Rotational Atherectomy, Lithotripsy, or Laser for Calcified Coronary Stenosis: The ROLLER COASTR-EPIC22 Trial

Rotational Atherectomy, Lithotripsy, or Laser for Calcified Coronary Stenosis: One-Year Outcomes From the ROLLER COASTER-EPIC22 Trial

BACKGROUND

The ROLLER COASTR-EPIC22 was the first randomized trial to directly compare rotational atherectomy (RA), excimer laser coronary angioplasty (ELCA), and intravascular lithotripsy (IVL) for the treatment of patients with calcified coronary stenosis.

AIMS

The aim of this study is to report and compare its 1-year clinical outcomes.

METHODS

The ROLLER COASTR-EPIC22 trial randomized 171 patients with angiographic moderate to severe calcified coronary lesions to PCI with RA (n = 57), IVL (n = 57), or ELCA (n = 57). A pre-specified analysis of clinical events at one year from the index PCI was conducted. The clinical endpoints analyzed at one year were the rate of major adverse cardiovascular events (MACE), defined as the occurrence of cardiac death, target vessel myocardial infarction (TV-MI), target lesion revascularization (TLR), target vessel revascularization (TVR) and stent thrombosis. Furthermore, the rate of all-cause mortality, non-fatal TV-MI, TVR, TLR, and stent thrombosis were analyzed separately. Kaplan-Meier analysis was performed to assess time-to-event outcomes. The adjudication of clinical events was conducted in accordance with the intention-to-treat principle.

RESULTS

The mean age was 70.9 ± 8.2 years and 77.2% of the patients were men. Clinical presentation was acute coronary syndrome in 35.7% of patients and severe angiographic calcification was observed in 82.5% of lesions by the independent core laboratory unaware to the treatment arm. All patients showed criteria of severe calcification, either angiographic or at optical coherence tomography (OCT). At OCT evaluation, mean calcium arc was 300.8° ± 78.9°, maximum calcium thickness 1.17 ± 0.24 mm, calcification length 30.9 ± 12.9 mm and 30.5% of patients presented calcium nodules. Baseline characteristics were well balanced between groups. At one year, there were no significant differences in MACE incidence among the three arms (RA 5.3%, IVL 5.3%, ELCA 3.5%; p = 0.88). Furthermore, there were no significant differences in all-cause death between groups (p = 0.22), with no events in the IVL group (RA 5.3%, IVL 0%, ELCA 5.3%). No significant differences were observed among the 3 arms in the terms of TV-MI (RA 1.7, IVL 1.7, ELCA 0%; p = 0.61), TVR (RA 3.5%, IVL 5.3%, ELCA 1.7%; p = 0.59), TLR (RA 1.7%, IVL 1.7%, ELCA 1.7%; p = 1.00), or stent thrombosis (RA 1.7%, IVL 0%, ELCA 1.7; p = 0.61).

CONCLUSIONS

This is the first randomized trial comparing RA, IVL, and ELCA for the treatment of patients with calcified coronary lesions and reporting long-term clinical outcomes. At one year, no significant differences were observed among the three arms in the composite endpoint of one-year all-cause mortality, AMI, TVR, TLR and stent thrombosis. Similarly, no significant differences were found when analyzing the individual components of the endpoint separately.

Calcium modification techniques in complex percutaneous coronary intervention: State-of-the-art review

As patients increase in age and medical complexity, coronary artery calcification is frequently encountered and its presence portends worse outcomes following percutaneous coronary intervention (PCI) - negatively impacting procedural success and long-term outcomes. This review paper explores available imaging techniques and calcium modification technique that can identify, characterize and modify these lesions to facilitate stent implantation. The data supporting these techniques are explored and an algorithm for decision-making during lesion modification is presented. Current barriers and future directions are additionally discussed.