MULTICENTER CLINICAL-EXPERIENCE WITH RESCUE ATHERECTOMY FOR FAILED ANGIOPLASTY

Directional coronary atherectomy (DCA) has been proposed as a ''rescue'' technique for failed or suboptimal percutaneous transluminal coronary angioplasty (PTCA) in an attempt to avoid myocardial infarction or emergency coronary artery bypass grafting. In this report we review the utilization and outcome of rescue atherectomy from the clinical experience of The Cleveland Clinic Foundation and Medical College of Virginia from November 1988 through January 1993, and from the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) database. This analysis includes 100 patients with 103 treated lesions from 44 patients at the Cleveland Clinic, 36 patients from the Medical College of Virginia, and 20 patients from the CAVEAT database. The etiology of failed PTCA was primarily from dissection in 52 lesions (50.5%), ''recoil'' in 43 lesions (41.8%), and recurrent thrombosis in 8 lesions (7.8%). Complete vessel closure was present in 23 lesions (22.3%). The vessels treated included 51.5% left anterior descending, 24.3% right coronary, and 16.5% circumflex coronary arteries. The average reference vessel diameter in the group was 3.10 +/- 0.06 mm (SEM), with an average stenosis of 78.9 +/- 1.2% before PTCA, 55.8 +/- 2.4% after PTCA, and 24.1% +/- 2.2% after rescue DCA. DCA was successful (Thrombosis in Myocardial Infarction [TIMI] grade 3 flow with >20% stenosis reduction without death, Q-wave myocardial infarction, or coronary artery bypass grafting) in 94 of 103 lesions (91.3%). Complications included 1 patient with perforation (1%), 2 deaths within 24 hours (2.0%), and 6 patients requiring coronary artery bypass grafting (6%). In 33 patients with TIMI grade 0-2 flow or acute closure after PTCA, TIMI grade 3 flow was restored in 30 (90.9%). Rescue atherectomy thus may play a beneficial role in the treatment of acute angioplasty complications and/or suboptimal results, although vessel perforation is an uncommon complication.