Randomized evaluation of vessel preparation with orbital atherectomy prior to drug-eluting stent implantation in severely calcified coronary artery lesions: Design and rationale of the ECLIPSE trial

Orbital atherectomy versus balloon angioplasty before drug-eluting stent implantation in severely calcified lesions eligible for both treatment strategies (ECLIPSE): a multicentre, open-label, randomised trial

BACKGROUND

Coronary artery calcification is common among patients undergoing percutaneous coronary intervention (PCI), and severe coronary artery lesion calcification is associated with increased procedural complexity, stent under-expansion, and high rates of intraprocedural complications and out-of-hospital adverse events. Whether calcium ablation before stent implantation can mitigate these adverse events is not currently established. We aimed to prospectively compare orbital atherectomy with a balloon angioplasty-based strategy before stent implantation for the treatment of severely calcified coronary lesions.

METHODS

In this multicentre, open-label, randomised controlled trial conducted at 104 medical centres in the USA, patients (aged ≥18 years) with severely calcified coronary lesions were randomly assigned (1:1) to orbital atherectomy or balloon angioplasty before PCI with drug-eluting stents using a web-based system (block sizes of four and six) and stratified by intended treatment of single versus multiple lesions and enrolling site. Randomly assigned lesions were deemed by operators to be eligible for both treatment strategies. Operators and patients were not masked to treatment. The two powered coprimary study endpoints were target vessel failure at 1 year (a composite of cardiac death, target vessel myocardial infarction, or ischaemia-driven target vessel revascularisation) and post-procedural minimal stent area at the site of maximal calcification, as assessed by intravascular optical coherence tomography in an imaging patient cohort. Primary analyses were by intention-to-treat. The trial is registered at ClinicalTrials.govNCT03108456, and 2-year follow-up is ongoing.

FINDINGS

From March 27, 2017, to April 13, 2023, 2005 patients with 2492 lesions were randomly assigned to lesion preparation with orbital atherectomy (1008 patients with 1250 lesions) or balloon angioplasty (997 with 1242 lesions) before stent implantation. Median patient age was 70·0 years (IQR 64·0-76·0). 541 (27·0%) of 2005 patients were female and 1464 (73·0%) were male. Angiographically severe calcium was confirmed by the core laboratory in 1088 (97·1%) of 1120 lesions assigned to orbital atherectomy and 1068 (97·0%) of 1101 lesions assigned to balloon angioplasty. PCI was guided by intravascular imaging in 627 (62·2%) of 1008 patients in the orbital atherectomy group and 619 (62·1%) of 997 in the balloon angioplasty group. Target vessel failure events within 1 year occurred in 113 of 1008 patients in the orbital atherectomy group (1-year target vessel failure 11·5% [95% CI 9·7 to 13·7]) and in 97 of 997 patients in the balloon angioplasty group (10·0% [8·3 to 12·1]; absolute difference 1·5% [96% CI -1·4 to 4·4]; hazard ratio 1·16 [96% CI 0·87 to 1·54], p=0·28). Among those in the optical coherence tomography substudy cohort (276 patients with 286 lesions in the orbital atherectomy group and 279 patients with 292 lesions in the balloon angioplasty group), the mean minimal stent area at the site of maximal calcification was 7·67 mm2 (SD 2·27) in the orbital atherectomy group and 7·42 mm2 (2·54) in the balloon angioplasty group (mean difference 0·26 [99% CI -0·31 to 0·82]; p=0·078). Cardiac death events within 1 year occurred in 39 of 1008 patients in the orbital atherectomy group and in 26 of 997 in the balloon angioplasty group.

INTERPRETATION

Routine treatment with orbital atherectomy before drug-eluting stent implantation did not increase minimal stent area or reduce the rate of target vessel failure at 1 year compared with a balloon angioplasty-based approach in severely calcified lesions deemed eligible for both treatment strategies. These data support a balloon-first approach for most calcified coronary artery lesions that can be crossed and dilated before stent implantation, guided by intravascular imaging.

FUNDING

Abbott Vascular (Abbott).

Orbital Atherectomy in Calcified Coronary Lesions: A 1-Year Retrospective Observational Outcome Study

BACKGROUND

Percutaneous coronary intervention (PCI) has advanced rapidly since its inception. Not only in stent technology, but there have been advancements in adjunctive tools including intra-coronary imaging, stent delivery tools and calcium modification techniques. The interventional community is well aware of the difficulties posed by calcified coronary lesions and their impact on outcomes. More recently, orbital atherectomy (OA) has seen itself on the fore front of managing such complex and challenging situations.

