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Published on: February 26, 2013
Percutaneous coronary intervention with rotational atherectomy for severely calcified unprotected left main:
Juan Garcia-Lara1, Eduardo Pinar, Raul Valdesuso
1Department of Cardiology, Virgen de la Arrixaca University Hospital, Murcia, Spain. jgarciadelara@gmail.com
Insights
Rotational atherectomy (RA) is a feasible treatment for severe, calcified unprotected left main (ULM) stenosis in high-risk patients ineligible for bypass surgery. While mortality rates are high, RA may offer the only effective treatment option.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Coronary bypass surgery is standard for unprotected left main (ULM) stenosis.
- Percutaneous coronary intervention (PCI) is an alternative for high-surgical-risk patients.
- Severe calcification in ULM stenosis poses a challenge for PCI.
Purpose of the Study:
- To evaluate the feasibility and outcomes of rotational atherectomy (RA) for severely calcified ULM stenosis.
- To assess RA as a treatment option for patients ineligible for coronary artery bypass grafting.
Main Methods:
- Retrospective analysis of 40 high-surgical-risk patients with severely calcified ULM stenosis.
- Patients underwent rotational atherectomy (RA) at a single center.
- Data collected included procedural details, complications, and long-term clinical outcomes.
Main Results:
- RA was performed on 40 patients (mean age 73 years) with ULM stenosis, 67% with distal stenosis.
- In-hospital mortality was 7.5% (3/40 patients).
- At 2-year follow-up, survival free of cardiac death was 71%, with 19.3% requiring target vessel revascularization.
Conclusions:
- Rotational atherectomy (RA) is a feasible treatment for severely calcified unprotected left main (ULM) stenosis in high-risk patients.
- Despite significant mortality, RA may represent the sole effective therapeutic option for this challenging patient group.
- Further research is warranted to optimize outcomes and patient selection for RA in ULM stenosis.
Introduction:
According to current practice guidelines, coronary bypass surgery is the standard care option for unprotected left main (ULM) stenosis. However, a group of high surgical risk patients who are not eligible for coronary bypass surgery could benefit from percutaneous coronary intervention (PCI). Severe calcification hampers PCI in this setting, and rotational atherectomy (RA) could be of great help.
Methods:
We retrospectively analyzed a cohort of 40 patients with severely calcified ULM stenosis, not eligible for coronary artery bypass grafting, who underwent RA in our center.
Results:
Forty patients (mean age, 73 ± 8 years; 26 males) with ULM stenosis were treated with RA. Twenty-seven (67%) had distal stenosis. The mean number of treated vessels was 2.38 ± 0.74, with a mean lesion length of 30 ± 18 mm. Abciximab was used in 12 (30%) cases and an intra-aortic balloon pump in three cases. One patient died during the procedure and another two patients died in the first 24 hr after the procedure. The major events registered after the procedure included one significant branch loss, and two minor and one major case of bleeding (the latter requiring transfusion) at the puncture point. After a median of 24.7 (IQR 19.6-34.3) months of follow-up, 12 cardiac deaths were recorded. Survival free of cardiac death was 71 ± 7% and clinical guided target vessel revascularization 19.3 ± 7% at 2 years.
Conclusion:
In a group of high surgical risk patients, RA on severely calcified left main stenosis is feasible and, in spite of high mortality rates, could pose the only possible effective treatment.
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