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Effect of Rotablator atherectomy and adjunctive balloon angioplasty on coronary blood flow
T R Bowers1, R E Stewart, W W O'Neill
1Division of Cardiology (Department of Medicine), William Beaumont Hospital, Royal Oak, Mich 48073, USA.
Insights
Rotablator atherectomy and PTCA improve coronary blood flow velocity and diameter stenosis. However, coronary flow reserve (CFR) remains low, indicating potential microvascular issues after plaque removal.
Area of Science:
- Cardiovascular medicine
- Interventional cardiology
- Physiology
Background:
- Rotablator atherectomy pulverizes plaque, potentially causing distal embolization.
- Assessing serial changes in coronary blood flow velocity is crucial after Rotablator and percutaneous transluminal coronary angioplasty (PTCA).
Purpose of the Study:
- To evaluate serial changes in coronary blood flow velocity post-Rotablator atherectomy and adjunctive PTCA.
- To determine the impact of these procedures on coronary flow reserve (CFR).
Main Methods:
- Intracoronary Doppler Flowire used for velocity measurements.
- Assessed basal average peak velocity (bAPV), hyperemic APV (hAPV), diastolic/systolic velocity ratio (DSVR), and CFR.
- Measurements taken before intervention, after Rotablator, and after PTCA in 22 patients.
Main Results:
- Significant increase in minimum lumen diameter and decrease in diameter stenosis.
- Significant increases observed in bAPV, hAPV, and DSVR (P < .001).
- CFR remained abnormally low in most patients despite procedural improvements.
Conclusions:
- Rotablator atherectomy and PTCA enhance coronary blood flow velocity and DSVR but not CFR.
- Low CFR may result from microvascular dysfunction, distal embolization, spasm, or residual stenosis.
- Adjunctive PTCA significantly contributes to the overall physiological benefits of the combined procedure.
Background:
The purpose of this study was to assess serial changes in coronary blood flow velocity before and after Rotablator atherectomy and after adjunctive percutaneous transluminal coronary angioplasty (PTCA). Since Rotablator atherectomy results in luminal enlargement by plaque pulverization and distal embolization, improvement in coronary blood flow could be attenuated despite luminal enlargement.
Methods And Results:
Intracoronary Doppler blood flow velocity measurements were obtained with a Doppler Flowire. Basal average peak velocity (bAPV), hyperemic APV (hAPV), diastolic/systolic velocity ratio (DSVR), and coronary flow reserve (CFR) were assessed before intervention, after Rotablator, and after adjunctive PTCA. Complete clinical, angiographic, and Doppler data were obtained in 22 patients. There was a small but significant difference (P = .02) in resting heart rate and mean arterial pressure before and after Rotablator and after adjunctive PTCA. Minimum lumen diameter increased from 0.8 +/- 0.1 to 1.5 +/- 0.2 to 2.0 +/- 0.1 mm (P < .001), corresponding to decreases in diameter stenosis from 72 +/- 3% to 41 +/- 4% to 36 +/- 3% (P < .001). Although bAPV, hAPV, and DSVR increased significantly (P < .001), CFR remained abnormally low in 19 of 22 patients (despite an increase from baseline to post-PTCA). hAPV > 30 cm/s was the best Doppler correlate of angiographic success.
Conclusions:
Rotablator atherectomy and adjunctive PTCA significantly improve distal coronary blood flow velocity and DSVR but not CFR. Failure to normalize CFR could be secondary to parallel increases in bAPV and hAPV, "acquired" microvascular disease due to distal microembolization or spasm, and/or angiographically inapparent dissection or residual stenosis. Adjunctive PTCA contributes significantly to the overall physiological benefit of a combined procedure.