Specialized revascularization devices in the management of coronary heart disease
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
The management of coronary heart disease (CHD) has evolved significantly due in part to improvement in both surgical and percutaneous revascularization techniques. While the majority of patients with chronic stable angina are treated with medical therapy, revascularization on top of medical therapy is the preferred treatment strategy in many clinical subgroups. (See "Stable ischemic heart disease: Indications for revascularization".)
The majority of patients who undergo revascularization receive percutaneous coronary intervention (PCI) with stenting, as opposed to coronary artery bypass graft surgery (CABG). (See "Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention".)
Most patients who undergo PCI receive stents. Specialized revascularization devices such as rotational atherectomy (for severely calcified lesions) or laser angioplasty (for in-stent restenosis) have been evaluated in clinical trials.
Neither short- nor long-term benefits have been shown consistently with these revascularization devices. In particular, atherectomy devices have generally failed to improve patient survival or the durability of the revascularization [1,2]. These findings indicate that ROUTINE use of specialized device therapies (over the combination of balloon dilation and stent implantation) is not justified.
The use and efficacy of rotational atherectomy, cutting balloon atherectomy, and excimer laser angioplasty will be reviewed here. The complications associated with their use are discussed separately. (See "Coronary complications of atheroablative devices".)
Subscribers log in hereLiterature review current through: Jul 2017. | This topic last updated: Aug 25, 2015.References
- Bittl JA, Chew DP, Topol EJ, et al. Meta-analysis of randomized trials of percutaneous transluminal coronary angioplasty versus atherectomy, cutting balloon atherotomy, or laser angioplasty. J Am Coll Cardiol 2004; 43:936.
- King SB 3rd, Yeh W, Holubkov R, et al. Balloon angioplasty versus new device intervention: clinical outcomes. A comparison of the NHLBI PTCA and NACI registries. J Am Coll Cardiol 1998; 31:558.
- Motwani JG, Raymond RE, Franco I, et al. Effectiveness of rotational atherectomy of right coronary artery ostial stenosis. Am J Cardiol 2000; 85:563.
- MacIsaac AI, Bass TA, Buchbinder M, et al. High speed rotational atherectomy: outcome in calcified and noncalcified coronary artery lesions. J Am Coll Cardiol 1995; 26:731.
- Abdel-Wahab M, Richardt G, Joachim Büttner H, et al. High-speed rotational atherectomy before paclitaxel-eluting stent implantation in complex calcified coronary lesions: the randomized ROTAXUS (Rotational Atherectomy Prior to Taxus Stent Treatment for Complex Native Coronary Artery Disease) trial. JACC Cardiovasc Interv 2013; 6:10.
- Thomas WJ, Cowley MJ, Vetrovec GW, et al. Effectiveness of rotational atherectomy in narrowed left internal mammary artery grafts to the left anterior descending coronary artery. Am J Cardiol 2000; 86:86.
- Kishi K, Hiasa Y, Ogata T, et al. Comparison of results of rotational atherectomy for diffuse coronary artery disease in diabetics versus nondiabetics. Am J Cardiol 2001; 87:894.
- Dauerman HL, Baim DS, Cutlip DE, et al. Mechanical debulking versus balloon angioplasty for the treatment of diffuse in-stent restenosis. Am J Cardiol 1998; 82:277.
- Sharma SK, Duvvuri S, Dangas G, et al. Rotational atherectomy for in-stent restenosis: acute and long-term results of the first 100 cases. J Am Coll Cardiol 1998; 32:1358.
- Radke PW, Klues HG, Haager PK, et al. Mechanisms of acute lumen gain and recurrent restenosis after rotational atherectomy of diffuse in-stent restenosis: a quantitative angiographic and intravascular ultrasound study. J Am Coll Cardiol 1999; 34:33.
- vom Dahl J, Dietz U, Haager PK, et al. Rotational atherectomy does not reduce recurrent in-stent restenosis: results of the angioplasty versus rotational atherectomy for treatment of diffuse in-stent restenosis trial (ARTIST). Circulation 2002; 105:583.
