Transluminal Extraction Atherectomy Research Articles

Effectiveness of transluminal extraction atherectomy for debulking saphenous vein graft in-stent restenosis

Treatment of in-stent restenosis in saphenous vein grafts often requires initial debulking, but transluminal extraction catheter (TEC) atherectomy is seldom used for this purpose, and most discussions omit this option. Our experience with 6 episodes of TEC used successfully for saphenous vein graft in-stent restenosis and review of 7 other reported cases suggests TEC may be safe and effective for debulking saphenous vein graft restenosis lesions.

Assessing a strategy of initial stand-alone extractional atherectomy followed by staged stent placement in degenerated saphenous vein graft lesions

To assess whether a staged strategy (initial stand alone transluminal extraction atherectomy and coumadin therapy followed by stenting six weeks later) could reduce ischemic complications in degenerated saphenous vein graft (SVG) interventions, we studied 72 patients undergoing percutaneous interventions of degenerated SVG. Patients were divided into two groups; 28 were treated with a staged strategy (group I) and 44 with similar lesion characteristics were treated with a definitive initial procedure with transluminal extraction atherectomy ± adjunctive balloon angioplasty and stenting (group II). Procedural success, major in-hospital complications (death, Q-wave myocardial infarction, and emergent coronary bypass surgery), and incidence of distal embolization were compared between the 2 groups. Procedural success was lower (92% vs 100%, p = 0.14) and major in-hospital complications were higher (0% vs 11%, p = 0.14) in group II. Distal embolization occurred in 11% of the patients in group I compared with 23% of the patients in group II (p = 0.19). At 6 week follow-up (group I), 9 patients (33%) had negative symptoms, 11 (41%) underwent stent implantation, 3 (11%) did not require any further therapy (without significant stenosis), and 4 (14%) had total occlusions. We therefore conclude that this staged strategy in degenerated SVG appears to reduce distal embolization but most importantly avoids major in-hospital complications, including any deaths either at the time of initial procedure or during the 6-week follow-up period.

Guías de práctica clínica de la Sociedad Española de Cardiología en cardiología intervencionista: angioplastia coronaria y otras técnicas

Interventional cardiology has had an extraordinary expansion in last years. This clinical guideline is a review of the scientific evidence of the techniques in relation to clinical and anatomic findings. The review includes: 1. Coronary arteriography. 2. Coronary balloon angioplasty. 3. Coronary stents. 4. Other techniques: directional atherectomy, rotational atherectomy, transluminal extraction atherectomy, cutting balloon, laser angioplasty and transmyocardial laser and endovascular radiotherapy. 5. Platelet glycoprotein IIb/IIIa inhibitors. 6. New diagnostic techniques: intravascular ultrasound, coronary angioscopy, Doppler and pressure wire. For the recommendations we have used the classification system: class I, IIa, IIb, III like in the guidelines of the American College of Cardiology and the American Heart Association.

Risk of distal embolization and infarction with transluminal extraction atherectomy in saphenous vein grafts and native coronary arteries

Risk of distal embolization and infarction with transluminal extraction atherectomy in saphenous vein grafts and native coronary arteries

Risk of distal embolization and infarction with transluminal extraction atherectomy in saphenous vein grafts and native coronary arteries. NACI Investigators. New Approaches to Coronary Interventions.

