilatation after device use. We describe our initial experience with peripheral arterial angioplasty balloons as adjuncts to percutaneous coronary revascularization.

Phase I Results of Pullback Atherectomy for Hemodialysis Access

Balloon angioplasty and directional atherectomy frequently have short-lived results for stenoses associated with hemodialysis. Results are reported for a phase I trial of the pullback atherectomy catheter (PAC) for treatment of hemodialysis access-related stenoses. Six intragraft and six venous stenoses in nine patients were treated with the PAC. Two lesions were treated with adjunctive balloon angioplasty, and two were treated with adjunctive directional atherectomy. Clinical and angiographic follow-up were obtained for all patients. All specimens were examined histologically. Initial procedural success was achieved in 83% of stenoses (10 of 12). For intragraft stenoses, the 6-month primary patency was 60% (three of five) and the 6-month secondary patency was 80% (four of five). All six venous stenoses restenosed or thrombosed within 3 months. All specimens contained fibrous plaque or intimal hyperplasia. In addition, all six venous stenosis specimens contained media and two contained adventitia. Significant complications during treatment of venous stenoses included severe venous spasm in three and venous pseudoaneurysms in two. One PAC tip fracture occurred during treatment of an intragraft stenosis. Pullback atherectomy is potentially safe and effective for intragraft stenoses; however, it is not safe or effective for venous stenoses.