title: Mechanisms and immediate and long-term results of adjunct directional coronary atherectomy after rotational atherectomy.
abstract: OBJECTIVE
  The purpose of this study was to confirm the mechanisms and the immediate and long-term results of rotational atherectomy and adjunct directional coronary atherectomy.
  
  
  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 ultrasound were used for lesion analysis. A 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 area increased from 1.7 +/- 0.8 (mean +/- 1 SD) to 3.9 +/- 1.1 mm(2) after rotational atherectomy, owing to a decrease in plaque plus media area from 16.8 +/- 5.0 to 15.2 +/- 5.2 mm(2) (both p < 0.0001). After adjunct directional coronary atherectomy, lumen area increased even more to 6.7 +/- 2.0 mm(2) (vs. 5.1 +/- 1.4 mm(2) after adjunct coronary angioplasty, p < 0.0001) as a result of both vessel expansion (18.8 +/ 5.3 to 20.8 +/- 5.7 mm(2)) and additional plaque removal (to 14.1 +/- 5.0 mm(2), all p < 0.0001). The total arcs of calcium decreased from 207 +/- 107 degrees to 166 +/- 93 degrees after rotational atherectomy and to 145 +/- 87 degrees 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 a larger overall atherectomy index (84% vs. 59%, p = 0.048).
  
  
  CONCLUSIONS
  There is a synergistic relationship between rotational atherectomy and directional coronary atherectomy in the treatment of calcific lesions. The immediate results show a 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.
authors.affiliation: Intravascular Ultrasound Imaging and Cardiac Catheterization Laboratories, The Washington Hospital Center, Washington, D.C. USA.
authors.forename: G R
authors.initials: GR
authors.lastname: Dussaillant
authors.forename: G S
authors.initials: GS
authors.lastname: Mintz
authors.forename: A D
authors.initials: AD
authors.lastname: Pichard
authors.forename: K M
authors.initials: KM
authors.lastname: Kent
authors.forename: L F
authors.initials: LF
authors.lastname: Satler
authors.forename: J J
authors.initials: JJ
authors.lastname: Popma
authors.forename: T A
authors.initials: TA
authors.lastname: Bucher
authors.forename: J
authors.initials: J
authors.lastname: Griffin
authors.forename: M B
authors.initials: MB
authors.lastname: Leon
mesh_terms: D000368:Aged; D017225:Atherectomy, Coronary / Q000379:methods*; D017023:Coronary Angiography; D003327:Coronary Disease / Q000473:pathology / Q000601:surgery; D003331:Coronary Vessels / Q000000981:diagnostic imaging; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D018084:Ultrasonography, Interventional