Contemporary clinical outcomes of patients treated with or without rotational coronary atherectomy — An analysis of the UK central cardiac audit database
Introduction
Life expectancy is increasing, and more patients are presenting with anginal syndromes at a later age [1]. A consequence of this is the increased likelihood of coronary vascular calcification, which in turn presents a challenge to successful percutaneous revascularization. Prevalence estimates for coronary calcification in patients undergoing percutaneous coronary intervention (PCI) range from 17 to 35% [2], [3]. Coronary calcification reduces wall compliance, prevents adequate lumen expansion, predisposes to coronary dissection and incomplete stent apposition [4], [5], [6], and is associated with instent re-stenosis (ISR), an increased need for target lesion revascularization (TLR), and stent thrombosis (ST) [7], [8]. Moreover, it has been shown to be an independent predictor of mortality [9].
Rotational atherectomy (RA) (Boston Scientific, Natwick, MA, USA) is a useful adjunct for treating coronary stenoses associated with significant coronary calcification, allowing plaque modification by debulking to facilitate balloon and stent delivery [10], and has been investigated in a number of different clinical settings (Table 1) [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26].
Initial studies investigated RA alone relative to “plain old balloon angioplasty” (POBA), but despite good procedural success, results were associated with high procedural complication rates and restenosis rates ≥ 50% [16], [17]. With the advent of bare metal stents (BMS), procedural complications reduced and restenosis rates fell to between 10–20% [18], [19], [20]. More recently RA has made a resurgence based on the use of drug eluting stent (DES) technology, which has reduced restenosis and TLR rates further to about 11% [21], [22], [23]. Furthermore, contemporary RA technique involves lower burr:artery ratios and lower burr speeds than were previously recommended [14], [15], [16], [17], [18], [19].
To date many of the studies looking at clinical and procedural outcomes relating to RA have been single centre series, with small sample sizes, performed prior to the advent of second and third generation DES platforms, and with limited follow-up [14], [15], [16], [17], [18], [19]. We therefore analysed the incidence and outcomes of RA in contemporary coronary angioplasty practice in the UK between September 2007 and March 2011.
Section snippets
Methods
Since 1991, the British Cardiovascular Intervention Society (BCIS) CCAD database has captured details on all PCI procedures performed in the UK, using a bespoke compulsory dataset [27], managed by the National Institute for Cardiovascular Outcomes Research (NICOR) [28].
Results
During the 3.5-year period under consideration, 221,669 patients underwent PCI in England, Wales and Northern Ireland. 2152 (0.97%) of these patients underwent PCI with adjunctive RA.
Discussion
Our analyses provide significant insights into the contemporary role of RA in modern PCI treatment, and provide a timely update with regard to RA procedural outcomes and complication rates. RA remains the main interventional tool for dealing with obstructive coronary calcification, the presence of which has shown to be an independent predictor of mortality [9]. The technique however has been widely critiqued for its association with high complication rates [14], [15], [16], [17], [18], [19],
Conclusions
Rotational atherectomy is usually undertaken in patients with high pre-procedural risk. In this context, procedural success and complication rates seem acceptable in this large, contemporary series of patients. Rotational atherectomy remains a technique of significant value for patients with heavily calcified plaque burden, though mortality in this group during medium term follow-up remains significant, a proportion of which appears to be linked to the premorbid risk of the patient population
Conflict of Interest
AdB and SD receive honoraria for running the UK National Rotational Atherectomy course, sponsored by Boston Scientific.
Acknowledgements
The statistical methods used in this study have been independently reviewed by Steve Coad, Reader in Statistics, School of Mathematical Sciences, University of London, and Stephanie Goubet, Medical Statistician, Clinical Information and Research Unit, Eastern Road, Brighton.
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