Rotational atherectomy for treatment of in-stent restenosis: role of intracoronary ultrasound guidance.
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In-stent restenosis is becoming increasingly frequent as greater numbers of intracoronary stents are implanted, and may pose a particularly challenging management problem. Recurrent restenosis following balloon angioplasty for in-stent restenosis is common, and thus the possible role of debulking has been considered. This report describes the successful treatment of severe restenosis within a Palmaz-Schatz stent with high-speed rotational atherectomy, using intracoronary ultrasound guidance.Keywords:
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Stenting is a safe and efficient method for treatment of ischaemic heart disease. Nevertheless, it gives rise to some additional problems, especially in-stent restenosis. Several techniques including balloon angioplasty, restenting, rotaablation, excimer laser angioplasty, directional coronary atherectomy, cutting balloon angioplasty, brachitherapy and radioactive stents have been performed to treat in-stent restenosis. Balloon angioplasty is preferred in focal lesions (<10 mm). Restenting can be used only in selective cases. The clinical results of debulking techniques associated with balloon angioplasty in patients with long lesions are better especially in diabetic patients. In addition to these procedures, coronary bypass surgery in patients in-stent restenosis with multivessel disease seems to yield to best outcomes. On the other hand, current smoking, diabetes mellitus, unstable angina pectoris, and time to reintervention and in-stent restenosis in saphenous vein lesions are important negative predictors for re-restenosis. The main goal of the treatment of in-stent restenosis is the prevention of the restenosis. Unless this problem is solved the newer techniques will develop, and they will also carry on the newer problems.
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In-stent restenosis is becoming increasingly frequent as greater numbers of intracoronary stents are implanted, and may pose a particularly challenging management problem. Recurrent restenosis following balloon angioplasty for in-stent restenosis is common, and thus the possible role of debulking has been considered. This report describes the successful treatment of severe restenosis within a Palmaz-Schatz stent with high-speed rotational atherectomy, using intracoronary ultrasound guidance.
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The original aim of atherectomy was to reduce restenosis by means of aggressive plaque debulking, and the failure of large randomized trials to show any advantage of atherectomy over balloon angioplasty restricted its wider application. However, single-center registries in which aggressive debulking was performed by experienced operators have reported favorable results in terms of reduced restenosis and improved clinical outcomes when atherectomy was performed before stenting. Plaque debulking reduces the potential for plaque shift and facilitates subsequent high-pressure stent expansion, smoothes the internal vessel surface, scaffolds intimal flaps, and prevents elastic recoil. It has also been demonstrated that atherectomy can play a role in the treatment of complex lesions (ostial left anterior descending coronary artery lesions, left main lesions, and bifurcations), in which plaque shift may compromise the result of the procedure. New-generation devices have shown that atherectomy can be safely and effectively used to treat even relatively small vessels. In the current era of drug-eluting stents characterized by a considerable reduction in restenosis rates, optimal stent geometry and final luminal diameter are still important predictors of restenosis. Given the possible role of plaque shifting at the edges of a stent in causing restenosis, debulking could be added to the local drug effect in complex lesions.
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Despite the advent of intracoronary brachytherapy, treatment of in-stent restenosis, particularly diffuse in-stent restenosis, remains problematic. Adjunctive debulking prior to brachytherapy may improve long-term outcomes. We review the literature and report our results of a series of patients treated with excimer laser coronary atherectomy along with balloon angioplasty and brachytherapy for in-stent restenosis. We conclude that adjunctive debulking may improve the long-term clinical outcomes of patients with diffuse in-stent restenosis treated with angioplasty and intracoronary radiation. A randomized controlled trial is warranted.
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The BARASTER registry was formed to evaluate the initial success and long-term results of rotational atherectomy in the management of in-stent restenosis. Rotational atherectomy was used in 197 cases of in-stent restenosis: 46 with stand-alone rotational atherectomy or at most 1 atmosphere of balloon inflation (Rota strategy), and 151 with rotational atherectomy and adjunctive balloon angioplasty <1 atmosphere (Combination strategy). These were compared with 107 episodes of in-stent restenosis treated with balloon angioplasty alone. In this observational study, the use of Combination therapy was associated with a slightly higher initial success rate (95% vs. 87% with the Rota strategy and 89% with Balloons, P = 0.08). There was a reduction in one year clinical outcomes (death, myocardial infarction or target lesion revascularization) in the combination group (38% vs. 60% with Rota and 52% with balloons, P = 0.02). These data support a benefit of the strategy of debulking with rotational atherectomy followed by adjunctive balloon angioplasty, in the management of in-stent restenosis. Cathet. Cardiovasc. Intervent. 51:407–413, 2000. © 2000 Wiley-Liss, Inc.
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