Lower success rates have been reported when treating high-risk lesions in saphenous vein grafts (SVGs) and native coronary arteries with balloon angioplasty. The transluminal extraction atherectomy catheter (TEC) has been proposed to reduce the incidence of distal embolization (DE) in subsets of high-risk lesions. To define the utility of TEC in reducing the incidence of DE, all patients who were enrolled in the New Approaches to Coronary Interventions (NACI) Registry and had TEC planned as the sole treatment were studied (329 patients with 381 lesions). Of the lesions treated, 75.9% were in SVGs; 37.5% were thrombotic; and 15% were total occlusions. Adjunctive percutaneous transluminal coronary angioplasty (PTCA) was performed in 87.4% of lesions. Multivariate predictors of DE were: noncardiac disease, stand alone TEC, thrombus, and larger vessel size. DE was associated with an 18.5% in-hospital mortality vs. 3.0% without DE (P < 0.01) and a 25.9% MI rate vs. 5.0% without DE (P < 0.01). In conclusion, in this high-risk subset of patients, TEC is associated with an 8.3% incidence of DE with thrombotic and SVGs lesions. DE associated with TEC appears to carry high morbidity and mortality. Additional techniques to control DE are needed to reduce the frequency of complications in these patients.

Update on Interventions in Saphenous Vein Grafts

Interventions in saphenous vein grafts present some of the most challenging problems in preventing acute complications and limiting restenosis. Available options include repeat bypass surgery, balloon angioplasty, directional atherectomy, transluminal extraction atherectomy, rotational atherectomy, laser angioplasty, and stenting. Stenting appears to provide the best acute and long‐term results. Debulking with directional atherectomy prior to stenting may be helpful but its role is unproven. With any device, it is essential to attain the lowest possible residual stenosis with the least amount of manipulation. Complications with vein graft interventions are most commonly related to distal embolization, which occurs most frequently in older vein grafts with diffuse disease, large plaque volume or thrombus, or those with total occlusion. Use of thrombolytics, glycoprotein Ilb/IIIa receptor inhibitors, and thrombectomy devices may be helpful when thrombus is present. Calcium channel blockers may be beneficial when embolization of plaque debris results in slow flow or no‐flow during interventions.

Utilisation of transluminal extraction atherectomy in the treatment of saphenous vein graft disease: two case reports

Saphenous vein graft disease is an increasing problem as more patients undergo bypass grafting and to date the most effective management strategy remains undefined. The major limitations of angioplasty for saphenous vein graft lesions are the risk of distal embolization and restenosis. Primary stenting in this situation results in superior lumen enlargement and higher procedural success but is still associated with significant restenosis. We describe two cases in which transluminal extraction (TEC) atherectomy is utilised for the treatment of vein graft disease with good immediate and long term angiographic results. The first case reports the use of TEC atherectomy for the primary treatment of a discrete eccentric filling defect, and the second case describes the use of this technique in the management of in-stent restenosis.

One-Year Follow-Up of Recanalization of Totally Occluded Aortocoronary Saphenous Vein Grafts Using Transluminal Extraction Atherectomy

Recanalization of totally occluded aortocoronary saphenous vein grafts with extraction atherectomy was successful in 80% of patients. Whereas all patients with unsuccessful procedures were dead at 1 year, 75% of those with successful procedures are alive and free of events.

Predictors of Acute and Long-Term Outcome With Transluminal Extraction Atherectomy: The New Approaches to Coronary Intervention (NACI) Registry

