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[Rotational atherectomy and PTCA in complex coronary lesions (B2 and C): the immediate and long-term results]
G Isabella1, A Ramondo, P Cardaioli
1Servizio di Emodinamica e Cardiologia Interventistica, Università degli Studi, Padova.
Insights
Coronary rotational ablation with facilitated angioplasty is safe for complex coronary lesions, especially calcified ones. However, this interventional cardiology technique still has a high rate of restenosis.
Area of Science:
- Interventional Cardiology
- Cardiovascular Medicine
Background:
- Complex coronary lesions (type B2 and C) have lower success rates and higher dissection risks with standard Percutaneous Transluminal Coronary Angioplasty (PTCA).
- Coronary rotational ablation followed by PTCA offers an alternative approach for these challenging lesions.
Purpose of the Study:
- To evaluate the safety and efficacy of coronary rotational ablation combined with low-pressure PTCA for complex coronary lesions.
- To assess outcomes in patients with stable or unstable angina undergoing this combined interventional procedure.
Main Methods:
- Twenty-six patients with type B2/C lesions underwent rotational ablation and complementary PTCA.
- Rotational ablation was chosen for lesions with risk factors like calcification, eccentricity, or severe stenosis.
- Low inflation pressures and long balloons were used during complementary PTCA to minimize dissection risk.
Main Results:
- Successful rotational ablation in 92.3% of cases, reducing stenosis significantly.
- Overall success rate of 100% with no major complications (MI, death, bypass surgery).
- A high rate of clinical restenosis (45.8%) was observed, with angiographic confirmation in all cases.
Conclusions:
- Coronary rotational ablation with facilitated PTCA is safe and effective for complex, calcified coronary lesions.
- The high restenosis rate necessitates further research and management strategies.
Background:
Percutaneous transluminal coronary angioplasty (PTCA) in complex coronary lesions (type B2 and C of the modified AHA/ACC classification) presents a lower primary success rate and higher risk of dissection than type A and B1 lesions. An alternative approach to this lesions is coronary rotational ablation (Rotablator, Heart Technology) with complementary PTCA using low inflation pressures ("facilitated angioplasty").
Materials And Methods:
Twenty-six type B2 and C lesions in 24 patients (pts) (8 female, 16 male, age 37-80 years) were treated with coronary rotational ablation and complementary PTCA between January 1993 and December 1994 (4.7% of all interventional coronary procedures performed in this period in our laboratory). Eleven pts had stable effort angina and 13 pts had unstable, class IB, IIB, and IIC, angina. The treated vessel was the LAD in 15 cases, CX in 5, RCA in 5, and an intermediate branch in one case. Coronary rotational ablation was proposed because of the presence of two or more risk factors for uneffective or complicated PTCA: eccentricity, calcified lesions, bifurcation stenosis, lesion length > 10 mm, severe stenosis (90-99%), ostial location and bend location (45-60 degrees). No lesion showed coronary thrombus, considered as absolute contraindication to coronary rotational ablation. We used small burrs (burr/artery ratio < 0.75), and complementary PTCA was performed using low inflation pressure (< 8 atm) and long balloons for long lesions (> 10 mm) in order to minimize the risk of dissection.
Results:
Coronary rotational ablation was successfully performed in all but two cases (24/26; 92.3%), with a reduction of the stenosis from 88 +/- 9% to 45 +/- 10% (range 30-60%). In two pts (7.7%) the procedure was complicated by acute occlusion: both pts underwent effective salvage PTCA with 30% residual stenosis. Small type A and B dissections occurred in 4/26 cases (15.4%). All but one lesions complicated by acute occlusion or dissection following coronary rotational ablation were not or only slightly calcified. Complementary PTCA was performed in all but two pts who already presented 30% residual stenosis after rotational ablation. A further reduction of stenosis to 20 +/- 9% (range 5-30%) was achieved. After complementary PTCA four pts (15.4%) developed type A and B dissections; in one of these a Palmaz-Schatz stent was implanted, whereas the remaining three pts presented a residual stenosis below 30% and no further procedures were undertaken. Overall success rate of rotational atherectomy plus salvage or complementary PTCA or stenting was 100%, and no major complications (Q-wave myocardial infarction, emergency bypass surgery or death) occurred. Three pts showed delayed coronary run-off (slow reflow) after rotational ablation, and two of these released a small amount of cardiac specific enzymes (CK MB) without ECG changes and wall motion alteration on echocardiographic examination. Clinical restenosis, defined as recurrent angina and/or positive exercise stress test, developed in 45.8% (11 pts); in all these pts restenosis was angiographically evidenced (75-99%).
Conclusions:
Our experience suggests that coronary rotational ablation along with complementary PTCA using low inflation pressure and long balloons is safe and effective in type B2 and C lesions if calcifications are present; however, restenosis rate remains high.