Acute directional coronary atherectomy prior to stenting in complex coronary lesions: ADAPTS Study
R S Kiesz1, M M Rozek, D M Mego
1Department of Medicine, University of Texas Health Science Center, South Texas Veteran Health System, Audie Murphy Division, San Antonio 78284-7872, USA. kiesz@uthscsa.edu
Insights
Directional coronary atherectomy (DCA) combined with stenting offers a safe and effective treatment for high-risk patients with complex coronary lesions, demonstrating a low restenosis rate. This combined approach improved outcomes where single methods previously showed limitations.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Technology
Background:
- Complex coronary artery lesions, including aorto-ostial lesions, chronic occlusions, long lesions, and those with thrombus, present challenges for standard interventions.
- Directional coronary atherectomy (DCA) and stenting, when used alone, are associated with lower success rates and higher restenosis in high-risk patient groups.
- A combined approach may offer improved outcomes for these complex lesions.
Purpose of the Study:
- To evaluate the efficacy and safety of combining directional coronary atherectomy (DCA) with stenting in a high-risk patient population.
- To assess the procedural success, clinical outcomes, and restenosis rates of this combined interventional strategy.
- To compare the outcomes of the combined approach against known results for DCA or stenting alone in complex coronary lesions.
Main Methods:
- A retrospective analysis of 60 consecutive patients (89 lesions) treated between July 1993 and October 1996.
- Inclusion criteria focused on high-risk patients with complex coronary lesions.
- Quantitative coronary angiography was used for initial and follow-up assessments of lesion severity and lumen diameter.
Main Results:
- The combined DCA and stenting procedure was successful in all patients, with no emergent coronary artery bypass graft (CABG) or postprocedural deaths.
- Low rates of major adverse cardiac events were observed, including minimal myocardial infarction (MI) and subacute stent closure.
- Angiographic follow-up in 50% of patients revealed a low in-stent restenosis rate of 13.3%, with a significant increase in minimal luminal diameter post-procedure.
Conclusions:
- The combined use of directional coronary atherectomy and stenting is a safe and effective strategy for managing high-risk patients with complex coronary artery lesions.
- This combined approach demonstrates a low restenosis rate, offering an advantage over standalone DCA or stenting for challenging lesion types.
- The findings support the utility of combined DCA and stenting in improving procedural success and long-term outcomes in selected high-risk cardiovascular patients.
Abstract:
The purpose of this study was to determine the results of directional coronary atherectomy (DCA) combined with stenting in a high-risk patient population. The use of stenting or DCA alone for aorto-ostial lesions, total chronic occlusions, long lesions, and lesions containing thrombus is associated with lowered success and a relatively high restenosis rate. Between July 1993 and October 1996, we treated 89 lesions with the combined approach of DCA and stenting in 60 consecutive patients. Thirty-one (51.7%) patients were treated because of unstable angina, 11 (18.3%) for post-myocardial infarction (MI) angina, 3 (5.0%) for acute MI, and 15 (25.0%) patients for stable angina. A total of 43 (71.7%) patients had multivessel disease, 19 (31.7%) had undergone previous coronary artery bypass graft (CABG), and 17 (28.3%) patients had undergone multivessel revascularization. The procedure was successful in all patients; and no postprocedural deaths or emergent CABG occurred. Two patients (3.3%) had non-Q-wave MI after the procedure and 1 patient (1.7%) experienced Q-wave MI due to subacute stent closure 7 days after the procedure. During follow-up ranging from 6 months to 3 years, 2 (3.3%) patients died, 2 (3.3%) required CABG surgery, 1 (1.7%) patient had an MI, and 6 patients (10.0%) required target vessel revascularization. By the quantitative coronary angiography, the initial minimal luminal diameter (MLD) averaged 0.91+/-0.45 mm (74.7+/-11.8% stenosis) increasing to 3.80+/-0.44 mm (-6.7+/-12.1%) after the combined approach procedure. Thirty patients (50.0%) met criteria for late (> or =6 months) angiographic follow-up. Late MLD loss averaged 1.13+/-1.07 mm, for a mean net gain of 1.61+/-1.23 mm. Available angiographic follow-up evaluation showed a restenosis rate of 13.3%. A combined approach, defined as the use of both DCA and stenting, is safe and yields a low restenosis rate in high-risk patients who have lesions known to respond less favorably to stenting or DCA alone.
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