Long-term outcomes of rotational atherectomy of underexpanded stents. A single center experience

Rotational Atherectomy Versus Intravascular Lithotripsy for Calcified In-Stent Restenosis: A Single-Center Study With 1-Year Follow-Up

Although rotational atherectomy (RA) and intravascular lithotripsy (IVL) have been proved to be effective for calcified de novo coronary lesions, their use in patients with in-stent restenosis (ISR) is still controversial. No comparison of these techniques in patients with ISR has been published so far. We sought to evaluate safety and feasibility of RA and IVL in patients with calcified ISR. Furthermore, we aimed to compare in-hospital and 1-year clinical outcomes between both groups. This is a retrospective single-center study evaluating patients with calcified ISR treated with RA (between 2012 and 2021) and IVL (between 2019 and 2021). Inhospital and 1-year clinical outcomes were compared between IVL and RA patients. In total, 28 patients with ISR who underwent RA were compared with 24 ISR subjects after IVL. The procedural success rate was 100% in both the groups. Quantitative coronary analysis demonstrated a similar degree of stenosis prior (66.4 ± 11.4 vs 68.8 ± 19.7, p = nonsignificant [NS]), and after the procedure (21.5 ± 20.5 vs 22.8 ± 12.1, p = NS) with no difference in acute luminal gain (1.34 ± 0.60 vs 1.38 ± 0.59, p = NS). There was one in-hospital major adverse cardiovascular event in the RA group. At 1-year follow-up, no difference was observed with respect to major adverse cardiovascular event rate (14.3% vs 16.7%, p = NS) and target vessel revascularization (7.1% vs 12.5%, p = NS). In conclusion, RA and IVL are safe and feasible techniques for calcified ISR yielding comparable results at 1-year follow-up. Further clinical studies are warranted to confirm our findings and shed more light on patient and lesion characteristics associated with the best outcomes.

A Systematic Review and Meta-Analysis Including 354 Patients from 13 Studies of Intravascular Lithotripsy for the Treatment of Underexpanded Coronary Stents

Calcified coronary plaque (CCP) represents a challenging scenario for interventional cardiologists. Stent underexpansion (SU), often associated with CCP, can predispose to stent thrombosis and in-stent restenosis. To date, SU with heavily CCP can be addressed using very high-/high-pressure noncompliant balloons, off-label rotational atherectomy/orbital atherectomy, excimer laser atherectomy, and intravascular lithotripsy (IVL). In this meta-analysis, we investigated the success rate of IVL for the treatment of SU because of CCP. Studies and case-based experiences reporting on the use of IVL strategy for treatment of SU were included. The primary end point was IVL strategy success, defined as the adequate expansion of the underexpanded stent. A metanalysis was performed for the main focuses to calculate the proportions of procedural success rates with corresponding 95% confidence intervals (CIs). Random-effects models weighted by inverse variance were used because of clinical heterogeneity. This meta-analysis included 13 studies with 354 patients. The mean age was 71.3 years (95% CI 64.9 to 73.1), and 77% (95% CI 71.2% to 82.4%) were male. The mean follow-up time was 2.6 months (95% CI 1 to 15.3). Strategy success was seen in 88.7% (95% CI 82.3 to 95.1) of patients. The mean minimal stent area was reported in 6 studies, the pre-IVL value was 3.4 mm2 (95% CI 3 to 3.8), and the post-IVL value was 6.9 mm2 (95% CI 6.5 to 7.4). The mean diameter stenosis (percentage) was reported in 7 studies, the pre-IVL value was 69.4% (95% CI 60.7 to 78.2), and the post-IVL value was 14.6% (95% CI 11.1 to 18). The rate of intraprocedural complications was 1.6% (95% CI 0.3 to 2.9). In conclusion, the "stent-through" IVL plaque modification technique is a safe tool to treat SU caused by CCP, with a high success rate and a very low incidence of complications.

Prevalence, predictors, and management for balloon uncrossable or undilatable lesions in patients undergoing percutaneous coronary intervention with in-stent restenosis chronic total occlusion

Background

Percutaneous coronary intervention for in-stent restenosis (ISR) chronic total occlusion (CTO) has been a great challenge. There are occasions when the balloon is uncrossable or undilatable (BUs) even though the guidewire has passed, leading to failure of the procedure. Few studies have focused on the incidence, predictors, and management of BUs during ISR-CTO intervention.

Methods

Patients with ISR-CTO were recruited consecutively between January 2017 and January 2022 and divided into two groups based on the presence of BUs. The clinical data of the two groups (BUs group and non-BUs group) were retrospectively analyzed and compared to explore the predictors and clinical management strategies of BUs.