AIMS

This retrospective study analyses a 1-year experience of using OA in a high-volume primary PCI center in a UK district general hospital.

METHODS

Patient demographics, procedural details, and outcomes, including MACE rates and procedural success, were reviewed in all-comers undergoing OA between January 1 and December 31, 2024.

RESULTS

A total 53 patients were identified that had undergone OA in a 1-year period. Procedural success was achieved in 98.1% of patients. Thirty-days MACE was 5.7% (three patients). One patient experiencing in-hospital procedural related myocardial infarction and two patients had major bleeding events during the follow up period which is not related to OA. No-flow/slow-flow were observed in seven patients (13.2%), and seven patients (13.2%) experienced coronary dissection that were successfully treated with stent implantation.

CONCLUSION

OA is a new but safe and effective tool for calcium modification in an all-comers cohort of patients treated in a high-volume UK district general hospital setting.

The Role of Calcified Nodules in Acute Coronary Syndrome: Diagnosis and Management

Calcified nodules (CNs) are increasingly recognized as critical contributors to the pathophysiology of acute coronary syndrome (ACS). This review provides a comprehensive synthesis of the recent literature, focusing on the prevalence of CNs, their underlying mechanisms, and their implications for the clinical management of coronary artery disease (CAD). CNs are characterized by unique pathophysiological processes, and the diagnosis and treatment of CNs during percutaneous coronary interventions (PCIs) underscore the importance of advanced intravascular imaging techniques, such as optical coherence tomography (OCT) and intravascular ultrasound (IVUS), for precise identification and prognostic evaluation. Current therapeutic strategies aim to modulate CN characteristics, enhance arterial wall stability, and reduce the risk of ACS and sudden cardiac death. This review highlights the impact of CNs in ACS, the role of intravascular imaging in diagnosis, and the importance of targeted interventions to improve clinical outcomes, as by bridging diagnostic insights with emerging atherectomy modalities, this review also seeks to advance the understanding and management of CNs in PCI, fostering improved patient outcomes.

Calcified plaque modification during percutaneous coronary revascularization

The presence and severity of calcified coronary plaque negatively impacts angiographic and clinical outcomes following percutaneous coronary intervention (PCI). Severe coronary calcification is associated with suboptimal stent delivery, deployment, apposition and expansion which can lead to in-stent restenosis and/or thrombosis. Severe coronary calcification is associated with incremental hazard for adverse clinical events, including death, during 5-10 years following PCI despite the use of new generation drug- eluting stents. Multiple technologies including high-pressure noncompliant and modified (cutting/scoring) balloons, atheroablative technologies (laser, rotational or orbital atherectomy), and more recently, intravascular lithotripsy have been used to modify calcified plaque and facilitate optimal coronary stent implantation. Intravascular imaging is critically important to determine the extent and distribution (superficial or deep) of coronary calcification and to aid selection and sequence for use of calcium modifying technologies. Unfortunately, large scale randomized comparative trials of calcium modifying technologies are limited and the relative safety and effectiveness of these modalities is poorly defined. Recent mechanistic and clinical data supporting the use of plaque modifying technologies are reviewed to provide insights into their optimal use.

Advances in Technology and Technique in Percutaneous Coronary Intervention: A Clinical Review

Percutaneous coronary intervention (PCI) has become the standard procedure for patients with angina and acute coronary syndrome. From the perspective of technology and technique, PCI has advanced over the last four decades, resulting in considerably improved clinical outcomes in patients with coronary artery disease in the current era. In this review article, we summarize recent advances, promising technologies, and areas for research in the field of PCI.

Calcified coronary lesions: Imaging, prognosis, preparation and treatment state of the art review

Calcific coronary artery stenosis is a complex disease associated with adverse outcomes and suboptimal percutaneous treatment. Calcium plaque modification has emerged as a key strategy to tackle the issues that accompany calcific stenosis - namely reduced device deliverability, unpredictable lesion characteristics, and difficult dilatation. Atherectomy has traditionally been the treatment modality of choice for heavily calcified coronary stenoses. Contemporary technologies have emerged to aid with planning, preparation, and treatment of calcified coronary stenosis in an attempt to improve procedural success and long-term outcomes. In this State Of The Art Review, we synthesize the body of data surrounding the diagnosis, imaging, and treatment of calcific coronary disease, with a focus on i) intravascular imaging, ii) calcific lesion preparation, iii) treatment modalities including atherectomy, and iv) updated treatment algorithms for the management of calcified coronary stenosis.