The New Approaches to Coronary Intervention (NACI) registry was established to define the role of new coronary devices in overcoming the limitations of balloon angioplasty. The purpose of the present study was to evaluate the acute and long-term efficacy of the transluminal extraction catheter (TEC) device utilizing data from the NACI registry and identify clinical and anatomic patient subsets who may benefit from this device. From 1990–1994, >4,300 patients from 39 clinical sites enrolled consecutive patients treated with one of the 7 new devices to the NACI registry. The study population consists of 331 patients (385 lesions) treated with planned TEC as the sole new device. Of these patients, 243 (292 lesions) were treated for saphenous vein graft (SVG) disease and 88 (93 lesions) for native disease. Patients undergoing SVG treatment were older and more likely to be male. They had lower ventricular function, more unstable angina, and a higher incidence of congestive heart failure. Multivessel disease was more prevalent in the SVG cohort, as was evidence of thrombus before treatment. Although device success was achieved in 50% of SVG lesions and 41% of native lesions, lesion success was achieved in 90% and 78%, respectively, after adjunctive balloon angioplasty, and procedure success rates were 86% and 79%, respectively. The in-hospital major complication (death/Q-wave myocardial infarction/emergency coronary artery bypass graft [CABG] surgery) rate was higher in the SVG cohort (6.2% vs 2.3%), mainly due to higher mortality rate (5.3% vs 1.1%). Multivariate analysis showed that SVG was not an independent predictor for either an in-hospital major complication or clinical failure. The risk factors for major in-hospital complications were history of congestive heart failure (odds ratio = 3.17) and thrombus (odds ratio = 3.36). For clinical failure the risk factors were diabetes (odds ratio = 1.88), thrombus (odds ratio = 2.08), and calcium (odds ratio = 3.09). One-year rates of death, Q-wave myocardial infarction, or any repeat revascularization were 51% in the SVG cohort and 41% in the native cohort. Following adjustment, patients treated for SVG disease did not have a higher risk when compared with those treated for native disease. The factors significantly associated with this composite event at 1 year are male (relative risk = 1.41), patients with history of congestive heart failure (relative risk = 1.56), and total occlusions (relative risk = 1.52). This study shows that for both SVG and native cohorts, device success rates were low with TEC alone, but acceptable lesion success rates were achieved when adjunctive PTCA was used. In-hospital as well as 1-year major complications were higher in the SVG cohort. However, after adjusting for other risk factors, SVG attempt was not significantly associated with either in-hospital or 1-year events.

Transluminal Extraction Atherectomy for Restenosis Following Palmaz-Schatz Stent Implantation

Transluminal extraction atherectomy with adjunctive balloon angioplasty was successfully performed in 9 patients who had restenosis after Palmaz-Schatz stent implantation. Although 4 patients with either totally occluded lesions or with saphenous vein graft lesions had recurrence, this strategy may be a potential treatment for in-stent restenosis.

Transluminal extraction atherectomy for aortosaphenous vein graft stent restenosis

Transluminal extraction atherectomy for aortosaphenous vein graft stent restenosis

Extraction atherectomy for the recanalization of totally occluded aortocoronary saphenous vein grafts

This report describes the successful treatment of totally occluded aortocoronary saphenous vein grafts with percutaneous transluminal extraction atherectomy (TEC) in three patients with severe angina and high reoperative surgical risk. The method presented here may provide an alternative to overnight urokinase infusion or repeat surgery in high risk patients.

Treatment of Diffuse Coronary Artery and Vein Graft Disease With a 60-mm-Long Balloon: Early Clinical Experience

To report our preliminary clinical experience with a new 60-mm-long angioplasty balloon. We reviewed the results in patients who underwent this type of angioplasty between May and October 1993 at our institution. The study group consisted of 14 high-risk patients (57% with rest-related angina) and 19 treated coronary segments--52% in native coronary arteries and 48% in saphenous vein grafts (mean age, 9 years). Often, long balloon angioplasty was used in conjunction with laser or transluminal extraction atherectomy. Angiographic success (40% or more visual reduction in diameter stenosis) was achieved in all patients. Intimal dissection occurred in 4 of the 19 treated segments (21%), but each was less than 50% obstructive. No patient required intracoronary stenting. Clinical success was achieved in 13 patients (93%). The one death that occurred was from vein graft distal embolization. At a mean follow-up of 9 months, three patients had required reinterventional procedures, and one patient had undergone a coronary artery bypass operation. No myocardial infarction or death occurred during this period. Preliminary clinical experience with a 60-mm-long angioplasty balloon to treat complicated coronary lesions in high-risk patients suggests that, when used alone or in combination with other devices, this new balloon results in high initial success and low complication rates. A larger clinical experience is necessary for accurate assessment of the role of this new balloon catheter.

