DIRECTIONAL CORONARY ATHERECTOMY (DCA) - A REPORT FROM THE NEW-APPROACHES-TO-CORONARY-INTERVENTION (NACI) REGISTRY

Directional coronary atherectomy (DCA) with the Simpson coronary ather ocath seeks to debulk rather than simply displace obstructive tissue a nd is a means of enlarging the stenotic coronary lumen. This report fr om the New Approaches to Coronary intervention (NACI) registry describ es the experience of 1,196 patients who underwent DCA as the sole trea tment for either native vessel or vein graft lesions. Device success ( post-DCA residual stenosis <50% and greater than or equal to 20% impro vement) was achieved in 87.8%, with a lesion success rate (postprocedu ral residual stenosis <50% and greater than or equal to 20% improvemen t) of 94.0%. The mean resultant stenosis after all interventions (by c ore laboratory) was 19%. Significant in-hospital complications occurre d in 2.8% of patients with DCA attempts, including death 0.6%, Q-wave myocardial infarction (MI) 1.5%, and emergent coronary artery bypass g raft surgery (CABG) 2.8%. At 1-year follow-up, cumulative mortality wa s 3.6%, with repeat revascularization in 28% (repeat percutaneous tran sluminal coronary angioplasty, 20.1%; CABG, 10.6%). This reflected per cutaneous or surgical revascularization of the original lesion (target lesion revascularization) in 22.6% of patients. Subgroup analysis sho wed a lower lesion success rate and an increased complication rate for unplanned use, vein graft treatment, and treatment of a de nova (vs a restenotic) lesion. Multivariate analysis shows that diabetes mellitu s, unstable angina, treatment of a restenotic lesion, and greater resi dual stenosis after the initial procedure were independent predictors of the composite endpoint of death/Q-wave MI/target lesion revasculari zation by 1-year follow-up. Among these generally favorable acute and 1-year results, the NACI directional atherectomy data confirm the ''bi gger is better'' hypothesis: that lesions with a lower residual stenos is after a successful procedure had significantly fewer target lesion revascularizations between 30 days and 1 year, with no increase in maj or adverse events. (C) 1997 by Excerpta Medica, Inc.