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Coronary morphology after percutaneous directional coronary atherectomy in humans: autopsy analysis of three patients
K N Garratt1, W D Edwards, R E Vlietstra
1Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905.
Insights
Percutaneous directional atherectomy causes distinct vascular injury compared to balloon angioplasty. This procedure can lead to intimal hyperplasia and restenosis, potentially causing myocardial ischemia and infarction.
Area of Science:
- Cardiovascular Pathology
- Interventional Cardiology
- Vascular Surgery
Background:
- The underlying pathology of successful percutaneous directional atherectomy (PDA) and subsequent restenosis in coronary arteries remains unclear.
- Understanding the tissue response to PDA is crucial for optimizing interventional cardiology procedures.
Observation:
- Autopsy examination of three patients who underwent PDA revealed distinct vascular wall defects.
- Atherectomy specimens showed atheromatous and fibroproliferative tissues from the intima, media, and adventitia.
- Vascular defects correlated with the depth of tissue resection, extending into atheroma, media, or adventitia.
Findings:
- PDA-induced vascular injury differs from balloon angioplasty, with less widespread disruption.
- Acute mural thrombus deposition was observed in the resection zone in one patient.
- Late findings included significant intimal hyperplasia, leading to lumen narrowing and implicated in myocardial ischemia.
Implications:
- PDA creates a unique injury pattern, distinct from balloon angioplasty.
- The risk of acute mural thrombus exists even with limited intimal resection.
- Intimal hyperplasia following PDA can cause significant lumen stenosis and late ischemic events, necessitating further research into prevention and management strategies.
Abstract:
The morphologic basis of angiographically successful percutaneous directional atherectomy and subsequent restenosis in human coronary arteries is unknown. The clinical and pathologic features of three patients who died after coronary atherectomy are described. Tissue fragments obtained with atherectomy demonstrated atheromatous and fibroproliferative intima, media and adventitia. At autopsy, treated vascular segments (from the left anterior descending artery in two patients and a vein graft in one patient) demonstrated discrete defects in the vascular wall. Defects extending into atheroma, media or adventitia corresponded with the presence of these tissues in the atherectomy specimens. Tissues were otherwise not disrupted in the manner associated with balloon angioplasty. Acute mural thrombus deposition was evident in the resection zone in one patient. Late findings included fibroproliferative intimal tissue extending from the resected areas into the vascular lumen. In one patient intimal hyperplasia was sufficient to narrow the vascular lumen by 82% and was implicated in subsequent myocardial ischemia and infarction. The study indicates that 1) the vascular injury associated with atherectomy is distinct from that associated with balloon angioplasty, 2) acute mural thrombus deposition may occur even with resection limited to the intima, and 3) intimal hyperplasia may develop in regions treated with atherectomy and may be associated with late myocardial ischemia and infarction.