Impact of Pre-Stent Plaque Debulking
Impact of Pre-Stent Plaque Debulking
Background. While stenting improves the long-term angiographic outcomes of successfully recanalized chronic coronary total occlusions (CTO), the restenosis rate still remains high. The massive plaque burden in CTO is considered to be one of the causes of in-stent restenosis.
Methods. We examined the pre-stent plaque debulking strategy with high-speed rotational atherectomy (RA) for 50 CTO (Thrombolysis in Myocardial Infarction flow grade 0; estimated occlusive duration, > 3 months). Angiographic follow-up results were compared to those of 120 consecutive CTO recanalized with primary stenting in which RA could be indicated retrospectively. Angiographic restenosis was defined as diameter stenosis > 50% at 6-month follow-up.
Results. RA could be performed safely in all lesions without any major complications. Adjunctive ballooning and stenting could be performed without high-pressure dilatation (8.4 ± 1.7 atmospheres). Follow-up angiography was performed in 48 lesions 184 ± 61 days after the procedure. There were no significant differences in baseline characteristics between the two groups; however, the implanted stent type was different. Quantitative coronary angiography revealed that diameter stenosis was smaller at follow-up (36.2 ± 20.0% versus 52.2 ± 26.7%; p = 0.0003) as well as post-procedure (7.8 ± 11.5% versus 17.8 ± 13.6%; p < 0.0001) compared with the control group. Angiographic restenosis was also significantly reduced (29.2% versus 52.5%; p = 0.0061).
Conclusions. RA is a safe procedure for plaque debulking of CTO in selected cases. Plaque debulking of CTO facilitates subsequent stent expansion and may reduce the restenosis rate.
Recently, revascularization of chronic coronary total occlusions (CTO) by percutaneous transluminal coronary angioplasty (PTCA) has been widely attempted. Advances in technique and devices, particularly conventional wires, have increased the recanalization success rate for CTO. Furthermore, adjunctive stenting after successful recanalization has reduced restenosis compared with balloon angioplasty and improved the long-term patency. However, the restenosis rate still remains high in the real world. Massive plaque burden in CTO is considered to interfere with full stent expansion and/or accelerate in-stent neointimal proliferation following balloon and stent expansion. Plaque burden is therefore a possible cause of restenosis in CTO cases following intervention. On the other hand, reports indicate that pre-stent plaque debulking by directional coronary atherectomy may reduce restenosis for complex lesion subsets. Since there are a wide variety of vessel and lesion morphologies, directional coronary atherectomy may not always be applied to debulk the plaque for CTO cases. High-speed rotational atherectomy (RA) is thought to be more applicable for plaque debulking of CTO, but complications such as vessel perforation or no flow phenomenon need to be considered. We report here on the procedural safety and efficacy of pre-stent debulking with rotational atherectomy for CTO.
Background. While stenting improves the long-term angiographic outcomes of successfully recanalized chronic coronary total occlusions (CTO), the restenosis rate still remains high. The massive plaque burden in CTO is considered to be one of the causes of in-stent restenosis.
Methods. We examined the pre-stent plaque debulking strategy with high-speed rotational atherectomy (RA) for 50 CTO (Thrombolysis in Myocardial Infarction flow grade 0; estimated occlusive duration, > 3 months). Angiographic follow-up results were compared to those of 120 consecutive CTO recanalized with primary stenting in which RA could be indicated retrospectively. Angiographic restenosis was defined as diameter stenosis > 50% at 6-month follow-up.
Results. RA could be performed safely in all lesions without any major complications. Adjunctive ballooning and stenting could be performed without high-pressure dilatation (8.4 ± 1.7 atmospheres). Follow-up angiography was performed in 48 lesions 184 ± 61 days after the procedure. There were no significant differences in baseline characteristics between the two groups; however, the implanted stent type was different. Quantitative coronary angiography revealed that diameter stenosis was smaller at follow-up (36.2 ± 20.0% versus 52.2 ± 26.7%; p = 0.0003) as well as post-procedure (7.8 ± 11.5% versus 17.8 ± 13.6%; p < 0.0001) compared with the control group. Angiographic restenosis was also significantly reduced (29.2% versus 52.5%; p = 0.0061).
Conclusions. RA is a safe procedure for plaque debulking of CTO in selected cases. Plaque debulking of CTO facilitates subsequent stent expansion and may reduce the restenosis rate.
Recently, revascularization of chronic coronary total occlusions (CTO) by percutaneous transluminal coronary angioplasty (PTCA) has been widely attempted. Advances in technique and devices, particularly conventional wires, have increased the recanalization success rate for CTO. Furthermore, adjunctive stenting after successful recanalization has reduced restenosis compared with balloon angioplasty and improved the long-term patency. However, the restenosis rate still remains high in the real world. Massive plaque burden in CTO is considered to interfere with full stent expansion and/or accelerate in-stent neointimal proliferation following balloon and stent expansion. Plaque burden is therefore a possible cause of restenosis in CTO cases following intervention. On the other hand, reports indicate that pre-stent plaque debulking by directional coronary atherectomy may reduce restenosis for complex lesion subsets. Since there are a wide variety of vessel and lesion morphologies, directional coronary atherectomy may not always be applied to debulk the plaque for CTO cases. High-speed rotational atherectomy (RA) is thought to be more applicable for plaque debulking of CTO, but complications such as vessel perforation or no flow phenomenon need to be considered. We report here on the procedural safety and efficacy of pre-stent debulking with rotational atherectomy for CTO.
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