Coronary atherectomy continues to be an important tool for percutaneous coronary intervention (PCI), particularly as the population ages and more patients present with complex calcified coronary artery disease. Early studies using rotational and laser atherectomy failed to demonstrate a clear advantage over angioplasty alone, and as such, atherectomy of straightforward atherosclerotic disease is not commonly used.1 With the very low restenosis rates of second-generation drug-eluting stents (DESs) in many lesion types, contemporary practice is to use atherectomy primarily as adjunctive therapy for plaque modification of calcific lesions that cannot be crossed with devices or dilated with balloons to enable DES delivery.
Utilization of atherectomy composes approximately 3% of PCIs in the United States1 and between 0.8% and 3.1% worldwide (Table 34-1).2 Yet, as the population ages, more PCIs are performed in higher risk patients with more complex coronary artery disease,3 and in a recent evaluation of patients undergoing PCI, 33% were found to have moderate to severe coronary calcification (Fig. 34-1).4 Furthermore, the extent of vessel calcification is often underappreciated fluoroscopically. In one study, significant calcification seen by intravascular ultrasound (IVUS) was seen only 50% of the time fluoroscopically,5 which is often the cause for “rota-regret” when a stent cannot be delivered or dilated.
Prevalence of moderate to severe calcification in 1800 patients undergoing percutaneous coronary intervention (COMPARE study).4 ACC, American College of Cardiology; AHA, American Heart Association; CTO, chronic total occlusion.
Table 34-1Percentage of Atherectomy by Total Percutaneous Coronary Interventions by Country |Favorite Table|Download (.pdf) Table 34-1 Percentage of Atherectomy by Total Percutaneous Coronary Interventions by Country
|Country ||Rate |
|United Kingdom ||3.1% |
|United States ||3.0% |
|France ||2.9% |
|Spain ||2.3% |
|Austria ||1.8% |
|Italy ||1.3% |
|Australia ||1.0% |
|Germany ||0.8% |
Vessel calcification remains a major independent predictor of PCI failure6 and adverse outcomes (Fig. 34-2),7,8 and atherectomy is a critical component to improve PCI success in these situations. Some studies are already starting to show an increasing trend in the number of operators and centers performing atherectomy.9
Increasing risk associated with degree of lesion calcification among patients being treated with percutaneous coronary intervention (HORIZONS-AMI and ACUITY studies).7 P < .05 for all comparisons. MACE, major adverse cardiac events; MI, myocardial infarction; ST, stent thrombosis; TLR, target lesion revascularization.
Rotational atherectomy is the most widely used form of atherectomy, although utilization of laser and orbital atherectomy has been increasing. The majority of clinical data regarding coronary atherectomy is based on evaluation of the Rotablator device (Boston Scientific, Marlborough, MA). As such, this chapter will focus primarily on rotational atherectomy, with more brief discussion of the potential utility of other atherectomy devices.
RATIONALE FOR ATHERECTOMY