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The presence of angiographically detected calcium in the atherosclerotic lesions that cause significant coronary stenosis has been assumed as a limit to the use of directional coronary atherectomy (DCA) because of the inability of the device to cut and remove the calcified plaque. The new Flexicut DCA device is smaller and more flexible, and the titanium cutter allows more extensive and effective ablation of tissue. Such technical improvements offer potential advantages that can make DCA also feasible in calcified lesions. As to its effectiveness for the treatment of in-stent restenotic lesions, experience is limited to small series performed with the former DCA device.
We present the histologic findings of a de-novo, calcified plaque (below, first left) and the macro- and microscopic aspects of in-stent restenotic material successfully retrieved with DCA (below, centre and right).
The images demonstrate that the new DCA Flexicut device has the potential for effective ablation of solid components of the coronary artery. On the one hand such capability could enlarge the applications of DCA in more complex lesions; on the other hand, the aggressive profile of the new cutter should be kept in mind when performing debulking of the soft tissue located within restenotic stents to avoid procedural complications. The ultrasound vascular assessment of the actual stent expansion may be useful to detect underexpanded stents and select the diameter of the DCA device, or to decide for a repeated balloon dilatation.
Haematoxylin and eosin microscopy of a “de-novo” plaque with calcifications. The thin arrow indicates fine, superficial “sand-like” calcium. The thick arrow indicates a large calcified core deep in a fibrotic cellular plaque that caused unstable angina. The two aspects may represent different stages of the process of coronary calcification. Red blood cells identify the luminal side of the plaque (arrowheads).
Radiographic image of the same stent struts embedded in the paraffin.
Haematoxylin and eosin microscopy of the in-stent restenotic plaque. The arrow shows a small metallic fragment retrieved with the DCA cutter. Close to the metal there is an inflammatory infiltrate. Deep in the plaque the neointima is composed mainly of smooth muscle cells and fibrosis.
Macroscopic view of in-stent restenotic material embedded in paraffin. The arrows indicate the presence of metallic fragments of the stent struts retrieved with DCA.