BAIL-OUT DIRECTIONAL ATHERECTOMY FOR ABRUPT CORONARY-ARTERY OCCLUSIONFOLLOWING CONVENTIONAL ANGIOPLASTY

Abrupt coronary occlusion following conventional balloon angioplasty ( PTCA) remains a serious complication afflicting up to 10% of patients. Although repeat PTCA for prolonged durations can restore blood flow i n approximately 50% of patients, if this technique fails, the patient is generally referred for emergent coronary bypass surgery. In this re port, we describe the use of directional coronary atherectomy (DCA) as a bail-out technique on 16 patients (17 lesions) undergoing angioplas ty who demonstrated a flow limiting dissection and clinical evidence o f ongoing ischemia following the procedure which could not be reversed with repeat dilatation (mean 3.5 inflations) at prolonged balloon inf lations (mean 6.9 min). Ten of these patients presented to the hospita l with a diagnosis of unstable angina and the remaining patients were admitted with acute myocardial infarction. The majority of the inciden ces of abrupt occlusion (83%) occurred while the patient was still in the cardiac catheterization laboratory. Successful rescue atherectomy was achieved in 15 of the target arteries (88%). In two patients, this technique failed to stabilize the artery and emergent coronary bypass surgery was performed. A complication related to the bail-out procedu re developed in three of the successfully treated patients during the same hospitalization. Two patients experienced recurrent abrupt occlus ion which was successfully treated with a repeat bail-out atherectomy procedure and one patient developed a non Q wave myocardial infarction . All patients were followed clinically for a mean interval of 9.93 mo nths. Ten patients (71%) remained free of symptoms and cardiovascular events for this period. Stress electrocardiography was performed on el even (79%) of the successfully treated patients and in no case was isc hemia demonstrated. Seven patients also underwent repeat angiography a t a mean interval of 5 months post-procedure. 75% ot the target arteri es in these patients demonstrated no evidence of significant restenosi s at the site of the bail-out procedure. It is concluded that in caref ully selected patients with suitable anatomy, bail-out atherectomy is a safe and effective treatment alternative for abrupt coronary occlusi on following angioplasty when repeated and prolonged balloon dilatatio ns fail.