The Significance of Coronary Artery Calcification for Percutaneous Coronary Interventions

The prevalence of calcium deposits in coronary arteries grows with age. Risk factors include, e.g., diabetes and chronic kidney disease. There are several underlying pathophysiological mechanisms of calcium deposition. Severe calcification increases the complexity of percutaneous coronary interventions. Invasive techniques to modify the calcified atherosclerotic plaque before stenting have been developed over the last years. They include balloon- and non-balloon-based techniques. Rotational atherectomy has been the most common technique to treat calcified lesions but new techniques are emerging (orbital atherectomy, intravascular lithotripsy, laser atherectomy). The use of intravascular imaging (intravascular ultrasound and optical coherence tomography) is especially important during the procedures in order to choose the optimal strategy and to assess the final effect of the procedure. This review provides an overview of the role of coronary calcification for percutaneous coronary interventions.

[REFORCE registry]

Severe coronary artery calcification, too often underestimated, increases the complexity of percutaneous coronary interventions. Atherectomy is one of preferred approach for the preparation of calcified lesions before stent placement. Orbital atherectomy is a new method that has proven to be safe and effective in the preparation of calcium plaques (ORBIT I and ORBIT II studies). The recent introduction in France allows to perform a prospective registry named REFORCE. Its main objective is to include 300 patients in order to evaluate security and safety of the device in France during routine use.

Rotational Atherectomy, Orbital Atherectomy, and Intravascular Lithotripsy Comparison for Calcified Coronary Lesions

In order to improve the percutaneous treatment of coronary artery calcifications (CAC) before stent implantation, methods such as rotational atherectomy (RA), orbital atherectomy (OA), and coronary intravascular lithotripsy (IVL) were invented. These techniques use different mechanisms of action and therefore have various short- and long-term outcomes. IVL employs sonic waves to modify CAC, whereas RA and OA use a rapidly rotating burr or crown. These methods have specific advantages and limitations, regarding their cost-efficiency, the movement of the device, their usefulness given the individual anatomy of both the lesion and the vessel, and the risk of specified complications. This study reviews the key findings of peer-reviewed articles available on Google Scholar with the keywords RA, OA, and IVL. Based on the collected data, successful stent delivery was assessed as 97.7% for OA, 92.4% for IVL, and 92.5% for RA, and 30-day prevalence of MACE (Major Adverse Cardiac Events) in OA-10.4%, IVL-7.2%, and RA-5%. There were no significant differences in the 1-year MACE. Compared to RA, OA and IVL are cost-effective approaches, but this is substantially dependent on the reimbursement system of the particular country. There is no standard method of CAC modification; therefore, a tailor-made approach is required.

Coronary Intra-orbital Atherectomy Complications and Procedural Failure: Insight From the Manufacturer and User Facility Device Experience (MAUDE) Database

BACKGROUND

The Diamondback 360® Coronary Orbital Atherectomy System (Cardiovascular Systems Inc., St. Paul, MN) is the first and only orbital atherectomy system approved by the US FDA for the treatment of severely calcified lesions. While the device has proven to be safe in clinical trials, real-world data are minimal.

METHODS

The Manufacturer and User Facility Device Experience (MAUDE) database was queried for reports on the Diamondback 360® Coronary from January 2019 to January 2022.

RESULTS

A total of 566 events were reported during the study period. After the exclusion of duplicate reports, the final cohort included 547 reports. The most common mode of failure was break or separation of a device part (40.4%, n = 221) mainly due to breaking in the tip of the ViperWire (66.1%), driveshaft (22.7%), or crown (12.2%). The most common vessel associated with events was the left anterior descending artery (31.4%), followed by the right coronary artery (26.9%), left circumflex (21.6%), and left main coronary artery (6.4%). The most common clinical adverse outcome was perforation (33.0%, n = 181) with 23.7% resulting in cardiac tamponade. Most perforation cases were treated by covered stent (44.2%), surgery (30.5%), stent (98%), and balloon angioplasty (9%). There were 89 (16.3%) events of death with 67% due to perforation (p < 0.001).

