Treatment of stent-jailed side branch stenoses with rotational atherectomy

While debulking with rotational atherectomy (RA) prior to balloon angioplasty (BA) improves acute results by reducing elastic recoil, treatment of an ostial side branch lesion that is covered (jailed) by a stent represents a particular challenge. We report our experience with RA in conjunction with BA for the treatment of ostial stenosis in jailed side branches.

Thirty-two lesions in side branches jailed by a stent were treated with RA and BA 39 times in 30 patients. The mean age was 65.5 +/- 11.5 years; 26.3% were women; 18.4% had diabetes mellitus; and 18.4% had a history of prior bypass surgery. Of the treated side branches, 53.9% were diagonals, 71.8% were jailed by a slotted-tube stent, and 86.5% were previously dilated prior to RA. The burr sizes used to treat the jailed side branch origin ranged from 1.25 to 2.25 mm, with a mean burr size of 1.62 +/- 0.31 mm. An average of 1.53 +/- 0.72 burrs were used per lesion. Quantitative coronary angiography was performed prior to, and after, intervention. The mean diameter stenosis of the side branch prior to revascularization was 77.8% +/- 12.6%; this was reduced to a mean stenosis of 23.0% +/- 17.9% following treatment with RA and BA. Angiographic success (residual stenosis < 50% and TIMI 3 flow) in the side branch occurred in 36 of 39 lesions (92.3%). Procedural success (angiographic success in both the side branch and the parent vessel in the absence of death, emergent CABG, urgent TVR, and myocardial infarction (CK-MB > or = 3 times normal) during the index hospitalization) was achieved in 33 of 38 cases (86.8%). One patient suffered a periprocedural myocardial infarction; another patient presented with stent thrombosis in the parent vessel requiring emergency revascularization 36 hours after the index procedure. Clinically-driven revascularization of either the side branch or the side branch or parent was performed in 44.8% and 46.4% of patients, respectively. The estimated freedom from any target lesion revascularization was 47.7% at 300 days. One patient died of unknown causes 253 days following the index procedure.

RA in conjunction with BA can effectively treat stent-jailed ostial side branch stenosis with excellent acute angiographic and procedural results. However, the long-term efficacy is limited by a high rate of repeat revascularization.