Circulation, Vol 89, 882-892, Copyright © 1994 by American Heart Association
SG Ellis, JJ Popma, M Buchbinder, I Franco, MB Leon, KM Kent, AD Pichard, LF Satler, EJ Topol and PL Whitlow
BACKGROUND: Rotational atherectomy using the Rotablator has recently become
available to treat coronary stenoses. This study was performed to determine
the relation of patient characteristics, stenosis morphology, and operator
technique to procedural outcome to gain insight into which patients might
be best treated with this device. METHODS AND RESULTS: Four hundred
stenoses from 316 patients randomly selected from the initial Rotablator
experience at three major referral institutions were analyzed. Angiographic
data were assessed at a central angiographic laboratory using standardized
morphological criteria and caliper measurement. Patients were somewhat more
elderly than most percutaneous transluminal coronary angioplasty
(PTCA)-treated groups (mean age, 64 +/- 11 years), 74% were men, and the
lesions treated were often complex (modified American College of
Cardiology/American Heart Association lesion type A, 24%; B1, 40%; B2, 30%;
and C, 6%). Elective adjunctive PTCA was used for 82% of stenoses treated.
Procedural success was achieved in 89.8% of stenoses (93.5% if results with
creatine kinase two to three times normal are not counted as failures), and
major ischemic complications (death, 0.3%; non-Q-wave myocardial
infarction, 5.7%; Q-wave myocardial infarction, 2.2%; or emergency bypass
surgery, 0.9%) occurred in 8.9% of patients. Complications were due to
epicardial coronary obstruction in 3.8% of patients and to delayed coronary
runoff ("slow reflow") in 5.1% of patients. Procedural failure was
correlated independently with outflow obstruction (success rate, 64%; odds
ratio for failure, 5.4; multivariate P = .002), lesion irregularity (76%;
odds ratio, 3.3; P = .003), stenosis bend > or = 60 degrees (73%; odds
ratio, 3.7; P = .03), and female sex (84%; odds ratio, 2.4; P = .03).
Ischemic complications were correlated independently with lesion length
(> or = 50% narrowing) > or = 4 mm (complication rate, 12%; odds
ratio, 3.6; multivariate P = .005), right coronary artery stenosis (13%;
odds ratio, 2.4; P = .02), stenosis bend > or = 60 degrees (27%; odds
ratio, 6.1; P = .03), and female sex (13%; odds ratio, 3.0; P = .04). Slow
reflow was correlated with total burring duration (odds ratio, 1.005/s;
multivariate P = .001), right coronary artery stenosis (incidence, 17%;
odds ratio, 4.5; P = .009), and to a lesser extent with recent myocardial
infarction in the treated territory (44%; odds ratio, 4.3; P = .08).
CONCLUSIONS: The procedural outcome of rotational atherectomy is highly
correlated with stenosis morphology and location and sex of the patient.
After stratification for these parameters, overall outcome with the
Rotablator appears to be similar to that with balloon angioplasty and other
competing techniques. Short-term outcome with specific subsets of patients
may be superior with the Rotablator (calcified stenoses), but this
technique might best be avoided in some patients (those with irregular or
possibly thrombus-containing stenoses, highly angulated stenoses, and
possible right coronary artery stenoses or those associated with impaired
distal runoff caused by a recent myocardial infarction or manifest by a
fixed thallium defect).
ARTICLES
Relation of clinical presentation, stenosis morphology, and operator technique to the procedural results of rotational atherectomy and rotational atherectomy-facilitated angioplasty
Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195.
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