Atherectomy plus stenting: what do we gain?
Coronary stents have improved the short and long-term outcomes of selected patients undergoing catheter-based coronary interventions. However, the use of these devices in complex coronary lesions has also created an incessant form of in-stent restenosis that still defies treatment. Plaque burden has been recognized as an important factor that may incite neo-intimal proliferation after stent implantation. Prospective non-randomized experience has shown that plaque removal prior to stent implantation using directional atherectomy is a promising approach to reduce restenosis in selected patients. However, the proof of concept awaits the results of the randomized trials. Ultimately, the clinical utility of this approach will depend upon: (1) further improvements on the current directional atherectomy device; (2) minimizing the incidence of non-Q-wave myocardial infarction with selective use of IIb-IIIa platelet receptor antagonists or distal protection devices; (3) targeting patients at high risk for restenosis in whom efficient debulking is feasible such as non-calcified lesions in vessels >2.75 mm and <3.5 mm in diameter that require long stents, aorto-ostial lesions, bifurcational lesions, and chronic total occlusions.
Lenox Hill Heart and Vascular Institute, NY, USA. Imoussa@worldnet.att.net
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Moussa
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Moses
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Colombo
D017225:Atherectomy, Coronary; D003324:Coronary Artery Disease / Q000601:surgery / Q000628:therapy*; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000473:pathology; D006801:Humans; D006965:Hyperplasia; D016015:Logistic Models; D055502:Secondary Prevention; D015607:Stents; D016896:Treatment Outcome; D017539:Tunica Intima / Q000473:pathology; D018084:Ultrasonography, Interventional