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Directional atherectomy of coronary and saphenous vein graft ostial stenoses
W J Stephan1, E R Bates, K N Garratt
1Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0119, USA.
Insights
Directional coronary atherectomy (DCA) effectively treats coronary ostial stenoses with high procedural success and low major complications. However, the 6-month restenosis rate remains significant, particularly for vein graft lesions.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Vascular Surgery
Background:
- Coronary ostial stenoses pose treatment challenges.
- Long-term efficacy of Directional Coronary Atherectomy (DCA) for these lesions is not well-established.
- DCA is a proposed alternative to balloon angioplasty.
Purpose of the Study:
- To evaluate the procedural success and long-term efficacy of DCA in treating coronary ostial stenoses.
- To assess complication rates and restenosis rates following DCA for various lesion types.
Main Methods:
- Retrospective review of clinical data from a large registry and two single centers.
- Inclusion of patients undergoing DCA for aortocoronary, non-aortocoronary, or vein graft ostial stenoses.
- Analysis of procedural success, complication rates, and 6-month angiographic follow-up for restenosis.
Main Results:
- Overall procedural success was 87% in 160 lesions across 158 patients.
- Major complication rate was low at 0.6%, with no deaths or Q-wave myocardial infarctions.
- The 6-month angiographic restenosis rate was 48%, with higher rates for restenotic (61%) versus de novo (40%) lesions and particularly high rates for vein graft lesions (93% for restenotic).
Conclusions:
- DCA is an effective revascularization strategy for coronary ostial stenoses, offering high procedural success and low major complication rates.
- Significant restenosis rates observed post-DCA necessitate further investigation and potential adjunctive therapies.
- Vein graft ostial stenoses demonstrate particularly high restenosis rates after DCA, suggesting limited long-term benefit for this specific indication.
Abstract:
Directional coronary atherectomy (DCA) has been proposed as an alternative to balloon dilatation for treating coronary ostial stenoses, but the long-term efficacy of this procedure has not been well studied. To determine the procedural success and long-term efficacy of DCA for ostial stenoses, clinical data from 1 large registry database and from 2 single centers were retrospectively reviewed. Patients included in the study underwent DCA of aortocoronary (left main or right coronary artery), non-aortocoronary (left anterior descending or circumflex), or vein graft ostial stenoses. In 158 patients undergoing DCA of 160 lesions (30 left main or right coronary, 73 left anterior descending or circumflex, and 57 vein graft stenoses), overall procedural success, defined as < 50% residual stenosis without death, Q-wave myocardial infarction, or need for urgent bypass graft surgery, was 87%. The major complication rate was 0.6%. There were no deaths or Q-wave infarctions; only 1 patient required urgent bypass surgery. Other complications included non-Q-wave myocardial infarction (9%), arterial dissection (9%), abrupt closure (4%), and distal coronary embolization (4%). Angiographic follow-up was available for 65% of the 138 eligible patients. The overall 6-month angiographic restenosis rate, defined as > 50% diameter stenosis at the site of DCA, was 48% (de novo lesions 40% and restenotic lesions 61%). Restenosis rates for de novo and restenotic lesions were: aortocoronary (33%/50%), native coronary (38%/35%), and vein graft (47%/93%), respectively. We conclude that DCA of ostial stenoses is an effective revascularization strategy associated with a high procedural success rate and a low incidence of major complications.(ABSTRACT TRUNCATED AT 250 WORDS)