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Percutaneous transluminal rotational atherectomy for coronary artery disease
E V Villanueva1, J Wasiak, E S Petherick
1Monash Institute of Health Services Research, Monash University, 246 Clayton Road, Clayton, Victoria, Australia, 3168.
Insights
Percutaneous transluminal coronary rotational atherectomy (PTCRA) shows no benefit for non-complex lesions. For complex lesions, PTCRA with angioplasty offers no significant advantage over angioplasty alone, with increased risks of spasm and perforation.
Area of Science:
- Cardiovascular Interventions
- Interventional Cardiology
- Atherectomy Techniques
Background:
- Percutaneous transluminal coronary rotational atherectomy (PTCRA) uses an abrasive burr to remove atherosclerotic plaque.
- PTCRA selectively removes hard tissue during rotation within coronary arteries.
Purpose of the Study:
- To evaluate the effectiveness of PTCRA for coronary artery disease.
- Assessed PTCRA in both non-complex and complex coronary lesions, including ostial, long, diffuse, and in-stent restenosis.
Main Methods:
- Systematic review and meta-analysis of randomized and quasi-randomized controlled trials.
- Included 9 trials with 3,066 patients, comparing PTCRA with other interventions or no treatment.
Main Results:
- No evidence of PTCRA effectiveness in non-complex coronary lesions.
- In complex lesions, PTCRA with angioplasty (PTCRA/PTCA) showed no significant difference in restenosis rates compared to angioplasty alone.
- PTCRA/PTCA was associated with increased risks of vascular spasm, perforation, and transient occlusions, but fewer dissections and bailout stenting.
Conclusions:
- PTCRA offers no additional benefit when conventional angioplasty is feasible.
- Limited evidence supports routine use of PTCRA for in-stent restenosis due to lack of long-term data.
- PTCRA may be useful in specific cases, such as patients ineligible for surgery or with complex lesions resistant to angioplasty.
Background:
Percutaneous transluminal coronary rotational atherectomy (PTCRA) debulks atherosclerotic plaque from coronary arteries using an abrasive burr. On rotation, the burr selectively removes hard tissue.
Objectives:
To assess the effects of PTCRA for coronary artery disease in patients with non-complex and complex lesions (e.g., ostial, long, or diffuse lesions or those arising from in-stent restenosis) of the coronary arteries.
Search Strategy:
We searched the Heart Group specialised register, the Cochrane Library to Issue 2, 2001, and MEDLINE, CINAHL, EMBASE and Current Contents to December 2002 and reviewed reference lists for relevant articles.
Selection Criteria:
We included randomised and quasi-randomised controlled trials of PTCRA compared with placebo, no treatment or another intervention and excluded cross-over trials.
Data Collection And Analysis:
Data were extracted independently by two authors. We asked authors of trials to provide information when missing data was encountered. Statistical summaries used risk ratios (RR) and weighted mean differences.
Main Results:
We included 9 trials enrolling 3,066 patients. There was no evidence of the effectiveness of PTCRA in non-complex lesions. In complex lesions, there were no statistically significant differences in restenosis rates at 6 months (relative risk 1.00; 95% confidence interval 0.83 to 1.20) and 1 year (relative risk 1.21; 95% confidence interval =0.95 to 1.55) in those receiving PTCRA with adjunctive PTCA (PTCRA/PTCA) compared to those receiving PTCA alone. Morphological characteristics distinguishing complex lesions have not been examined in parallel-arm randomised controlled trials. There is equivocal evidence of the effectiveness of PTCRA in in-stent restenosis. Compared to angioplasty alone, PTCRA/PTCA did not result in a statistically significant increase in the risk of major adverse cardiac events (myocardial infarction, emergency cardiac surgery or death) during the in-hospital period (relative risk 1.19; 95% confidence interval =0.78 to 1.83). Compared to angioplasty, PTCRA was associated with 9 times the risk of an angiographically-detectable vascular spasm (relative risk 9.23; 95% confidence interval 4.61 to 18.47), 4 times the risk of perforation (relative risk 3.87; 95% confidence interval 0.82 to 18.21) and about 2 times the risk of transient vessel occlusions (relative risk 2.28; 95% confidence interval 1.00, 5.19) while angiographic dissections (relative risk 0.49; 95% confidence interval 0.33 to 0.75) and stents used as a bailout procedure (relative risk 0.38; 95% confidence interval 0.22 to 0.65) were less common.
Reviewer'S Conclusions:
When conventional PTCA is feasible, PTCRA appears to confer no additional benefits. There is limited published evidence and no long-term data to support the routine use of PTCRA in in-stent restenosis. In certain circumstances (e.g., patients ineligible for cardiac surgery, those with architecturally complex lesions, or those with lesions that fail PTCA), PTCRA may achieve satisfactory revascularisation in subsequent procedures.
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