CLINICAL AND ANGIOGRAPHIC COMPARISON OF MATCHED PATIENTS WITH SUCCESSFUL DIRECTIONAL COROLLARY ATHERECTOMY OR STENT IMPLANTATION FOR PRIMARY CORONARY-ARTERY LESIONS

Objectives. This study was designed to compare the long-term clinical and angiographic effects of successful directional atherectomy and ste nt implantation and to examine whether restenosis is related to the me chanism of lumen improvement as well as the extent of lumen gain. Back ground. Directional atherectomy and coronary stent implantation have b een shown to achieve a more optimal immediate result that may lead to a more favorable long-term angiographic outcome and fewer target vesse l revascularizations than does angioplasty. However, it remains to be determined whether one of the devices used in these interventions prov ides consistently better results than the other. Methods. To allow mea ningful comparisons, a prospectively collected series of 117 patients successfully treated with atherectomy were individually matched with a prospectively collected series of 117 patients successfully treated w ith stent implantation. Matching for baseline characteristics identifi ed patients with identical lesion location and lesion severity, and im mediate and late angiographic and clinical outcome were compared. To e valuate the possibility of a procedure effect on restenosis, patients were further matched for both immediate angiographic outcome and basel ine characteristics, providing 150 matched patients for comparison. As confirmatory analysis, multivariate models were constructed to predic t late lumen diameter. Results. Matching resulted in two comparable gr oups with equivalent baseline clinical and stenosis characteristics (n = 117 pairs). Atherectomy led to a smaller immediate gain than stenti ng and, because late loss was similar in both groups, stenting resulte d in a larger late lumen (1.96 +/- 0.51 vs. 1.66 +/- 0.55 mm, p < 0.00 01). When patients were matched for immediate gain and baseline charac teristics (n = 75 pairs), lumen loss was more pronounced after atherec tomy, and thus the minimal lumen diameter at follow-up differed signif icantly between the two groups (1.66 +/- 0.53 vs. 1.90 +/- 0.47 mm, p = 0.004). This beneficial angiographic effect of stenting was accompan ied by a reduced need for repeat interventions. Multivariate analysis confirmed the independent effect of the interventional device used, wh ereby less loss and greater lumen diameter at follow up were predicted for stent implantation than for atherectomy. Conclusions. Successful stent implantation provided a more favorable long-term angiographic ou tcome and lower rates of restenosis and need for target lesion revascu larization than did atherectomy. This favorable effect of stenting not only is related to a larger immediate gain, but also seems to attenua te late lumen loss.