title: Directional atherectomy before stenting versus stenting alone in percutaneous coronary interventions: a meta-analysis.
abstract: Plaque debulking before stenting is still controversial. We performed a meta-analysis of 12 randomized and non-randomized trials comparing directional coronary atherectomy (DCA) before stenting versus stenting alone. Angiographic end points were acute gain, late loss and angiographic restenosis rate. Clinical end points were early major adverse cardiac events [MACEs: death, Q-wave myocardial infarction (MI), non-Q-wave MI], late MACEs (death, Q-wave MI) and target lesion revascularization (TLR). Data are expressed as odds ratio (OR) with 95% confidence intervals (CI) or weighted mean difference (WMD) with 95% CI, as appropriate. A total of 1216 patients undergoing DCA before stent and 1484 patients undergoing stent alone have been included. DCA before stent was associated to a better acute gain compared to stenting alone (WMD 0.23, [0.18-0.28]; p<0.0001), to a striking reduction of angiographic restenosis rate (OR of 0.67, [0.54-0.84], p=0.0003) and to a significantly lower rate of late TLR (OR 0.73 [0.59-0.91], p=0.006). Late loss did not differ between the two groups (WMD 0.00 [-0.08 and 0.08], p=0.98). We found a higher rate of early MACEs for the combined approach (OR 1.87 [1.16-3.02], p=0.01), with similar prevalence of late MACEs (OR 0.83 [0.65-1.06], p=0.13). In conclusion, this meta-analysis demonstrates that DCA before stenting is superior to stenting alone with regard to acute angiographic results and TLR with a similar prevalence of late MACEs. The higher prevalence of early MACEs with DCA before stenting, however, is disturbing and probably related to distal embolization.
authors.affiliation: Institute of Cardiology, Catholic University, Largo F. Vito 1-00168 Rome, Italy. gniccoli73@virgilio.it
authors.forename: Giampaolo
authors.initials: G
authors.lastname: Niccoli
authors.forename: Luca
authors.initials: L
authors.lastname: Testa
authors.forename: Rocco
authors.initials: R
authors.lastname: Mongiardo
authors.forename: Annalisa
authors.initials: A
authors.lastname: Ricco
authors.forename: Flavia
authors.initials: F
authors.lastname: Belloni
authors.forename: Enrico
authors.initials: E
authors.lastname: Romagnoli
authors.forename: Antonio Maria
authors.initials: AM
authors.lastname: Leone
authors.forename: Francesco
authors.initials: F
authors.lastname: Burzotta
authors.forename: Carlo
authors.initials: C
authors.lastname: Trani
authors.forename: Mario A
authors.initials: MA
authors.lastname: Mazzari
authors.forename: Antonio G
authors.initials: AG
authors.lastname: Rebuzzi
authors.forename: Filippo
authors.initials: F
authors.lastname: Crea
mesh_terms: D000368:Aged; D017225:Atherectomy, Coronary; D003131:Combined Modality Therapy; D017023:Coronary Angiography; D023903:Coronary Restenosis / Q000517:prevention & control; D023921:Coronary Stenosis / Q000601:surgery / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D015607:Stents; D016896:Treatment Outcome