- Kini A, Reich D, Marmur JD, et al. Reduction in periprocedural enzyme elevation by abciximab after rotational atherectomy of type B2 lesions: Results of the Rota ReoPro randomized trial. Am Heart J 2001; 142:965.
- Koch KC, vom Dahl J, Kleinhans E, et al. Influence of a platelet GPIIb/IIIa receptor antagonist on myocardial hypoperfusion during rotational atherectomy as assessed by myocardial Tc-99m sestamibi scintigraphy. J Am Coll Cardiol 1999; 33:998.
- www.acc.org/qualityandscience/clinical/statements.htm (accessed September 18, 2007) www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007).
- King, SB, Smith, SC, Hirshfeld, JW Jr, et al. 2007 Focused update of the ACC/AHA/SCAI 2005 guideline update for PCI. Circulation 2008; 117:e1. Available at: http://circ.ahajournals.org (accessed January 29, 2008).
- Chambers JW, Feldman RL, Himmelstein SI, et al. Pivotal trial to evaluate the safety and efficacy of the orbital atherectomy system in treating de novo, severely calcified coronary lesions (ORBIT II). JACC Cardiovasc Interv 2014; 7:510.
- Martí V, Martín V, García J, et al. Significance of angiographic coronary dissection after cutting balloon angioplasty. Am J Cardiol 1998; 81:1349.
- Adamian M, Colombo A, Briguori C, et al. Cutting balloon angioplasty for the treatment of in-stent restenosis: a matched comparison with rotational atherectomy, additional stent implantation and balloon angioplasty. J Am Coll Cardiol 2001; 38:672.
- Albiero R, Silber S, Di Mario C, et al. Cutting balloon versus conventional balloon angioplasty for the treatment of in-stent restenosis: results of the restenosis cutting balloon evaluation trial (RESCUT). J Am Coll Cardiol 2004; 43:943.
- Silber S, Albertsson P, Avilés FF, et al. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 2005; 26:804.
- Litvack F, Eigler N, Margolis J, et al. Percutaneous excimer laser coronary angioplasty: results in the first consecutive 3,000 patients. The ELCA Investigators. J Am Coll Cardiol 1994; 23:323.
- Köster R, Hamm CW, Seabra-Gomes R, et al. Laser angioplasty of restenosed coronary stents: results of a multicenter surveillance trial. The Laser Angioplasty of Restenosed Stents (LARS) Investigators. J Am Coll Cardiol 1999; 34:25.
- Mehran R, Mintz GS, Satler LF, et al. Treatment of in-stent restenosis with excimer laser coronary angioplasty: mechanisms and results compared with PTCA alone. Circulation 1997; 96:2183.
- Mehran R, Dangas G, Mintz GS, et al. Treatment of in-stent restenosis with excimer laser coronary angioplasty versus rotational atherectomy: comparative mechanisms and results. Circulation 2000; 101:2484.
- Köster R, Kähler J, Terres W, et al. Six-month clinical and angiographic outcome after successful excimer laser angioplasty for in-stent restenosis. J Am Coll Cardiol 2000; 36:69.
- Hamburger JN, Foley DP, de Feyter PJ, et al. Six-month outcome after excimer laser coronary angioplasty for diffuse in-stent restenosis in native coronary arteries. Am J Cardiol 2000; 86:390.
- ROTATIONAL ATHERECTOMY
- Calcified and complex lesions
- Use prior to stenting
- Internal mammary artery graft stenosis
- Saphenous vein graft lesions
- Use in diabetic patients
- In-stent restenosis
- Adjunctive therapy with abciximab
- Rotational atherectomy summary
- ORBITAL ATHERECTOMY
- CUTTING BALLOON ANGIOPLASTY
- EXCIMER LASER ANGIOPLASTY
- Efficacy for in-stent restenosis