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Directional coronary atherectomy (DCA): a report from the New Approaches to Coronary Intervention (NACI) registry
R Waksman1, J J Popma, E D Kennard
1Department of Internal Medicine (Cardiology), Washington Hospital Center, DC, USA.
Insights
Directional coronary atherectomy (DCA) effectively enlarges narrowed coronary arteries. Achieving lower residual stenosis after DCA significantly reduces the need for repeat procedures and adverse events within one year.
Area of Science:
- Interventional Cardiology
- Cardiovascular Medicine
- Medical Device Technology
Background:
- Directional coronary atherectomy (DCA) aims to remove obstructive plaque, improving coronary lumen diameter.
- The Simpson coronary atherocath is a device used for debulking lesions.
- Previous studies have explored atherectomy techniques for coronary artery disease.
Purpose of the Study:
- To evaluate the efficacy and safety of DCA as a standalone treatment for coronary artery and vein graft lesions.
- To assess acute procedural success and 1-year clinical outcomes.
- To identify predictors of adverse events after DCA.
Main Methods:
- Analysis of 1,196 patients from the New Approaches to Coronary Intervention (NACI) registry who underwent DCA.
- DCA was used as the sole treatment for native vessel or vein graft lesions.
- Core laboratory analysis determined residual stenosis; 1-year follow-up data were collected.
Main Results:
- Device success was 87.8% and lesion success was 94.0%, with a mean residual stenosis of 19%.
- In-hospital complications occurred in 2.8% of patients (0.6% death, 1.5% MI, 2.8% CABG).
- At 1 year, cumulative mortality was 3.6%, and repeat revascularization was 28% (22.6% target lesion revascularization).
Conclusions:
- DCA is an effective treatment for coronary and vein graft lesions, achieving favorable acute and 1-year outcomes.
- Lower residual stenosis post-DCA is associated with fewer target lesion revascularizations and no increase in major adverse events.
- Diabetes, unstable angina, restenotic lesions, and higher residual stenosis predict adverse 1-year outcomes.
Abstract:
Directional coronary atherectomy (DCA) with the Simpson coronary atherocath seeks to debulk rather than simply displace obstructive tissue and is a means of enlarging the stenotic coronary lumen. This report from the New Approaches to Coronary Intervention (NACI) registry describes the experience of 1,196 patients who underwent DCA as the sole treatment for either native vessel or vein graft lesions. Device success (post-DCA residual stenosis <50% and > or =20% improvement) was achieved in 87.8%, with a lesion success rate (postprocedural residual stenosis <50% and > or =20% improvement) of 94.0%. The mean resultant stenosis after all interventions (by core laboratory) was 19%. Significant in-hospital complications occurred in 2.8% of patients with DCA attempts, including death 0.6%, Q-wave myocardial infarction (MI) 1.5%, and emergent coronary artery bypass graft surgery (CABG) 2.8%. At 1-year follow-up, cumulative mortality was 3.6%, with repeat revascularization in 28% (repeat percutaneous transluminal coronary angioplasty, 20.1%; CABG, 10.6%). This reflected percutaneous or surgical revascularization of the original lesion (target lesion revascularization) in 22.6% of patients. Subgroup analysis showed a lower lesion success rate and an increased complication rate for unplanned use, vein graft treatment, and treatment of a de novo (vs a restenotic) lesion. Multivariate analysis shows that diabetes mellitus, unstable angina, treatment of a restenotic lesion, and greater residual stenosis after the initial procedure were independent predictors of the composite endpoint of death/Q-wave MI/target lesion revascularization by 1-year follow-up. Among these generally favorable acute and 1-year results, the NACI directional atherectomy data confirm the "bigger is better" hypothesis: that lesions with a lower residual stenosis after a successful procedure had significantly fewer target lesion revascularizations between 30 days and 1 year, with no increase in major adverse events.