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Impact of Clinical Presentation on Outcomes After Rotational Atherectomy in Patients Who Underwent Percutaneous
Ali Farooq1, Anoop N Koshy2, Gennaro Giustino1
1The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
Insights
Rotational atherectomy (RA) is safe for treating calcified coronary lesions in acute coronary syndromes (ACS) like unstable angina and non-ST-elevation myocardial infarction. While NSTEMI patients face higher long-term risks, RA offers similar procedural success and safety compared to chronic coronary syndromes.
Area of Science:
- Interventional Cardiology
- Cardiovascular Medicine
- Percutaneous Coronary Intervention
Background:
- Rotational atherectomy (RA) is standard for chronic coronary syndromes (CCS) with calcified lesions.
- RA's role in acute coronary syndromes (ACS) remains less defined, often considered a relative contraindication.
- Evaluating RA in non-ST-elevation ACS (NSTE-ACS) is crucial for expanding treatment options.
Purpose of the Study:
- To assess the efficacy and safety of RA in patients with NSTE-ACS (unstable angina [UA] and non-ST-elevation myocardial infarction [NSTEMI]).
- To compare procedural outcomes and 1-year adverse events between NSTE-ACS and CCS patients undergoing RA.
- To determine if RA is a viable option for heavily calcified lesions in the ACS setting.
Main Methods:
- Retrospective analysis of 2,122 patients undergoing RA for percutaneous coronary intervention (2012-2019).
- Patients were categorized into CCS, UA, and NSTEMI groups; ST-elevation MI patients were excluded.
- Primary endpoints: procedural success and complications. Secondary endpoint: 1-year risk of death or myocardial infarction (MI).
Main Results:
- No significant differences in procedural success or complications (dissection, perforation, side-branch closure) were observed between NSTE-ACS and CCS groups.
- A higher rate of slow-flow/no-reflow occurred in the UA population (p=0.03).
- At 1 year, NSTEMI patients had a higher risk of death or MI compared to CCS patients (aHR 1.79), but no significant difference between combined NSTE-ACS and CCS.
Conclusions:
- RA demonstrates comparable procedural success and safety to CCS in NSTE-ACS patients with heavily calcified lesions.
- While NSTEMI patients face increased long-term risks, RA is feasible and safe in this subgroup.
- RA can be considered a valuable therapeutic option for selected NSTE-ACS patients requiring treatment for complex calcified coronary lesions.
Abstract:
Rotational atherectomy (RA) is widely used in the percutaneous treatment of heavily calcified coronary artery lesions in patients with chronic coronary syndromes (CCS). However, the safety and efficacy of RA in acute coronary syndrome (ACS) is not well established and is considered a relative contraindication. Therefore, we sought to evaluate the efficacy and safety of RA in patients presenting with non-ST-elevation myocardial infarction (NSTEMI), unstable angina (UA), and CCS. Consecutive patients who underwent percutaneous coronary intervention with RA between 2012 and 2019 at a tertiary single center were included. Patients presenting with ST-elevation myocardial infarction (MI) were excluded. The primary end points of interest were procedural success and procedural complications. The secondary end point was the risk of death or MI at 1 year. A total of 2,122 patients who underwent RA were included, of whom 1,271 presented with a CCS (59.9%), 632 presented with UA (29.8%), and 219 presented with NSTEMI (10.3%). Although an increased rate of slow-flow/no-reflow was noted in the UA population (p = 0.03), no significant difference in procedural success or procedural complications, including coronary dissection, perforation, or side-branch closure, was noted (p = NS). At 1 year, there were no significant differences in death or MI between CCS and non-ST-elevation ACS (NSTE-ACS: UA + NSTEMI; adjusted hazard ratio 1.39, 95% confidence interval 0.91 to 2.12); however, patients who presented with NSTEMI had a higher risk of death or MI than CCS (adjusted hazard ratio 1.79, 95% confidence interval 1.01 to 3.17). Use of RA in NSTE-ACS was associated with similar procedural success without an increased risk of procedural complications compared with patients with CCS. Although patients presenting with NSTEMI remained at higher risk of long-term adverse events, RA appears to be safe and feasible in patients with heavily calcified coronary lesions presenting with NSTE-ACS.
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