Successful Directional Atherectomy Research Articles

Troponin T elevation after successful directional atherectomy.

The incidence and correlates of postinterventional cardiac troponin T (cTnT) elevation have not been evaluated in patients with successful directional atherectomy (DCA). Total creatine kinase (CK) activity, CK-MB mass concentrations and cTnT levels were measured in 36 patients before, and serially 4, 24, 48 and 72 hours after successful DCA. Patients were followed for death, Q-wave infarction, need for emergency bypass surgery, periprocedural vascular complications (transient in-lab vessel closure, side branch compromise, large dissection), and non-Q-wave infarction on ECG. Patients were followed for clinical outcomes and angiographic restenosis for 6 months. Vascular correlates were studied by coronary angiography and intravascular ultrasound before, immediately after and 4 hours after elective and successful DCA. 25 patients (69.4%) had elevated levels of cTnT, whereas CK-MB mass > or = 6 ng/ml and mild elevations of total CK activity were present in only 36.1 and 5.6%, respectively. Elevated cTnT was related to vascular complications in 44% of cases. Inapparent microembolization of platelets or plaque debris was considered responsible for most of the remaining micronecroses. During 6 month follow-up rates of clinical restenosis (44 vs 9%, p = 0.059) tended to be higher in patients with as compared to patients without cTnT release after DCA. Successful DCA is associated with postprocedural elevations of cTnT which relate to minor vascular complications and presumably microembolization of platelets or plaque debris. The superior diagnostic performance of cTnT compared to CK-MB mass may relate to more sensitive identification of microinfarction. Further studies are mandatory to confirm the association between elevation of cTnT and risk of restenosis and TVR.

Successful Directional Atherectomy of de Novo Coronary Lesions Assessed With Three-dimensional Intravascular Ultrasound and Angiographic Follow-up

Successful Directional Atherectomy of de Novo Coronary Lesions Assessed With Three-dimensional Intravascular Ultrasound and Angiographic Follow-up

Successful directional atherectomy of de Novo coronary lesions assessed with three-dimensional intravascular ultrasound and angiographic follow-up

Successful directional atherectomy of de Novo coronary lesions assessed with three-dimensional intravascular ultrasound and angiographic follow-up

Successful Directional Atherectomy of De Novo Coronary Lesions Assessed With Three-Dimensional Intravascular Ultrasound and Angiographic Follow-Up

Recent histopathologic and intravascular ultrasound (IVUS) data indicate that inadequate compensatory enlargement of atherosclerotic lesions contributes to the development of significant arterial stenoses. Such lesions may contain less plaque, which may have implications for atheroablative interventions. In this study, we compared lesions with (group A, n = 16) and without inadequate compensatory enlargement (group B, n = 30) as determined by IVUS. The acute results and the follow-up lumen dimensions of angiographically successful directional coronary atherectomy procedures were compared. Inadequate compensatory enlargement was considered present when the preintervention arterial cross-sectional area at the target lesion site was smaller than that at the (distal) reference site. Three-dimensional IVUS analysis and quantitative angiography were performed in 46 patients before and after intervention. IVUS measurements included the arterial, lumen, and plaque (arterial minus lumen) cross-sectional areas at the target lesion site (i.e., smallest lumen site) and the (distal) reference site. Angiographic follow-up was performed in 42 patients. Preintervention and postintervention angiographic measurements and IVUS lumen cross-sectional area measurements were similar in both groups. However, at follow-up, the angiographic minimum lumen and reference diameters were significantly smaller in group A compared with group B (1.71 ± 0.47 mm vs 2.14 ± 0.73 mm, p <0.03, and 2.97 ± 0.29 mm vs 3.39 ± 0.76 mm, p <0.02; group A vs B). The data of this observational study suggest that lesions with inadequate compensatory enlargement, as determined by IVUS before intervention, may have less favorable long-term lumen dimensions after directional coronary atherectomy procedures.

Clinical and angiographic comparison of matched patients with successful directional coronary atherectomy or stent implantation for primary coronary artery lesions

Objectives. This study was designed to compare the long-term clinical and angiographic effects of successful directional atherectomy and stent implantation and to examine whether restenosis is related to the mechanism of lumen improvement as well as the extent of lumen gain.Background. Directional atherectomy and coronary stent implantation have been shown to achieve a more optimal immediate result that may lead to a more favorable long-term angiographic outcome and fewer target vessel revascularizations than does angioplasty. However, it remains to be determined whether one of the devices used in these interventions provides consistently better results than the other.Methods. To allow meaningful comparisons, a prospectively collected series of 117 patients successfully treated with atherectomy were individually matched with a prospectively collected series of 117 patients successfully treated with stent implantation. Matching for baseline characteristics identified patients with identical lesion location and lesion severity, and immediate and late angiographic and clinical outcome were compared. To evaluate the possibility of a procedure effect on restenosis, patients were further matched for both immediate angiographic outcome and baseline characteristics, providing 150 matched patients for comparison. As confirmatory analysis, multivariate models were constructed to predict late lumen diameter.Results. Matching resulted in two comparable groups with equivalent baseline clinical and stenosis characteristics (n = 117 pairs). Atherectomy led to a smaller immediate gain than stenting and, because late loss was similar in both groups, stenting resulted in a larger late lumen (1.96 ± 0.51 vs.1.66 ± 0.55 mm, p < 0.0001). When patients were matched for immediate gain and baseline characteristics (n = 75 pairs), lumen loss was more pronounced after atherectomy, and thus the minimal lumen diameter at follow-up differed significantly between the two groups (1.66 ± 0.53 vs 1.90 ± 0.47 mm, p = 0.004). This beneficial angiographic effect of stenting was accompanied by a reduced need for repeat interventions. Multivariate analysis confirmed the independent effect of the interventional device used, whereby less loss and greater lumen diameter at follow-up were predicted for stent implantation than for atherectomy.Conclusions. Successful stent implantation provided a more favorable long-term angiographic outcome and lower rates of restenosis and need for target lesion revascularization than did atherectomy. This favorable effect of stenting not only is related to a larger immediate gain, but also seems to attenuate late lumen loss.

