DETAILED ANGIOGRAPHIC ANALYSIS OF HIGH-SPEED MECHANICAL ROTATIONAL ATHERECTOMY IN HUMAN CORONARY-ARTERIES

Background. Several types of atherectomy devices have been developed r ecently for treatment of patients with ischemic heart disease. Methods and Results. Mechanical rotational atherectomy (MRA) using a high-spe ed rotational burr (Rotablator) was performed on 116 lesions in 104 pa tients. MRA alone, was performed in 27 lesions (23%), and conventional balloon angioplasty (PTCA) was performed after MRA in 89 lesions (77% ). Diameter stenosis decreased from 70+/-13% before MRA to 54+/-23% af ter MRA, and the final diameter stenosis (after MRA alone or with adju nctive PTCA) was 30+/-20% (P<.001). Minimal lumen diameter increased f rom 1.0+/-0.5 mm before MRA to 1.4+/-0.7 mm after MRA, and the final m inimal lumen diameter was 2.3+/-0.7 mm (P<.001). MRA resulted in a dec rease in diameter stenosis of 20% or more in 44% of lesions, and the f inal diameter stenosis (after MRA alone or after PTCA) was less than 5 0% in 75% of lesions. Considering the small diameter of available burr s, the magnitude of lumen enlargement was equal to 91% of the burr dia meter, and only 9% of the burr diameter was ''lost'' due to elastic re coil or spasm. These angiographic results were obtained despite the pr esence of complex lesion morphology, including the presence of calcifi cation in 17% of lesions and ostial location in 26% of lesions. Signif icant angiographic complications included abrupt closure (13 lesions, 11.2%), no reflow (8 lesions, 7%), severe coronary vasospasm (16 lesio ns, 13.8%), and guide wire fracture (3 lesions, 2.7%). There were no c oronary artery perforations. Adjunctive therapy, including salvage PTC A, thrombolytic agents, and vasodilators, was successful in treating a ngiographic complications in 42 of 49 lesions (86%). Clinical complica tions included Q-wave myocardial infarction (5 patients, 4.8%), non-Q- wave myocardial infarction (3 patients, 2.9%), femoral vascular injury requiring surgery (3 patients, 2.9%) or blood transfusion (8 patients , 7.7%), abrupt closure requiring emergency bypass graft surgery (2 pa tients, 1.9%), and in-hospital death (1 patient, 1.0%). Angiographic f ollow-up (mean follow-up interval, 5.0+/-2.0 months) was available in 84% of successfully treated patients and revealed a restenosis rate of 51%, defined as a residual diameter stenosis of more than 50%. There was no significant difference in restenosis rates between de novo lesi ons (50%) and restenosis (54%) lesions. Conclusions. These data sugges t that for the treatment of most coronary stenoses, PTCA is required a fter MRA to achieve satisfactory lumen enlargement or to salvage compl ications. Angiographic complications appear to be more common after MR A, and salvage PTCA often is required to manage these device-induced c omplications. The combination of MRA and PTCA does not prevent resteno sis.