MECHANISMS AND IMMEDIATE AND LONG-TERM RESULTS OF ADJUNCT DIRECTIONALCORONARY ATHERECTOMY AFTER ROTATIONAL ATHERECTOMY

Objectives. The purpose of this study was to confirm the mechanisms an d the immediate and long-term results of rotational atherectomy and ad junct directional coronary atherectomy. Backg Background. Rotational a therectomy is best suited for treating calcific stenoses, but the abil ity of rotational atherectomy alone to optimize lumen dimensions in la rge vessels is limited; this is only partly improved by adjunct balloo n angioplasty. Methods. We treated 165 lesions in 163 patients by use of rotational atherectomy and adjunct directional coronary atherectomy . Quantitative angiography and intravascular ultrasound were used for lesion analysis. A matched comparison with 208 lesions treated with ro tational atherectomy and adjunct coronary angioplasty was performed. P atients were then followed up for at least 9 months, and target-lesion revascularization was assessed. Results. In the 61 lesions imaged seq uentially, lumen area in creased from 1.7 +/- 0.8 (mean +/- 1 SD) to 3 .9 +/- 1.1 mm(2) after rotational atherectomy, owing to a decrease in plaque plus media area from 16.8 +/- 5.0 to 15.2 +/- 5.2 mm(2) (both p < 0.0001). After adjunct directional coronary atherectomy, lumen area increased even more to 6.7 +/- 2.0 mm(2) (vs. 5.1 +/- 1.4 mm(2) after adjunct coronary angioplasty, p < 0.0001) as a result of both vessel expansion (18.8 +/- 5.3 to 20.8 +/- 5.7 mm(2)) and additional plaque r emoval (to 14.1 +/- 5.0 mm(2), all p < 0.0001). The total arcs of calc ium decreased from 207 +/- 107 degrees to 166 +/- 93 degrees after rot ational atherectomy and to 145 +/- 87 degrees after directional corona ry atherectomy. Overall, procedural success was 96%, and final diamete r stenosis was 15 +/- 17%. Target-lesion revascularization was 23%. Th e only independent predictor of target-lesion revascularization was a larger overall atherectomy index (84% vs. 59%, p = 0.048). Conclusions . There is a synergistic relationship between rotational atherectomy a nd directional coronary atherectomy in the treatment of calcific lesio ns. The immediate results show a high procedural success-lumen dimensi ons were larger and late target lesion revascularization was lower in lesions treated with rotational atherectomy and directional coronary a therectomy than in those treated with rotational atherectomy and adjun ct balloon angioplasty.