Results

A total of 218 patients with ISR-CTO were included in this study, 23.9% (52/218) of whom had BUs. The percentage of ostial stents, stent length, CTO length, the presence of proximal cap ambiguity, moderate to severe calcification, moderate to severe tortuosity, and J-CTO score were higher in the BUs group than in the non-BUs group (p < 0.05). The technical success rate and the procedural success rate were lower in the BUs group than in the non-BUs group (p < 0.05). Multivariable logistic regression analysis showed that ostial stents (OR: 2.011, 95% CI: 1.112-3.921, p = 0.031), the presence of moderate to severe calcification (OR: 3.383, 95% CI: 1.628-5.921, p = 0.024) and moderate to severe tortuosity (OR: 4.816, 95% CI: 2.038-7.772, p = 0.033) were independent predictors of BUs.

Conclusion

The initial rate of BUs in ISR-CTO was 23.9%. Ostial stents, presence of moderate to severe calcification, and moderate to severe tortuosity were independent predictors of BUs.

Effect of balloon pre-dilation on performance of self-expandable nitinol stent in femoropopliteal artery

Balloon pre-dilation is usually performed before implantation of a nitinol stent in a femoropopliteal artery in a case of severe blockage or calcified plaque. However, its effect on performance of the nitinol stent in a diseased femoropopliteal artery has not been studied yet. This study compares the outcomes of stenting with pre-dilation and without it by modelling the entire processes of stent deployment. Fatigue deformation of the implanted stent is also modelled under diastolic-systolic blood pressure, repetitive bending, torsion, axial compression and their combination. Reduced level of stress in the stent occurs after stenting with pre-dilation, but causing the increased damage in the media layer, i.e. the middle layer of the arterial wall. Generally, pre-dilation increases the risk of nitinol stent's fatigue failure. Additionally, the development of in-stent restenosis is predicted based on the stenting-induced tissue damage in the media layer, and no severe mechanical irritation is induced to the media layer by pre-dilation, stent deployment or fatigue loading.

Intravascular imaging in coronary stent restenosis: Prevention, characterization, and management

Despite the introduction of drug-eluting stents to combat the neointimal hyperplasia that occurred after BMS implantation, in-stent restenosis is still encountered in a significant number of patients, particularly as increasingly complex lesions are tackled by percutaneous coronary intervention. Many biological and mechanical factors interplay to produce restenosis, some of which are avoidable. Intravascular imaging provided unique insights into various forms of stent-related mechanical issues that contribute to this phenomenon. From a practical perspective, intravascular imaging can therefore help to optimize the stenting procedure to avert these issues. Moreover, once the problem of restenosis eventuates, imaging can guide the management by tackling the underlying identified mechanism. Finally, it can be used to evaluate the re-intervention results. Nevertheless, with the emergence of different treatment options, more evidence is needed to define patient/lesion-specific characteristics that may help to tailor treatment selection in a way that improves clinical outcomes.

Rotational atherectomy for the management of undilatable in-stent restenosis with single or multiple stent layers

BACKGROUND

There is no consensus on the best treatment of undilatable coronary in-stent restenosis (ISR) regardless of the number of stent layers. We aimed to evaluate the procedural and clinical outcomes of rotational atherectomy (RA) to treat undilatable coronary ISR with single or multiple stent layers.

METHODS

We retrospectively evaluated consecutive patients treated with RA for undilatable ISR with single or multiple stent layers in the Mount Sinai catheterization laboratory between January 2016 and September 2018. Procedural success was defined as angiographic success without in-hospital major adverse cardiac events (MACE): a composite of death, myocardial infarction (MI), and target lesion revascularization (TLR). Clinical outcomes were assessed at one-year post-procedure.

RESULTS

A total of 26 patients were included in the study, in which 18 (69.2%) patients were with multiple stent layers. After RA, 9 (34.6%) were received a new drug-eluting stent, and 6 (23.1%) were treated with intravascular brachytherapy. Angiographic success was achieved in 24 (92.3%) patients, and procedural success was achieved in 22 (84.6%) patients. In-hospital MACE occurred in 4 (15.4%) patients, all due to periprocedural non-Q wave MI. Within one year, MACE occurred in 9 (34.6%) patients with 5 (19.2%) TLR.

CONCLUSIONS

RA for undilatable ISR with single or multiple stent layers was performed with favorable procedural outcomes and a relatively high MACE rate driven by TLR within one year.

Optimized strategy of rotational atherectomy of underexpanded coronary stents in patients with acute coronary syndrome

BACKGROUND

Stent under-expansion is a main cause of acute coronary syndrome (ACS), which can lead to serious clinical outcomes. The rotational atherectomy of underexpanded coronary stents (academically called stent ablation, SA) by intravascular ultrasound (IVUS) may provide more visual reference in the intervention. We aim to analyze the procedural and long-term outcomes of the optimized strategy of SA in patients with ACS and to provide real-world data on this technique.

