Circulation, Vol 86, 1394-1399, Copyright © 1992 by American Heart Association
RE Kuntz, T Hinohara, RD Safian, MR Selmon, JB Simpson and DS Baim
BACKGROUND. Deep wall excision during directional atherectomy has been
reported in one study to increase the risk of subsequent restenosis. On the
other hand, we have observed that the probability of late (6-month)
restenosis is reduced by maximizing postprocedure luminal diameter.
Although such maximal luminal enlargement by directional atherectomy has
not increased procedural complications in our experience, it might well
increase the incidence of subintimal (deep wall component) recovery. We
performed this study to evaluate the relative influences of luminal
enlargement and deep wall component excision on postatherectomy restenosis.
METHODS AND RESULTS. Atherectomy resulted in a 7 +/- 15% residual stenosis
with < 0.5% incidence of angiographic vessel perforation. The minimal
luminal diameter of each lesion was measured before and after intervention
in 413 lesions, 389 (94%) of which had histological analysis of the excised
specimens. Specimens were categorized by the deepest layer retrieved: type
I (recovery of intima alone, n = 141), type II (recovery of media, n = 79),
and type III (recovery of adventitia, n = 65). Repeat angiographic
measurement of minimal luminal diameter was available for 329 (80%)
segments 6 months after atherectomy. Compared with the 32% restenosis rate
for type I excision, there was no increase in restenosis (stenosis >
50%) for type II, type III, or types II+III (p = 0.86). Stratification by
vessel characteristics also failed to show any association between
restenosis and deep wall component recovery in any subgroup, including
native coronary (p = 0.85), left anterior descending coronary artery (p =
0.70), right coronary artery (p = 0.51), saphenous graft (p = 0.78), or
prior restenosis lesions (p = 0.98). Paradoxically, the recovery of
adventitia (type III excision) was associated with a lower late percent
stenosis (p = 0.03) and a trend toward less restenosis (p = 0.11) compared
with type I excisions. A multiple logistic regression model was constructed
that demonstrated immediate postprocedure luminal diameter (p = 0.02) to be
an independent determinant of restenosis. In this model, the presence of
deep wall components (type II+III) did not adversely affect (p = 0.86)
restenosis, but the recovery of adventitia was associated with an
independent trend toward reduced restenosis (p = 0.06). CONCLUSIONS. The
immediate goal of directional atherectomy should be to safely provide the
largest lumen possible in order to reduce restenosis. The recovery of deep
wall components does not appear to jeopardize the beneficial effect that
obtaining a large immediate postprocedure lumen diameter has on reducing
the incidence of late restenosis.
ARTICLES
Restenosis after directional coronary atherectomy. Effects of luminal diameter and deep wall excision
Charles A. Dana Research Institute, Cardiovascular Division, Beth Israel Hospital, Boston, MA 02215.
This article has been cited by other articles:
 |
|
 |
|
  C. A. Simonton, M. B. Leon, D. S. Baim, T. Hinohara, K. M. Kent, R. M. Bersin, B. H. Wilson, G. S. Mintz, P. J. Fitzgerald, P. G. Yock, et al. `Optimal' Directional Coronary Atherectomy : Final Results of the Optimal Atherectomy Restenosis Study (OARS) Circulation, February 3, 1998; 97(4): 332 - 339. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Rud Andersen, M. Mæng, M. Thorwest, and E. Falk Remodeling Rather Than Neointimal Formation Explains Luminal Narrowing After Deep Vessel Wall Injury : Insights From a Porcine Coronary (Re)stenosis Model Circulation, May 1, 1996; 93(9): 1716 - 1724. [Abstract] [Full Text]
|
|
|
|
|
|
G. Pasterkamp, P. J. W. Wensing, M. J. Post, B. Hillen, W. P. T. M. Mali, and C. Borst Paradoxical Arterial Wall Shrinkage May Contribute to Luminal Narrowing of Human Atherosclerotic Femoral Arteries Circulation, March 1, 1995; 91(5): 1444 - 1449. [Abstract] [Full Text]
|
|
|
|
 |
|
 E. J. Topol, F. Leya, C. A. Pinkerton, P. L. Whitlow, B. Hofling, C. A. Simonton, R. R. Masden, P. W. Serruys, M. B. Leon, D. O. Williams, et al. A Comparison of Directional Atherectomy with Coronary Angioplasty in Patients with Coronary Artery Disease N. Engl. J. Med., July 22, 1993; 329(4): 221 - 227. [Abstract] [Full Text]
|
|
|
|
|
|
A. G. Adelman, E. A. Cohen, B. P. Kimball, R. Bonan, D. R. Ricci, J. G. Webb, L. Laramee, G. Barbeau, M. Traboulsi, B. N. Corbett, et al. A Comparison of Directional Atherectomy with Balloon Angioplasty for Lesions of the Left Anterior Descending Coronary Artery N. Engl. J. Med., July 22, 1993; 329(4): 228 - 233. [Abstract] [Full Text]
|
|