[Coronary rotational atherectomy: initial experience at a hospital without a special department for heart surgery]

Percutaneous transluminal coronary angioplasty (POBA) of complex lesions is hindered by a lower success rate and a higher risk of complications. New devices are now available for treatment of this type of lesions (type B-C of the modified AHA/ACC classification). We present our experience in the treatment of calcified, ostial, angled and long coronary lesions by means of percutaneous transluminal coronary rotational ablation (PTCRA, Rotablator Heart Technology, Bellevue, Washington).

From June 1991 to November 1995 we performed 71 procedures of rotational atherectomy on 72 lesions in 62 patients. Twenty-three patients presented stable angina, 30 patients unstable angina and 9 silent myocardial ischemia. Thirty-five patients had single, 16 double and 11 triple vessel coronary artery disease. Left ventricular mean ejection fraction was 58 +/- 8%. The lesions attempted were classified as type A in 2 cases, B1 in 23 cases, B2 in 31 cases and C in 16 cases according to the AHA/ACC modified classification. Calcifications detected at coronary angiography were present in 66 lesions; 53 lesions were longer than 10 mm; 12 were more than 45 degrees angulated; 9 were at a bifurcation site and 3 were ostial in location. The vessels treated were in 1 case a protected Left Main Trunk, in 40 the Left Anterior Descending, in 9 the Circumflex and in 22 the Right Coronary Artery. We did not treat lesions containing visible thrombus or located on old saphenous vein grafts because of the high risk of peripheral embolization. An average of 2 +/- 1 burrs was used; the mean burr/vessel diameter ratio was 0.59 +/- .07. "Complementary" low pressure PTCA was performed in all but 4 cases ("stand alone procedure").

Primary success was obtained in 62/71 procedures (92%) and in 67/72 lesions (94%). There were two major cardiac events during the hospital stay: one death and one acute myocardial infarction which occurred respectively at four days and 48 hours after the procedure due to late occlusion of the vessel treated with primary success. In three cases the procedure was unsuccessful but uncomplicated: In one the stenosis could not be crossed, in a second case a residual stenosis > 50% was present, in a third case the procedure resulted in dissection and occlusion of a vessel served by good intercoronary collaterals. No emergency or elective coronary artery bypass surgery was necessary. Coronary spasm occurred in 6 cases (9%). In two of them spasm was refractory to intracoronary nitrates and Verapamil, and stent implantation was required. Urapidil, a selective alpha 1 blocker, completely abolished the occurrence of coronary vasospasm in the last 16 cases. A no reflow phenomenon was observed in two cases associated with mild CK-MB elevation. In conclusions: our experience suggests that rotational atherectomy performed on lesions with complex morphology, most of them calcified, is a safe and effective procedure which therefore can be undertaken even in hospitals without on site cardiac surgery. Our data on late restenosis are inconclusive because of the lack of angiographic follow up.