Coronary Directional Atherectomy: Rescue for Failed Balloon Angioplasty and Treatment of Complicated Lesions

Balloon angioplasty of the coronaries is still limited by the problems of acute complication and restenosis. Percutaneous directional atherectomy was conceived as a method to remove obstructive material from within the vessel. After encouraging results were obtained in peripheral vessels, coronary atherectomy has been selectively performed in 25 patients with lesions either not well suited for PTCA [n = 11], or as a bail-out after resistant [n = 2] or failed PTCA [n = 12]. Twenty-one LAD lesions [4 ostial, 13 proximal, 2 mid, and 2 bifurcation] and four right coronary artery [RCA] lesions with a mean length of 9 +/- 6 mm (19 eccentric, and 6 concentric) could be effectively reduced from 90% +/- 12% to 18% +/- 22%. Seventy-five percent of rescue cases could be spared emergency bypass operation. At 6 months, angiographic restenosis has been documented in 3 out of 11 patients studied to date (27%). Histologically, rescue procedures resulted in the removal of obstructing plaque material and only minimal thrombus. The occurrence of two perforations during rescue procedures, although clinically insignificant, emphasizes the need for judicious excision. In summary, directional atherectomy appears to be useful to treat lesions not well suited for PTCA, and important as a bail-out method after failed PTCA.