Incidence of Bradycardia and Outcomes of Patients Who Underwent Orbital Atherectomy Without a Temporary Pacemaker.
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We analyzed the incidence of bradycardia and the safety of patients with severely calcified coronary lesions who underwent orbital atherectomy without the insertion of a temporary pacemaker.The presence of severely calcified coronary lesions can increase the complexity of percutaneous coronary intervention due to the difficulty in advancing and optimally expanding the stent. High-pressure inflations to predilate calcified lesions may cause angiographic complications like perforation and dissection. Suboptimal stent expansion is associated with stent thrombosis and restenosis. Orbital atherectomy safely and effectively modifies calcified plaque to facilitate optimal stent expansion. The incidence of bradycardia in orbital atherectomy is unknown.Fifty consecutive patients underwent orbital atherectomy from February 2014 to September 2016 at our institution, none of whom underwent insertion of a temporary pacemaker. The final analysis included 47 patients in this retrospective study as 3 patients were excluded because of permanent pacemaker implantation. The primary endpoint was significant bradycardia, defined as bradycardia requiring emergent pacemaker placement or a heart rate <50 bpm at the end of atherectomy.The primary endpoint occurred in 4% of all patients, all driven by patients who experienced a heart rate decreasing to <50 bpm. The major adverse cardiac and cerebral event rate was 6%, driven by death (2%) and myocardial infarction (4%). No patient experienced target-vessel revascularization, stroke, or stent thrombosis. Angiographic complications included perforation in 2%, slow-flow in 4%, and flow-limiting dissection in 0%.Significant bradycardia was uncommon during orbital atherectomy. Performing orbital atherectomy without a temporary pacemaker appears to be safe.Keywords:
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In-stent restenosis remains one of the main drawbacks of stenting the femoropopliteal segment, and leads to stent failure and repeated interventions. A variety of endovascular techniques have been investigated so far to reduce this phenomenon, including plain angioplasty, atherectomy, new stent deployment, cutting balloons and cryoplasty but without satisfactory mid- and long-term results. More recently drug-eluting devices have been applied in femoropopliteal in-stent restenosis with promising results. The aim of this review is to analyse the indication and effectiveness of those endovascular techniques for the treatment of in-stent restenosis.
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Abstract Directional atherectomy represents one potential approach for the treatment of restenosis in stented coronary arteries. In this case report we demonstrate an important pitfall of this angioplasty technique for stent restenosis—inadvertent entanglement of the stent wire in the device. While cutting and removal of part of the wire was achieved in the case presented, this potential adverse event limits the applicability of directional atherectomy for restenosis in coronary stents.
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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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In-stent restenosis remains a clinical therapeutic challenge. Rotational atherectomy (RA) is an attractive treatment option as it may cause less vascular injury than balloon angioplasty (BA) and, therefore, limit further neointimal response. In an animal model of coronary in-stent restenosis, thermal injury and stenting created neointima (old NI). The treatment of in-stent restenosis with either BA (n = 9) or RA (n = 11) also generated neointima (new NI). The average areas (mm2) of old NI in the BA and RA groups were similar (3.77 ± 0.40 vs. 3.67 ± 0.53; P = 0.32). However, new NI formed after treatment of in-stent restenosis was significantly less in the RA as compared to the BA group (0.33 ± 0.12 vs. 0.73 ± 36, P < 0.01). In this porcine coronary artery model of in-stent restenosis, treatment with rotational atherectomy resulted in significantly less recurrent neointimal hyperplasia than balloon angioplasty. This animal study, thus, provides a rationale for the clinical use of rotablation in the treatment of in-stent restenosis. Cathet. Cardiovasc. Diagn. 45:332–336, 1998. © 1998 Wiley-Liss, Inc.
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Nitinol self-expanding stents are increasingly used to treat symptomatic peripheral arterial disease. Despite reduction in procedural complications and rates of stent fracture, femoropopliteal in-stent restenosis (FP-ISR) remains a common and important clinical problem. Due to heterogenous patient and angiographic characteristics, treatment of FP-ISR continues to evolve. Multiple modalities have been evaluated including standard balloon angioplasty, cutting or scoring balloon angioplasty, repeat stenting (nitinol stent vs. stent-graft vs. drug eluting stent), excisional or laser atherectomy, drug coated balloon angioplasty, and atherectomy followed by drug coated balloon angioplasty. This review highlights the clinical evidence for the currently available modalities in the treatment of FP-ISR. Future studies should utilize uniform classification schemes and assess similar outcomes to help determine the optimal approach for endovascular treatment of FP-ISR.