Coronary Flow Velocity Reserve After Successful Balloon Angioplasty and Directional Atherectomy

Background: To ascertain whether transesophageal echocardiography (TEE) allows for measurement of coronary flow velocity “reserve” in patients with disease of the left anterior descending artery (LAD), and to establish the flow velocity response following angiographically successful angioplasty and atherectomy. Methods: Four groups of patients were studied: normal controls (n = 15) consisted of patients without obstructive coronary artery disease, a LAD stenosis group (n = 15) consisted of patients with &gt; 70% stenosis, an LAD postangiographically successful balloon angioplasty group (n = 12), and an LAD postangiographically successful directional atherectomy group (n = 6). Two‐dimensional horizontal plane TEE was used to image the proximal left coronary arterial system. Pulsed Doppler recordings were made of proximal LAD flow velocities at rest, and following an infusion of 0.56 mg/kg IV dipyridamole. Results: The peak diastolic flow velocity ratio (hyperemic flow/baseline flow) for normal controls was 3.46 ± 0.48 (mean ± standard deviation), for the LAD stenosis group was 1.35 ± 0.26, for the balloon angioplasty group was 2.08 ± 0.45, and for the directional atherectomy group was 2.10 ± 0.82. Conclusions: We conclude that: (1) it is feasible to record with TEE Doppler, flow velocity and flow reserve in normals, in obstructive coronary artery disease, and following revascularization; (2) coronary flow velocity ratio (CFVR) is decreased in patients with LAD stenosis; (3) CFVR remains subnormal in patients with angiographically successful directional atherectomy and balloon angioplasty; and (4) that flow velocity ratios following directional atherectomy were not significantly different from those following balloon angioplasty.

Clinical, histologic and quantitative angiographic predictors of restenosis after directional coronary atherectomy: A multivariate analysis of the renarrowing process and late outcome

Objectives. To characterize predictors of restenosis after successful directional atherectomy, we reviewed the clinical, angiographic and procedural data obtained 132 consecutive procedures.Methods. Clinical and angiographic follow-up data were obtained in a prospectively collected and consecutive series of 125 patients who underwent 132 atherectomy procedures for de novo (89%) or restenotic (11%) lesions in native coronary arteries. Restenosis was assessed clinically and by quantitative coronary angiography. A dual approach to data analysis was taken to gain insight into factors affecting the clinical outcome and vessel wall healing response. Therefore, multivariate analysis was performed to 1) determine the correlates of residual lumen diameter at follow-up (angiographic outcome), and 2) characterize the determinants of the late lumen loss (renarrowing process).Results. Clinical and angiographic follow-up data after successful atherectomy were obtained in 100% and 95%, respectively. Atherectomy achieved an acute lumen gain of 1.28 ± 0.48 mm (mean ± SD), resulting in a minimal lumen diameter of 2.44 ± 0.47 mm. At follow-up, the minimal lumen diameter decreased to 1.78 ± 0.64 mm. The angiographic restenosis rate was 28% if the traditional 50% stenosis cutoff criterion was applied. Larger vessel size and postatherectomy minimal lumen diameter and right coronary or left circumflex artery lesions were independent predictors of a larger minimal lumen diameter (angiographic outcome). Lumen loss during follow-up (renarrowing process) was independently predicted by relative lumen gain and preprocedural minimal lumen diameter.Conclusions. In analyzing the long-term results of new interventional techniques such as directional atherectomy, the late lumen loss during follow-up (renarrowing process), which is characterized by the vessel wall healing response after an intervention, should be considered together with the residual lumen at follow-up (clinical outcome). It is clear that whereas improved clinical outcome is associated with larger vessel size and postprocedural lumen diameter and non-left anterior descending artery location, greater relative gain at intervention is predictive of more extensive lumen renarrowing.

Angiographic follow‐up and clinical outcome of 126 patients after percutaneous directional atherectomy (simpson atherocath™) for occlusive peripheral vascular disease

Angiographic and clinical follow-up data were obtained in 115/126 patients who underwent directional atherectomy for peripheral vascular disease; of the 126, ten were excluded for appropriate reasons and one was lost to follow-up. Thus, 115/116 successful atherectomy patients (99%) had follow-up of 182/213 lesions (86%): 74 patients (64%) with angiography (mean time 5.4 mon), and 41 patients (36%) clinically. One hundred twenty-eight of 183 lesions (70%) had angiographic follow-up; the lesion recurrence as a stenosis or as an occlusion was 53%. Lesion distribution did not differ between angiography and clinical follow-up groups: nearly 85% were within the superficial femoral or popliteal arteries. Despite data stratification, angiographic follow-up indicated that patients after successful directional atherectomy, at a mean follow-up time of 5 mos, have more than a 50% lesion recurrence rate. Although directional atherectomy (Simpson AtheroCath) utilizing present techniques has excellent primary success and acceptable complication rates, angiographic follow-up statistics are bothersome.