Optimizing rotational atherectomy in high-risk percutaneous coronary interventions: insights from the PROTECT ΙΙ
Mauricio G Cohen1, Abhijit Ghatak, Neal S Kleiman
1University of Miami Miller School of Medicine, Miami, Florida.
Insights
Rotational atherectomy (RA) in high-risk PCI patients was associated with more complex disease and higher MI rates. Impella support showed fewer repeat revascularizations but more periprocedural MI with aggressive RA.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Device Technology
Background:
- Rotational atherectomy (RA) is crucial for treating heavily calcified coronary lesions during high-risk percutaneous coronary intervention (PCI).
- RA can lead to complications such as slow-flow, hypotension, and periprocedural myocardial infarction (MI).
- Hemodynamic support devices like the intra-aortic balloon pump (IABP) and Impella 2.5 are used to mitigate risks in high-risk PCI.
Purpose of the Study:
- To evaluate the outcomes of rotational atherectomy (RA) in patients undergoing high-risk percutaneous coronary intervention (PCI).
- To compare the efficacy and safety of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump (IABP) in patients requiring RA.
- To analyze the impact of RA technique and patient characteristics on procedural outcomes within the PROTECT II trial.
Main Methods:
- A comparative analysis of patients undergoing high-risk PCI with and without RA was performed.
- Baseline characteristics, angiographic data, procedural details, and clinical outcomes were compared between groups.
- The study specifically examined RA technique and outcomes in patients randomized to IABP or Impella 2.5 support.
Main Results:
- RA was utilized in 52 patients, with a trend towards more frequent use with Impella (32 vs. 20, P=0.08).
- RA patients were older, had more prior CABG, higher STS, and higher SYNTAX scores, indicating greater comorbidity and disease complexity.
- While RA use correlated with a higher incidence of MI at 90 days, there was no significant difference in mortality between the IABP and Impella groups for RA patients. Impella use was associated with fewer repeat revascularizations (P < 0.001).
Conclusions:
- Patients treated with RA exhibited more comorbidities and complex coronary artery disease.
- More aggressive RA utilization with Impella support led to reduced repeat revascularization but an increased rate of periprocedural MI.
- No significant differences in 90-day major adverse events were observed between IABP and Impella in patients undergoing RA, though Impella showed better outcomes in non-RA patients.
Objective:
To study rotational atherectomy (RA) outcomes in patients undergoing high-risk PCI randomized to receive hemodynamic support using either IABP or Impella 2.5 in the PROTECT II trial.
Background:
RA of heavily calcified lesions is often necessary for complex PCI but can be associated with slow-flow, hypotension, and higher risk of periprocedural MI.
Methods:
We compared baseline, angiographic, procedural characteristics, and outcomes of patients treated with and without RA. We examined also RA technique and outcomes.
Results:
RA was used in 52 of 448 patients (32 with Impella vs 20 with IABP, P = 0.08). RA patients were older (72 vs. 67 yo, P = 0.0009), more likely to have prior CABG (48 vs. 32%, P = 0.017), higher STS (8.1 vs. 5.7, P = 0.012) and higher SYNTAX scores (37 vs. 29, P < 0.0001). At 90 days, RA use was associated with higher incidence of MI but no mortality difference. RA was used more aggressively with Impella resulting in higher rate of periprocedural MI (P < 0.01), with no difference in mortality between groups (P = 0.78). Repeat revascularization occurred less frequently with Impella (P < 0.001). There were no differences in 90-day major adverse events between IABP and Impella in patients undergoing RA (P = 0.29). In patients not treated with RA, fewer MAEs were observed with Impella compared with IABP (P = 0.03).
Conclusions:
Patients who were treated with RA had more comorbidities, and more complex and extensive coronary artery disease. In patients with Impella, more aggressive RA use resulted in fewer revascularization events but higher incidence of periprocedural MI.
Related Concept Videos
01:26Coronary Artery Disease IV: Preventive Measures
01:26Atherosclerosis III: Management
01:27Peripheral Artery Disease III: Interprofessional Care
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:30Acute Coronary Syndrome I: Introduction
01:23Atherosclerosis IV: Nursing Management