Results of low speed rotational angioplasty for chronic peripheral occlusions

Percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease using a transluminal endatherectomy catheter (TEC): initial results and angiographic follow-Up

PURPOSE

To evaluate the clinical results of percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease.

METHODS

Rotational atherectomy was performed in 39 patients aged 39-87 years (mean 66.6 years). A total of 71 lesions (43 stenoses and 28 occlusions) were treated in 40 limbs. Additional balloon angioplasty was required in 54% of lesions. Fifteen patients (37.5%) presented in Fontaine stage II, 10 patients (25%) in Fontaine stage III and 15 patients (37.5%) in Fontaine stage IV. Rotational atherectomy at 750 rpm was carried out over a 0.014-inch guidewire with continuous aspiration into a vacuum bottle. Follow-up angiography and color flow Doppler examinations were performed in 22 patients (23 limbs) after a mean period of 6 months (range 2-14 months).

RESULTS

There was one primary technical failure. In 36 of 40 lesions there was a good angiographic result with residual stenoses in less than 30%. In 70 lesions treated by rotational atherectomy, however, 54% showed residual stenoses of 30%-50% and these cases required additional balloon angioplasty. The mean ankle-brachial index improved significantly (p << 0.001) from 0.49 before the procedure to 1.01 after the procedure. A single distal embolus, related to primary recanalization, occurred and there were two large inguinal hematomas. Cumulative clinical patency after 6 months was 83.8% and cumulative angiographic patency after 6 months was 79.1%.

CONCLUSION

Percutaneous rotational atherectomy is a promising approach for the treatment of chronic peripheral vascular disease. Further prospective, randomized studies are necessary to compare percutaneous transluminal angioplasty with this new technical approach.

Balloon angioplasty versus rotational angioplasty in chronic coronary occlusions (the BAROCCO study)

Chronic total coronary occlusion remains one of the limitations of percutaneous transluminal coronary angioplasty, and few therapeutic devices are specifically designed to address this problem. Among such devices, low-speed rotational angioplasty could improve the primary success rate of the procedure but has never been studied in a controlled trial. One hundred consecutive patients with total coronary occlusion (duration 10 days to 1 year) and an indication for myocardial revascularization were randomized to either rotational or conventional angioplasty if the occlusion morphology was judged suitable for either technique. All baseline variables were evenly distributed among the 2 groups. The primary success rate in the rotational angioplasty groupø was 66% (33 of 50) compared with 52% (26 of 50) in the conventional angioplasty group before crossover to the rotational technique (p=NS). According to lesion morphology, the respective primary success rates were 77% (10 of 13) versus 92% (11 of 12) for tapered occlusions (p=NS), and 61% (22 of 36) versus 38% (14 of 37) for "stump-like" occlusions (p < 0.05). After taking into account the crossovers after failed conventional angioplasty, there was no benefit in performing rotational angioplasty first versus conventional angioplasty first (primary success rates 66% vs 60%, p=NS). Thus, in chronic coronary occlusions of tapered morphology, rotational angioplasty is not superior to conventional angioplasty. In stump-like occlusions, the primary success rate is higher with the rotational angioplasty technique; however ther is a disadvantage in using rotational angioplasty as a second-line device if the conventional technique is unsuccessful.

The history of interventional cardiology: cardiac catheterization, angioplasty, and related interventions

The histories of cardiac catheterization, angioplasty, and other catheter interventions are spectacular journeys marked by undeterred genius, serendipity, and the vindication of the scientific method. Cardiac catheterization began with Hales's 1711 equine biventricular catheterization, other early experimental catheterizations in the nineteenth century, and Forssmann's dramatic 1929 right-heart self-catheterization. Cournand, Richards, and others finished unlocking the right heart in the 1940s; Zimmerman, Cope, Ross, and others unlocked the left heart in the 1950s; and the coronary arteries were inadvertently unlocked by Sones in 1958, leading to the advent of percutaneous femoral coronary angiography by Judkins and by Amplatz in 1967. Dotter's accidental catheter recanalization of a peripheral artery in 1963 ushered in the era of intervention, crowned by Gruentzig's balloon angioplasty in the mid-1970s and leading to today's panoply of devices used percutaneously to revascularize the coronary arteries in a variety of clinical settings.

Early outcome of PTCA in totally occluded coronary arteries

BACKGROUND

Since percutaneous transluminal coronary angioplasty (PTCA) was first introduced in 1977 by Gruentzig as a treatment for proximal short-segmental, non-calcified, concentric isolated coronary stenosis, it has been used with increasing frequency in patients of symptomatic coronary artery disease with broader indications, including patients with multi-vessel disease, unstable angina, acute myocardial infarction and totally occluded coronary arteries. Among these, total coronary occlusion constitutes a subdivision with specific features that require separate evaluation. The purpose of this study was to determine the initial results of PTCA for total coronary occlusion.

METHODS

Thirty-five patients with manifested ischemic heart disease with totally occluded coronary arteries, documented by coronary angiography, underwent recanalization procedure by PTCA between Jan. 1990 and Oct. 1991.

