Mechanisms and immediate and long-term results of adjunct directional coronary atherectomy after rotational atherectomy

Objectives. The purpose of this study was to confirm the mechanisms and the immediate and long-term results of rotational atherectomy and adjunct directional coronaryatherectomy. Background. Rotational atherectomy is best suited for treating calcific stenoses, but the ability of rotational atherectomy alone to optimize lumen dimensions in large vessels is limited; this is only partly improved by adjunct balloon angioplasty. Methods. We treated 165 lesions in 163 patients by use of rotational atherectomy and adjunct directional coronary atherectomy. Quantitative angiography and intravascular ultrasond were used for lesion analysis. matched comparison with 208 lesions treated with rotational atherectomy and adjunct coronary angioplasty was performed. Patients were then followed up for at least 9 months, and target-lesion revascularization was assessed. Results. In the 61 lesions imaged sequentially, lumen are increased from 1.7 ± 0.8 (mean ± 1 SD) to 3.9 ± 1.1 mm2 after rotational atherectomy, owing to decrease in plaque plus medi are from 16.8 ± 5.0 to 15.2 ± 5.2 mm2 (both p < 0.0001). After adjunct directional coronary atherectomy, lumen are increased even more to 6.7 ± 2.0 mm2 (vs. 5.1 ± 1.4 mm2 after adjunct coronary angioplasty, p < 0.0001) as result of both vessel expansion (18.8 ± 5.3 to 20.8 ± 5.7 mm2) and additional plaque removal (to 14.1 ± 5.0 mm2, all p < 0.0001). The total arcs of calcium decreased from 207 ± 107° to 166 ± 93° after rotational atherectomy and to 145 ± 87° after directional coronary atherectomy. Overall, procedural success was 96%, and final diameter stenosis was 15 ± 17%. Target-lesion revascularization was 23%. The only independent predictor of target-lesion revascularization was larger overall atherectomy index (84% vs. 59%, P = 0.048). Conclusions. There is synergistic relationship between rotational atherectomy and directional coronary atherectomy in the treatment of calcific lesions. The immediate results show high procedural success—lumen dimensions were larger and late target-lesion revascularization was lower in lesions treated with rotational atherectomy and directional coronary atherectomy than in those treated with rotational atherectomy and adjunct balloon angioplasty.