CONCLUSION

Our study provided a glimpse of real-world adverse outcomes and common modes of failure due to orbital atherectomy. The most common mode of failure was the break or separation of a device part and the most common complication was perforation according to the MAUDE database. It will help physicians to anticipate complications and escalate care appropriately.

Calcified coronary lesions

The treatment of calcific coronary lesions is still a major interventional issue in haemodynamics laboratories. The prevalence of the disease is even increasing, considering the general ageing of the population undergoing coronarography, as well as the often associated comorbidities. In recent years, new devices have been developed that allow both better identification and also better treatment of these lesions. The aim of this review is to summarize both imaging modalities and dedicated techniques and materials, thus providing a kind of compendium for the treatment approach.

The role of invasive and non-invasive imaging technologies and calcium modification therapies in the evaluation and management of coronary artery calcifications

The treatment of coronary artery disease (CAD) has advanced significantly in recent years due to improvements in medical therapy and percutaneous or surgical revascularization. However, a persistent obstacle in the percutaneous management of CAD is coronary artery calcification (CAC), which portends to higher rates of procedural challenges, post-intervention complications, and overall poor prognosis. With the advent of novel multimodality imaging technologies spanning from intravascular ultrasound to optical coherence tomography to coronary computed tomography angiography combined with advances in calcium debulking and modification techniques, CACs are now targets for intervention with growing success. This review will summarize the most recent developments in the diagnosis and characterization of CAC, offer a comparison of the aforementioned imaging technologies including which ones are most suitable for specific clinical presentations, and review the CAC modifying therapies currently available.

Contemporary Interventional Approach to Calcified Coronary Artery Disease

Calcific coronary artery disease is an increasingly prevalent entity in the catheterization laboratory which has implications for stenting and expected outcomes. With new interventional techniques and equipment, strategies to favorably modify coronary calcium prior to stenting continue to evolve. This paper sought to review the latest advances in the management of severe coronary artery calcification in the catheterization laboratory and discuss contemporary percutaneous interventional approaches.

One-Year Follow-Up of Vascular Intervention Trials Disrupted by the COVID-19 Pandemic: A Use-Case landscape

INTRODUCTION

The COVID-19 pandemic had an unprecedented impact on cardiovascular clinical research. The decision-making and state of study operations in cardiovascular trials 1-year after interruption has not been previously described.

METHODS

In the spring of 2020, we created a pandemic impact task force to develop a landscape of use case scenarios from 17 device trials of peripheral artery disease (PAD) and coronary artery disease (CAD) interventions. In conjunction with publicly available (clinictrials.gov) study inclusion criteria, primary endpoints and study design, information was shared for this use-case landscape by trial leadership and data owners.

RESULTS

A total of 17 actively enrolling trials (9 CAD and 8 PAD) volunteered to populate the use case landscape. All 17 were multicenter studies (12 in North America and 5 international). Fifteen studies were industry-sponsored, of which 13 were FDA approved IDEs, one was PCORI-sponsored and two were sponsored by the NIH. Enrollment targets ranged from 150 to 9000 pts. At the time of interruption, 5 trials were <20 % enrolled, 9 trials were 50-80 % enrolled and 3 trials were >80 % enrolled. At 1 year, the majority of studies were continuing to enroll in the context of more sporadic but ongoing pandemic activity.

CONCLUSIONS

At 1 year from the first surge interruptions, most trials had resumed enrollment. Trials most heavily interrupted were trials early in enrollment and those trials not able to pivot to virtual patient and site visits. Further work is needed to determine the overall impact on vascular intervention trials disrupted during the COVID-19 pandemic.

Contemporary Management of Severely Calcified Coronary Lesions

Coronary artery calcification is increasingly prevalent in our patient population. It significantly limits the procedural success of percutaneous coronary intervention and is associated with a higher risk of adverse cardiovascular events both in the short-term and long-term. There are several modalities for modifying calcified plaque, such as balloon angioplasty (including specialty balloons), coronary atheroablative therapy (rotational, orbital, and laser atherectomy), and intravascular lithotripsy. We discuss each modality’s relative advantages and disadvantages and the data supporting their use. This review also highlights the importance of intravascular imaging to characterize coronary calcification and presents an algorithm to tailor the calcium modification therapy based on specific coronary lesion characteristics.