METHODS

A total of 11 patients with ACS who underwent SA between April 2017 and January 2019 were analyzed. Clinical follow-ups were obtained either by telephone call or by scheduled visit. Clinical end-points included periprocedural and postprocedural myocardial infarction, stent thrombosis, target lesion revascularization, and major adverse cardiac events.

RESULTS

The mean age of patients was 69.6±6.5 years, and five (45.5%) patients were males. All cases presented with unstable angina and were admitted with ACS. All patients required at least two burrs during the intervention and the size of the burr was selected based on the data of minimum lumen diameter (MLD), and the first and the second burr/stent MLD ratios were 0.93 (0.88-0.99) and 1.09 (1.02-1.14), respectively. Nine patients were treated with drug-eluting stents and two were treated with drug-coated balloons. There were no complications including no flow, perforation, or burr entrapment during the intervention. No in-hospital deaths or major adverse cardiac events were documented during the follow-up period. In our study, less contrast agent and a lower dose of radiation were used during the intervention.

CONCLUSIONS

SA guided by IVUS can reduce the risk of complications, assess the results of surgery, inform the selection of stent size, and decrease the required dose of radiation and contrast.

Stentablation with Rotational Atherectomy for the Management of Underexpanded and Undilatable Coronary Stents

Stentablation with rotational atherectomy for the management of undilatable underexpanded coronary stents is a unique application associated with excellent periprocedural and in-hospital outcomes. Data regarding long-term outcomes remains limited, however the procedure appears to be associated with high prevalence of target lesion revascularization. Given the complexity of such lesions and few available interventional remedies; it is a reasonably safe and widely available approach of which operators should be aware. When stentablation is performed, the principles which guide contemporary rotational atherectomy and percutaneous coronary intervention, including intravascular imaging, should be applied.

Safety and Efficacy of Stentablation with Rotational Atherectomy for the Management of Underexpanded and Undilatable Coronary Stents

INTRODUCTION

Coronary stent underexpansion is associated with in-stent restenosis and few interventions are available for the management of undilatable underexpanded stents. Stentablation (SA) with rotational atherectomy (RA) is a unique application and has previously been described with encouraging results. Data regarding SA is limited to case reports and small case series; therefore, reasonable concern persists regarding procedural safety and long-term outcomes.

METHODS

This is a single-center retrospective study analyzing twenty consecutive patients who underwent SA with RA. The primary endpoint was procedural success and secondary endpoints included procedural safety outcomes and major adverse cardiac events (MACE) over a 12-month follow-up period.

RESULTS

Stentablation and secondary stenting were guided by intravascular ultrasound and procedural success was achieved in all cases. No in-hospital death or MACE was observed. The prevalence of MACE was 5% at 30 days as one patient developed recurrent MI without target lesion revascularization (TLR). At 12 months, MACE had occurred in 40% of patients, however this was strongly driven by a high prevalence of TLR (30%). Only one cardiac death (5%) and one additional NSTEMI were observed during the 11 additional months of follow up.

CONCLUSION

Stentablation with RA is a feasible and effective option for the acute management of symptomatic, underexpanded, and undilatable coronary stents. SA is associated with a high rate of procedural success as well as excellent in-hospital and short-term outcomes. However, our study population demonstrated substantial MACE at 12 months which was strongly driven by TLR and associated with minimal mortality.

Long-term outcomes of rotational atherectomy of underexpanded stents. A single center experience

OBJECTIVES

To analyze the procedural and long-term outcomes of the use of rotational atherectomy (RA) in underexpanded stents in our cohort and to provide an overview of currently available data on this technique.

BACKGROUND

Stent underexpansion (SU) has been related to stent thrombosis and restenosis. RA has been used to treat undilatable SU as a bail-out strategy with encouraging results.

METHODS

This is an observational, single-center study. We included patients who underwent stentablation between 2013 and 2017. Baseline demographics, procedural results, in-hospital major adverse cardiac events (MACE), and long-term follow-up MACE were retrospectively collected.

RESULTS

A total of 11 patients (90.9% males, mean age 65.4 ± 18.6) were included in this study. Median left ventricle ejection fraction was 53.5% [46.2-55]. Median calculated Syntax score was 16 [9-31] and 45.5% of patients were admitted for acute coronary syndrome. Radial approach was used in 63.6% of cases. Most patients only required one burr (45% used a 1.5 mm diameter burr) during the intervention. Procedural success was achieved in 90.9% of the cases. Acute lumen gain was 42.7% [30.7-61.49]. There were no in-hospital deaths or MACE. At a median follow-up of 26 months, only one patient (9.1%) suffered MACE in the context of acute coronary syndrome, and two patients (18.2%) required non-target lesion revascularization. No deaths were reported.

CONCLUSIONS

RA of under expanded stents is a feasible option with a high rate of procedural success. At long-term follow-up, all of them were alive and 90.9% of patients remained free from MACE.