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Abstract Despite the increasing use of percutaneous transluminal coronary angioplasty and intracoronary stent placement for the treatment of obstructive coronary artery disease, a large subset of coronary lesions cannot be adequately treated with balloon angioplasty and/or intracoronary stenting alone. Such lesions are often heavily calcified or fibrotic and undilatable with the present balloon technology and attempts to treat them with balloon angioplasty or intracoronary stent placement often lead to vessel dissection or incomplete stent deployment with resultant adverse outcomes. Rotational atherectomy remains a useful niche device for the percutaneous treatment of such complex lesions, usually as an adjunct to subsequent balloon angioplasty and/or intracoronary stent placement. In contrast to balloon angioplasty or stent placement that widen the coronary lumen by displacing atherosclerotic plaque, rotational atherectomy removes plaque by ablating the atherosclerotic material, which is dispersed into the distal coronary circulation. Other lesion subtypes amenable to treatment with this modality include ostial and branch‐ostial lesions, chronic total occlusions, and in‐stent restenosis. This review discusses the technique and principles of rotational atherectomy, the various treatment strategies for its use (including adjunctive pharmacotherapy), the lesion‐specific applications for this device, and the complications unique to this modality. Recommendations are also made for its use in the current interventional era. Catheter Cardiovasc Interv 2004;62:485–498. © 2004 Wiley‐Liss, Inc.
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The current routine use of intracoronary stents in percutaneous coronary intervention (PCI) has significantly reduced rates of restenosis, compared with balloon angioplasty alone. On the contrary, small post-stenting luminal dimensions due to undilatable, heavily calcified plaques have repeatedly been shown to significantly increase the rates of in-stent restenosis. Rotational atherectomy of lesions is an alternative method to facilitate PCI and prevent underexpansion of stents, when balloon angioplasty fails to successfully dilate a lesion. Stentablation, using rotational atherectomy to expand underexpanded stents deployed in heavily calcified plaques, has also been reported. We report a case via the transradial approach of rotational-atherectomy–facilitated PCI of in-stent restenosis of a severely underexpanded stent due to a heavily calcified plaque. We review the literature and suggest rotational atherectomy may have a role in treating a refractory, severely underexpanded stent caused by a heavily calcified plaque through various proposed mechanisms.
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The management of in-stent restenosis remains a subject for debate because no one revascularization option is considered the most appropriate. Since a high restenosis rate still occurs after repeat balloon angioplasty, new techniques are attempted in order to reduce this rate. A combination of high speed rotational atherectomy (HSRA) and adjunctive balloon angioplasty is likely to achieve good results. In small (<3.0 mm diameter) vessels, the risk of interaction between the burr and the stent increases. We thus used intravascular ultrasound (IVUS) guidance in the treatment of in-stent restenosis with HSRA in small <3.0 mm small diameter vessels. Nine patients with in-stent restenosis in small vessels were referred for repeat angioplasty. Initial IVUS examination was used to assess the minimal stent struts diameter and to guide the burr size selection. A combination of HSRA and additional balloon angioplasty was performed under IVUS and angiographic guidance. Mean angiographic reference diameter was 2.25 +/- 0.35 mm and mean stent struts diameter was 2.38 +/- 0.20 mm. Burr size was selected approximately 0.5 mm smaller than stent struts diameter and ranged from 1.75 to 2.5 mm, with a 0.88 +/- 0.12 mean burr/artery ratio (range 0.71, 1.08). In two patients, a second larger burr was used. In 4/9 patients, the burr size chosen under IVUS guidance was close to angiographic MLD at stent implantation and thus larger than what would be used without IVUS guidance. Additional balloon angioplasty was decided in all cases, using a 1.1 +/- 0.15 balloon/artery ratio. No complication occurred. Mean relative gain in minimal lumen diameter (MLD) was 94 +/- 90% after HSRA and 54 +/- 34% after balloon angioplasty (total relative gain 180 +/- 100%). IVUS guidance allowed safe management of in-stent restenosis in small vessels using combination of HSRA and balloon angioplasty. Long-term follow-up and comparison with other techniques are necessary to assess whether this technique should be used routinely.
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