RESULTS

Thirty-five patients were comprised of 20 acute myocardial infarction (MI), 7 old MI and 8 unstable angina. Eighteen (50.1%) patients had one major atherosclerosis risk factor and 10 (29.4%) had two or more. PTCA for total coronary artery occlusion was attempted in the left anterior descending artery (LAD) in 16 patients, right coronary artery (RCA) in 11, left circumflex artery (LCx) in 2 and protected left main in one. PTCA was successful in 23 patients (66%): LAD in 11/18 (61%) and RCA 11/14 (79%), showing significantly higher success rate with RCA than LAD (p < 0.05). Primary success rate of PTCA in accordance with the duration of the total occlusion estimated on the basis of clinical and angiographic data was 71% (15/21) when less than two weeks, 63% (5/8) when between 2 to 12 weeks, and 50% (3/6) longer than 12 weeks. Mean duration of the total occlusion in successful PTCA was 1.4 months (range; 10 days-5 months) and, 1.7 months (range; 3 weeks-3 years) in failed PTCA. Diameter stenosis of the lesions was significantly decreased from 100% to 19.7% after successful PTCA. There was no death but 2 patients were complicated with coronary artery embolization occluding major distal branches.

CONCLUSION

The study suggested that PTCA of total coronary artery occlusion can be performed safely and effectively in selected cases and might be more successful in the lesion with shorter duration of occlusion.

Management of the limitations in low-speed rotational transluminal angioplasty: technical note

The low-speed rotational transluminal angioplasty catheter system (ROTACS) is a recently available device for recanalization of occlusions prior to balloon angioplasty. The presence of large collaterals originating just proximal to the occlusion with an acute angle, and insufficient space between the puncture site and the occlusion for placing an introducer sheath are reported to be limitations for ROTACS. To avoid the rotating catheter entering the collateral, we propose a technique to create a pilot inlet on the proximal aspect of the occlusion. This technique was applied successfully in 4 patients. A contralateral approach was used in 3 patients, in whom an ipsilateral access was not possible because of the insufficient space to place an introducer sheath.

Sheath introducer technique for recanalizing total occlusions of the superficial femoral artery

Symptomatic patients with total superficial femoral artery occlusions were approached with a modified Dotter technique followed by PTA and/or atherectomy. In 21 lesions studied, 7 (33%) were crossed with a conventional guide wire. Of the remaining 14 lesions (67%), 12/14 (86%) were crossed successfully using the pliable distal tip of the sheath introducer. The average angiographic lesion length crossed was 42 +/- 29 mm (range 8-109 mm). One insertion site vessel complication requiring surgical repair was seen. Although more advanced technologies have been developed to treat "wire resistant" total occlusions, the use of the introducer technique described is effective in many patients and adds no additional cost or time to the standard angioplasty procedure.

Proximal rupture and intracoronary entrapment of a rotating device during low-speed rotational coronary angioplasty

While attempting to recanalize a right coronary artery obstruction by using a low-speed rotating catheter (Rotacs), proximal rupture of the catheter body occurred with entrapment of the blunt tip in the obstruction. To retrieve the device, it was necessary to severe the guiding catheter and the flexible tube of the Rotacs. At low-speed rotation the flexible segment of the catheter was then pulled back.

Total coronary occlusion: a different animal?

Provided collateralization is adequate, a chronic total coronary occlusion clinically imitates a 90% stenosis but is exempt from the risk of myocardial infarction. For angioplasty of vessels with chronic total coronary occlusion, technical difficulties and clinical risks are balanced against projected subjective benefit and amount of viable myocardium concerned. The primary success rate is approximately 65% and complications are rare because abrupt vessel reclosure may be common but is harmless. New Q wave infarction in that context has not been reported. The duration of occlusion is the most important predictor of success. The length of the occluded segment is also important. Recurrence averages 68% (21% reocclusion and 47% restenosis) and happens typically within 6 months. The high recurrence rate is due to competitive pressure exerted by collateral vessels and an often suboptimal local result. Even if the primary success rate of angioplasty in vessels with chronic total coronary occlusion can be improved by advanced technology and skill, the clinical yield will remain low compared with that of angioplasty of stenoses. Because low yield procedures must be low risk and low cost, there are definite limits to how sophisticated, risky and expensive new techniques can become. Derivatives of conventional balloon systems are likely to remain the equipment of first choice, perhaps complemented by mechanical drills. Although chronic total coronary occlusions are no clinical menace in contrast to stenoses, they frequently deserve revascularization and are the reason to select bypass surgery over angioplasty. These factors justify endeavors to improve recanalization techniques that help to refine coronary angioplasty of nontotal lesions, because total occlusion, albeit a different animal, is of the same species.

Advances in interventional cardiology

The field of interventional cardiology is growing widely. This growth is the result of improvements in existing technology, development of new technology, and expansion of criteria for the selection of patients. Percutaneous transluminal coronary angioplasty (PTCA) remains the mainstay and is used to treat an increasing number of patients with coronary artery disease that manifests as stable or unstable angina or acute myocardial infarction. Atherectomy is being used to "debulk" lesions and remove atheromatous plaque as well as to remove intimal flaps after PTCA. The insertion of an intracoronary stent is a strategy designed to treat intimal dissections and acute closure as well as to attempt to decrease the incidence of restenosis. Finally, intracoronary laser therapy--independently or in combination with PTCA--is being evaluated as a treatment approach for more diffuse disease, acute occlusion, and prevention of restenosis.