Contemporary clinical outcomes of patients treated with or without rotational coronary atherectomy — An analysis of the UK central cardiac audit database

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Abstract

Introduction

Rotational atherectomy (RA) is widely used for treating calcified coronary lesions. Clinical data however remain limited.

Methods

We assessed outcome and survival among patients undergoing percutaneous coronary intervention (PCI) with or without RA in the UK between September 2007 and March 2011.

Results

Data from 221,669 percutaneous coronary intervention (PCI) procedures were analysed; 2152 patients (0.97%) underwent RA (RA +); the remainder underwent conventional PCI (RA −). RA + patients were older (71.7 ± 9.6 vs. 64.1 ± 12.8 year; p < 0.001), and had a higher incidence of diabetes (26.4% vs. 18.0%; p < 0.001), hypertension, (61.9% vs. 49.4%; p < 0.001), peripheral vascular disease (9.9% vs. 4.2%, p < 0.001), cerebrovascular disease (5.5% vs. 3.4%, p < 0.001), renal impairment (3.4% vs. 1.5%, p < 0.001) and poor left ventricular function (11.4% vs. 4.3%,p < 0.001). Procedural success was lower among RA + patients (90.3% vs 94.6%; p < 0.001) and procedural complications were more frequent (9.7% vs 5.4%; p < 0.001). After 2.4 ± 1.2 years follow-up, unadjusted Cox proportional hazard modeling demonstrated poorer survival for RA + patients (HR 2.21, 95%CI 1.97–2.49; p < 0.0001). This disadvantage remained after adjustment for adverse variables (HR 1.26, 95%CI 1.11–1.44; p = 0.0004) and following propensity analysis. There was evidence however of improved survival for RA + patients with left main stem disease (HR 0.52, 95%CI 0.35–0.75, p < 0.0001), and peripheral vascular disease (HR 0.65, 95%CI 0.43–0.98, p < 0.0005).

Conclusions

Rotational atherectomy was undertaken in patients with higher pre-procedural risk. Medium term survival was worse among patients undergoing rotational atherectomy, and this survival disadvantage remained after correction for available adverse factors. Rotational atherectomy however remains clinically useful for patients with calcified coronary lesions.

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.

References (33)

  • R. Kawaguchi et al.

    Impact of lesion calcification on clinical and angiographic outcome after sirolimus-eluting stent implantation in real-world patients

    Cardiovasc Revasc Med

    (2008)
  • P. Fitzgerald et al.

    Contribution of localised calcium deposits to dissection after angioplasty. An observation study using intravascular ultrasound

    Circulation

    (1992)
  • P. Fitzgerald et al.

    Lesion composition impacts size and symmetry of stent expansion: initial report from the STRUT registry

    J Am Coll Cardiol

    (1995)
  • R. Mehran et al.

    Angiographic patterns of instent restenosis: classification and implications for long-term outcomes

    Circulation

    (1990)
  • M.P. Schenker et al.

    Inter-relation of coronary calcification, myocardial ischemia, and outcomes in patients with intermediate likelihood of coronary artery disease: a combined positron emission tomography/computed tomography study

    Circulation

    (2008)
  • R. Safian et al.

    Coronary angioplasty and rotoblator atherectomy trial (CARAT): immediate and late results of a prospective multicenter randomized trial

    Catheter Cardiovasc Interv

    (2001)
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