Registry Provides Reassurance About Rotational Atherectomy Pre-PCI

Apart from higher mortality at 1 year, the 1% of patients who receive rotational atherectomy before PCI have outcomes similar to patients who undergo PCI alone, reports an Australian registry study published online July 8, 2015, ahead of print in Catheterization and Cardiovascular Interventions. However, the difference in mortality may reflect the higher risk level of those targeted for the adjunctive treatment.

“Given the excellent results seen from this large registry, it may be worth considering more upfront [rotational atherectomy],” write James A. Shaw, PhD, of the Alfred Hospital and Baker IDI Heart and Diabetes Institute (Melbourne, Australia), and colleagues. “This could be considered for heavily calcified lesions where the operator has a strong impression that balloon angioplasty will not allow appropriate preparation to enable safe and effective stent deployment.

‘This has the potential to result in fewer procedures, shortened procedure time, and reduced risks to the patient and may warrant further study,” they conclude.

The researchers examined data from the Melbourne Interventional Group registry on 16,577 consecutive PCIs performed at 9 Australian centers between June 2004 and June 2012. Rotational atherectomy was used at operator discretion for 1.0% of patients (214 lesions).

Indications for atherectomy included calcification, inability to pass a balloon across the lesion, and inadequate expansion of the balloon used to predilate the lesion. Patients who received atherectomy were older (mean age 71.0 vs 64.4 years; P < .001), more likely to have various comorbidities and to present with chronic stable angina, and less likely to present with ACS. They also had higher rates of multivessel disease; complex ACC/AHA type B2 and C lesions; and ostial, left main, and proximal LAD lesions.

Good Results With Atherectomy

Procedural success and complication rates were similar between the patients who did and did not receive rotational atherectomy (table 1).

In-hospital outcomes, including death, MI, MACE, and stroke, also were similar in the 2 groups. Likewise, at 30 days, rates of death, MACE, MI, TLR, and TVR were comparable regardless of the use of rotational atherectomy.

At 1 year, rates of MACE (primary endpoint; death, MI, or TVR), MI, TLR, and TVR did not differ between groups, although patients who underwent rotational atherectomy had an elevated risk of death (table 2).

After propensity-score adjustment, MACE rates were similar between groups in the hospital (OR 1.05; 95% CI 0.99-1.10), at 30 days (OR 1.02; 95% CI 0.99-1.04), and at 1 year (OR 1.00; 95% CI 0.93-1.08).

Rotational Atherectomy Remains Important Option

Addressing the increased risk of 1-year mortality associated with rotational atherectomy, the authors point out that “considering there was no difference in 30-day mortality, this difference may be unrelated to [rotational atherectomy] itself and reflect the older demographic with higher prevalence of comorbidities in the cohort undergoing [the procedure].” They note, too, that there was no difference in the primary endpoint of MACE.

“Overall low rates of angiographic complications [and] 30-day and 12-month MACE are reassuring and show that despite the relatively small numbers and concerns about potential complications from [rotational atherectomy], such as vessel dissection and perforation, this was not the case in the current registry,” Dr. Shaw and colleagues write.  

Importantly, they say, 37.7% of patients who received atherectomy underwent a previous a PCI attempt that failed due to incomplete balloon dilatation of the lesion or the balloon being unable to cross the lesion. Without atherectomy, “these patients would not have been able to be revascularized percutaneously,” the authors write. “Thus, it is crucial that a small number of interventional cardiologists remain proficient in this technology.”

The availability of rotational atherectomy also may become more critical as the prevalence of calcified lesions increases along with the age of the population, they add.

“[Rotational atherectomy] remains an important adjunct for the treatment of calcified lesions and enables stent implantation in lesions that would otherwise not have been amenable to percutaneous intervention,” they conclude.

Source: 
Couper LT, Loane P, Andrianopoulos N, et al. Utility of rotational atherectomy and outcomes over an eight-year period. Catheter Cardiovasc Interv. 2015;Epub ahead of print.

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