The Role of the Perfusion Balloon Catheter After an Initially Unsuccessful Coronary Intervention

Major dissection and acute closure following conventional percutaneous transluminal coronary angioplasty (PTCA) occur in 5%-10% of cases and lead to significant morbidity. Newer percutaneous modalities such as directional coronary atherectomy (DCA), excimer laser coronary angioplasty (ELCA), rotational ablation, and transluminal extraction atherectomy (TEC) can also be complicated by dissection and acute closure. Redilatation with conventional balloon catheters can reestablish patency of the artery or improve flow in a minority of cases. The perfusion balloon catheter (PBC) has several advantages over conventional balloon angioplasty in this situation. In approximately 70% of these cases, subsequent use of a PBC yields an acceptable clinical and angiographic result. The PBC permits rapid resolution of ischemia caused by acute closure or a flow-limiting dissection. New modifications of the PBC make it possible to position the catheter in nearly all segments of the coronary arterial tree including locations not accessible to other modalities, such as coronary stents or DCA, that are also used for salvage after a failed coronary intervention. Even if the PBC does not yield a definitive result, it allows rapid restoration of antegrade flow prior to coronary artery bypass grafting or coronary stent placement. Because of its ease of use, wide applicability, and efficacy, the PBC should be considered as the initial means of treatment in cases of major dissection or acute closure following any modality of percutaneous coronary revascularization.

720-2 Predictors of Acute Complications After Percutaneous Coronary Revascularization with New Devices

Studies of conventional balloon angioplasty (PTCA) have identified female gender, age, unstable angina, prior coronary bypass surgery, diabetes, lesion thrombus, and dissection as predictors of acute complications, but predictors of the risks of new device interventions are unknown. New devices were performed on 596 lesions in 561 patients including excimer laser angioplasty (n = 125), rotablator atherectomy (n = 111), and transluminal extraction atherectomy (n = 330) followed by adjunctive PTCA in 84% of lesions. Final procedural success was achieved in 86%. Serious angiographic complications (sidebranch occlusion, distal embolization, no reflow, abrupt closure, perforation) occurred in 9.4% of procedures after the new device and persisting in 3.2% after adjunctive PTCA. Major complications (non-Q-wave infarction, Q-wave infarction, emergency bypass surgery, death) occurred in 9.1% of patients. Multiple logistic regression was performed on all clinical and angiographic variables to identify independent predictors of serious angiographic and clinical complications: Predictors of Outcomes Wald statistic Odds Ratio (95% CI) Serious angiographic complication Prior PTCA of target lesion -291, P = 0004 0.44 (026-0.77) Interaction of thrombus &unstable angina 2.25, P = 002 3.96 (1.20-13.14) Interaction of thrombus &vein graft 2.35, P = 0.019 5.41 (133-22.04) Major clinical complication Serious angiographic complication 3.30, P = 0.0010 3.22 (1.61-6.47) Prior angioplastyof a target lesion (restenosis) is protective for angiographic complications with new devices. Intralesional thrombus in the setting of unstable angina or saphenous vein grafts confers an increased risk of angiographic complications. These angiographic complications, in turn, are predictive of major complications including nonfatal MI, emergency bypass surgery, and death.

782-6 Clinical and Angiographic Followup to a Prospective Study of Transluminal Extraction Atherectomy in High Risk Patients with Acute Myocardial Infarction

