ATHERECTOMY (DIRECTIONAL, ROTATIONAL, EXTRACTIONAL) AND ITS ROLE IN PERCUTANEOUS REVASCULARIZATION

After an initial wave of enthusiasm, atherectomy devices face a number of difficult issues today. The first two randomized studies comparing balloon angioplasty with directional atherectomy, the Coronary Angiop lasty Versus Excisional Atherectomy Trial (CAVEAT) and the Canadian Co ronary Atherectomy Trial (CCAT), showed no clinical benefit for athere ctomy. Data from these trials, as well as other studies, suggest that the mechanism of lumen enlargement with atherectomy may be less benefi cial than expected. A number of investigations are currently evaluatin g the benefit of even more aggressive debulking with directional coron ary atherectomy, but in view of the increased incidence of acute compl ications, it is unlikely that this technique will increase its share i n routine coronary angioplasty in the near future. Clinical evaluation of rotational and extractional atherectomy has not reached a conclusi ve phase yet, but results from registries and single-center observatio ns show that these devices require adjunctive balloon angioplasty in a large proportion of cases, on the one hand, and that they do not solv e the issue of restenosis, on the other. The difficulty in delineating the rationale for use of these devices highlights the urgent need for controlled and carefully designed device trials.