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Published on: May 14, 2013
Directional atherectomy prior to stenting in bifurcation lesions: a matched comparison study with stenting alone
E Karvouni1, C Di Mario, T Nishida
1Department of Interventional Cardiology, Centro Cuore Columbus, San Raffaele Hospital, Milan, Italy.
Insights
Directional atherectomy (DCA) with stenting for coronary bifurcation lesions improved acute gain and follow-up lumen diameter compared to stenting alone. However, DCA increased procedural myocardial infarction, though long-term adverse events were lower.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Biology
Background:
- Coronary artery bifurcation lesions present unique challenges for percutaneous intervention.
- The optimal strategy for treating these complex lesions remains under investigation.
Purpose of the Study:
- To compare the acute and long-term outcomes of treating coronary bifurcation lesions using directional atherectomy (DCA) combined with stenting versus stenting alone.
Main Methods:
- A retrospective study comparing 31 patients treated with DCA and stenting (DCA group) to 31 matched patients treated with stenting alone (non-DCA group) for coronary bifurcation lesions.
- Outcomes assessed included procedural success, in-hospital and follow-up major adverse cardiac events (MACE), angiographic parameters (minimum lumen diameter, acute gain, diameter stenosis), and restenosis rates.
Main Results:
- Procedural success was lower in the DCA group (87.1%) compared to the non-DCA group (100%).
- In-hospital MACE, primarily non-Q-wave myocardial infarction, occurred in 12.9% of the DCA group versus 0% in the non-DCA group.
- The DCA group showed significantly greater acute gain and minimum lumen diameter (MLD) in the main branch post-procedure and at follow-up.
- Restenosis rates and follow-up MACE were numerically lower in the DCA group, though not statistically significant.
Conclusions:
- Directional atherectomy and stenting for coronary bifurcation lesions result in improved acute gain and sustained larger MLD in the main branch compared to stenting alone.
- While associated with a higher rate of procedural myocardial infarction, DCA may offer a trend towards reduced restenosis and long-term MACE.
Abstract:
The ideal catheter-based intervention for treatment of coronary lesions at bifurcation site still has to be defined. The aim of the study was to assess the acute and long-term outcome after treatment of bifurcation lesions with directional atherectomy (DCA) and stenting in comparison with stenting alone. Thirty-one consecutive patients treated for bifurcation coronary lesions (62 lesions) with DCA and stenting in at least one branch (DCA group) were compared with a matched group of 31 patients with bifurcation coronary lesions (62 lesions) treated with stenting alone in at least one branch (non-DCA group). Procedural success was 87.1% in the DCA group compared with 100% in the non-DCA group (P = 0.03). In-hospital major adverse cardiac events (MACE) occurred only in the DCA group (12.9% vs. 0%, P = 0.03), mainly non-Q-wave myocardial infarction. After the procedure, minimum lumen diameter (MLD) and acute gain were significantly greater (P = 0.004 and P = 0.05, respectively) and % diameter stenosis was significantly lower (P = 0.05) in the main branch in the DCA group. At follow-up angiogram, MLD in the main branch was still significantly greater in the DCA group compared to the non-DCA group (2.31 vs. 1.65, respectively, P = 0.04), with no significant difference in late loss and loss index between the two groups. Restenosis rate was 28.8% in the DCA group vs. 43.5% in the non-DCA group (P = 0.13). The incidence of follow-up MACE was 29% in the DCA group compared with 48.4% in the non-DCA group, mainly due to target lesion revascularization. In conclusion, treatment of bifurcation coronary lesions with DCA and stenting was associated with greater acute gain after the procedure and greater MLD at follow-up in the main branch compared with stenting alone. Procedural myocardial infarction was more frequent in the DCA group. Restenosis rates and follow-up MACE were lower following DCA and stenting, without reaching any statistical significance.