Acute myocardial infarction (AMI) patients with an infarct related artery (IRA) containing thrombus are a high risk group for percutaneous transluminal coronary angioplasty. TEC may be a useful device for treatment of these patients due to its ability to aspirate thrombus. TEC was prospectively evaluated in 63 patients (age 61 ± 12 years) including 23 (36.5%) ineligible for thrombolysis, 24 (38%) with lytic failure, and 16 (25.5%) with post infarct angina and a thrombotic coronary occlusion. Immediate, one week, and six month angiographic and clinical followup were obtained. The IRA was a SVG in 18 (29%) and a native coronary artery (NAT) in 45 (71%). Acute procedural success with a residual stenosis &lt; 50% and TIMI 2 or 3 grade flow was acheived in 94% of patients. There were no major procedural complications. Other events during the hospitalization included death in 3 (4.8%), CABG in 2 (3%) and blood transfusion in 12 (19%). Elective predischarge angiography revealed an IRA stenosis &lt; 50% in 34/38 (89%). Patients were followed for 6 months with clinical followup in 100% and angiographic in 38/63. Death CABG Patency at F/U IRA RePTCA NAT 3/45 (6.7%) 1145 (2.2%) 29/31 (94%) 15/45 (33%) SVG 4/18 (22.2%) 2/18 (11.1%) 4/7 (57%) 4/18 (22%) TOTAL 7/63 (11.1%) 3/63 (4.8%) 34/38 (90%) 19/63 (30%) Angiographic restenosis occurred in 27/38 (71%) although most patients returned for followup cath secondary to symptom recurrence. Clinical restenosis occurred in 22 (42%). High risk AMI patients can be successfully treated with TEC with a high technical success rate and a low incidence of complications. IRA patency at 1 week and 6 months was excellent; however, angiographic restenosis remains a problem. Extraction of thrombus in AMI may help maintain vessel patency but does not appear to prevent restenosis.

Clinical significance of distal embolization after transluminal extraction atherectomy in diffusely diseased saphenous vein grafts

Standard balloon angioplasty of degenerated saphenous vein graft lesions may be complicated by distal embolization, particularly in the presence of intragraft thrombus. Transluminal extraction atherectomy may be useful in this setting because of its ability to remove particulate debris. This study was designed to identify the incidence and prognostic significance of distal embolization after transluminal extraction atherectomy in high-risk saphenous vein graft lesions. To address these issues the clinical course of 65 consecutive patients (86 high-risk saphenous vein graft lesions) was reviewed after extraction atherectomy. Distal embolization occurred in 11 (12.8%) of 86 high-risk lesions. The majority (63.6%) of these episodes occurred after adjunct balloon dilatation following uncomplicated use of the extraction atherectomy catheter. Correlates of distal embolization included patient age and the presence of intragraft thrombus. Major in-hospital complications developed more often in patients with distal embolization (46% vs 2% in those without distal embolization, p < 0.001), resulting in a reduced procedural success rate in this group (55% vs 91%, p = 0.01). We conclude that the risk of distal embolization after saphenous vein graft angioplasty, although potentially reduced, is not eliminated with transluminal extraction atherectomy, particularly in lesions with superimposed thrombus.

Success, complications, and restenosis following rotational and transluminal extraction atherectomy of ostial stenoses.

Our objectives were to determine procedural success, clinical complications, and follow-up restenosis rates after rotational burr and transluminal extraction atherectomy of coronary artery and saphenous vein graft ostial stenoses. Balloon angioplasty of ostial lesions has been associated with low rates of success and high rates of clinical complications and restenosis compared to nonostial lesions. Atherectomy, due to its ability to excise (extraction atherectomy) or pulverize (rotational atherectomy) atheroma and the internal elastic lamina, may result in improved procedural outcome. We retrospectively studied 101 patients with ostial stenoses treated by rotational burr and transluminal extraction atherectomy over a 3-yr period. Quantitative angiography and clinical follow-up were reviewed to determine success, complication, and restenosis rates. Rotational burr (n = 29) and transluminal extraction (n = 72) atherectomy were associated with high procedural success (93% and 90%, respectively) and a low incidence of complications (6.9% and 4.2%, respectively). Post-atherectomy angiographic success was low (52% and 69%, respectively) and required adjunctive balloon angioplasty in 85% of patients overall. This lower success rate likely reflects device undersizing as the overall post-atherectomy artery to device ratio was near unity (0.95). The rates of angiographic ostial restenosis remain high (39.1% and 65.9%, respectively, P < 0.05). The high rate of restenosis after transluminal extraction atherectomy was due to the higher rate of restenosis in saphenous vein grafts (80%) compared to TEC treated coronary arteries (59%). When only coronary artery lesions were compared, there was no significant difference between atherectomy device groups with respect to restenosis rates or late loss.(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of percutaneous transluminal coronary angioplasty after new device coronary interventions

