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Directional atherectomy of left main stenoses
S B Laster1, B D Rutherford, D R McConahay
1Mid American Heart Institute, St. Luke's Hospital, Kansas City, MO 64111.
Insights
Directional coronary atherectomy (DCA) offers a promising alternative to balloon angioplasty for left main (LM) stenoses. DCA achieved excellent results and superior long-term outcomes in protected LM lesions.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Left main (LM) stenoses treated with balloon angioplasty (PTCA) often experience clinical restenosis.
- Directional coronary atherectomy (DCA) may offer improved outcomes for specific LM lesion types.
Purpose of the Study:
- To evaluate the acute and long-term efficacy of DCA in patients with protected LM lesions.
- To compare DCA outcomes with historical PTCA data for LM stenosis.
Main Methods:
- Retrospective analysis of 24 DCA procedures in 22 patients with protected LM lesions.
- Assessment of acute procedural success (residual stenosis < 40%) and complications.
- Long-term follow-up for clinical restenosis, survival, and event-free survival.
Main Results:
- Overall acute success rate of 88%, with 100% success in planned procedures.
- Mean LM stenosis reduced from 86% to 13% (P < 0.01).
- At 24 months, restenosis was 16%, survival 100%, and event-free survival 89%.
Conclusions:
- DCA achieves excellent angiographic results with low complication rates in protected LM lesions.
- DCA can be effective when PTCA results are suboptimal.
- DCA may offer superior long-term clinical outcomes compared to balloon angioplasty for LM stenosis.
Abstract:
Balloon angioplasty (PTCA) of left main (LM) stenoses is limited by frequent clinical restenosis. Directional coronary atherectomy (DCA) may be an effective alternative to PTCA due to its ability to achieve a greater postprocedural luminal diameter when treating bulky, eccentric plaques and aorto-ostial lesions. We analyzed the acute and long-term results following 24 DCA procedures in 22 patients with "protected" LM lesions. Acute success (residual stenosis < or = 40%, no major ischemic complications) was 88% overall, 100% in 13 planned procedures, and 73% in 11 adjunctive DCA procedures that followed suboptimal PTCA. Mean LM stenosis was reduced from 86% to 13% (P < 0.01). There were no procedural complications directly attributed to DCA. At a mean of 24 +/- 3 months, the clinical restenosis rate was 16%, survival was 100%, and event-free survival (freedom from death, MI, or repeat lesion-related interventions) was 89%. We conclude that DCA in protected LM lesions (1) can achieved excellent angiographic results with low procedural complication rates, (2) may succeed where PTCA yields suboptimal results, and (3) may provide late clinical outcomes superior to those of balloon angioplasty.