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Elective stent implantation after optimal debulking for complex coronary lesions: acute and mid-term results
D S Gambhir1, S Singh, S C Sinha
1Department of Cardiology, GB Pant Hospital, New Delhi.
Insights
Initial debulking with atherectomy before coronary stenting improves outcomes for complex lesions. This strategy enhances lumen size, reduces stent thrombosis, and promotes event-free survival.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Vascular Surgery
Background:
- Complex coronary artery lesions pose challenges for percutaneous interventions.
- Atherectomy followed by stenting is a strategy to manage these lesions.
- Optimal lesion preparation is crucial for successful stent implantation.
Purpose of the Study:
- To evaluate the efficacy and safety of initial atherectomy followed by elective stenting in patients with complex coronary lesions.
- To assess mid-term clinical outcomes, including event-free survival and target lesion revascularization rates.
Main Methods:
- A cohort of 45 patients with complex coronary lesions (Type B1, B2, C) underwent debulking with rotational atherectomy or directional coronary atherectomy.
- All patients subsequently received elective stent implantation.
- Patient demographics, lesion characteristics, procedural details, and clinical outcomes were analyzed.
Main Results:
- Angiographic success was 100%, and clinical success was 97.8%.
- Mid-term follow-up (median 13 months) showed an event-free survival of 85.8% at 6 months and 77.2% at 12 months.
- Target lesion revascularization was required in 11.4% of patients.
Conclusions:
- Optimal debulking using atherectomy prior to stent implantation in complex coronary lesions results in a larger lumen.
- This approach effectively eliminates sub-acute stent thrombosis and leads to high event-free survival rates.
- The strategy demonstrates a low frequency of target lesion revascularization on mid-term follow-up.
Abstract:
Between January 1995 to December 1997, 45 patients with complex lesions in coronary arteries were treated by using the strategy of initial debulking with an atherectomy device followed by elective stenting. Their age ranged from 35-73 years (mean +/- SD:53.9 +/- 9.1) and 93.3 percent were males. The lesion morphology was type B1 in 14 (31.1%), B2 in 16 (35.6%) and type C in 13 (28.9%) patients. The choice of atherectomy device, based primarily on the morphology of lesion, was rotational atherectomy in 23 (51.1%) and directional coronary atherectomy in 22 (48.9%) patients. While majority (73.9%) of the lesions treated by rotablation were long, diffuse and calcified, directional atherectomy was preferred for highly eccentric stenoses in large-sized arteries. All patients underwent elective stent implantation after optimal lesion debulking using a mean burr size of 1.74 +/- 0.2mm for rotablation and a 7Fr. atherocath in majority (90.9%) of patients treated by directional coronary atherectomy. Angiographic success was achieved in all, while clinical success was 97.8 percent. One patient died of acute-on-chronic renal failure during hospitalisation. There were no other major in-hospital adverse cardiac events. At a median follow-up of 13 months (range 1-36 months), recurrence of angina developed in 10 (22.7%), out in which target lesion revascularisation was required in 5 (11.4%) and elective coronary artery bypass graft surgery in one (2.2%) patient. The event-free survival as calculated by the Kaplan-Meier method was 85.8 percent at six, 77.2 at 12 71.7 percent at 18 months of follow-up. In conclusion, optimal debulking before stent implantation provides a larger lumen, and thus eliminates sub-acute stent thrombosis in complex coronary lesions. This strategy also resulted in a high incidence of event-free survival and a low frequency of target lesion revascularisation on mid-term follow-up.