Percutaneous transluminal coronary angioplasty (PTCA) is often required immediately after laser and atherectomy devices to enlarge lumen dimensions and to salvage device failures. Between January 1989 and June 1992, adjunctive PTCA was applied to 83% of narrowings treated with new interventional devices, including 85% of transluminal extraction atherectomy (n = 290), 72% of high-speed mechanical rotational atherectomy (n = 79), and 89% of excimer laser angioplasty (n = 118) lesions (p = NS). Device success was defined as a decrease in diameter stenosis ≥20%; procedural success was defined as a final diameter stenosis ≤ 50% after PTCA; and salvage PTCA was defined as use of PTCA to manage device-induced vessel occlusion. Although adjunctive PTCA was applied to 487 lesions, it was used to further enlarge the lumen after initial device success in 139 lesions (28.5%). In contrast, adjunctive PTCA was used after initial device failure in 348 lesions (71.5%), including after minimal or no change (decrease in diameter stenosis by 0 to 19%) in diameter stenosis in 244 lesions (50%) and after worsening of diameter stenosis in 104 lesions (21.5%). Salvage PTCA after device-induced vessel occlusion was performed in 61 lesions (12.6%). However, final procedural success after PTCA was achieved in 412 lesions (85%), with a low incidence of Q-wave myocardial infarction (3.5%), emergency bypass surgery (1.8%) and death (2.3%).

Are residual stenoses after excimer laser angioplasty and coronary atherectomy due to inefficient or small devices? comparison with balloon angioplasty

Objectives. The purpose of this study was to determine whether residual stenoses after excimer laser angioplasty and atherectomy were due to inefficient tissue ablation/removal or to undersized devices.BackgroundSignificant residual stenoses are commonly observed after use of laser and atherectomy devices. It is not known whether these residual stenoses are due to inefficient or undersized devices,Methods. To determine the relative contribution of these factors, the minimal lumen diameter, percent diameter stenosis and normal reference diameter were measured immediately before and after coronary interventions in 696 lesions, including transluminal extraction atherectomy, high speed mechanical rotational atherectomy, excimer laser angioplasty and conventional balloon angioplasty, The ratio of the diameter of the device to the normal reference diameter (D/A, a measure of device sizing) and the ratio of the residual lumen diameter after use of the device to the device diameter (RLD/D, a measure of the efficiency of lumen enlargement) were calculated.Results. Baseline diameter stenoses were similar for all interventions. The percent diameter stenosis were greater immediately after extraction atherectomy (60 ± 21%), rotational atherectomy (54 ± 23%) and excimer laser angioplasty (61 ± 18%) compared with balloon angioplasty (26 ± 12%, p < 0.001). The DA ratio was smaller after extraction atherectomy (0.63 ± 0.14), rotational atherectomy (0.59 ± 0.17) and excimer laser angioplasty (0.51 ±0.11) compared with balloon angioplasty (1.05 ± 0.13, p < 0.001). The RLD/D ratio was similar after extraction atherectomy (0.73 ±0.24) and balloon angioplasty (0.71 ±0.11) but was greater after rotational athereetomy (0.92 ± 0.16, p < 0.001) and excimer laser angioplasty (0.85 ± 0.30, p < 0.01) compared with balloon angioplasty.Conclusions. Residual stenoses after extraction atherectomy, rotational atherectomy and excimer laser angioplasty were more severe than after balloon angioplasty but were due to undersized devices (low DA ratio), not to inefficient devices (low RLD/D ratio). Rotational atherectomy and excimer laser angioplasty were more efficient (higher RLD/D) than balloon angiopiasty, whereas extraction atherectomy and balloon angioplasty were similar.