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Treatment of Severely Calcified Left Main Disease With Atherectomy

Issue: March/April 2016

ByMichael S. Lee, MD, FACC, FSCAI

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Severe coronary artery calcification poses unique challenges to successful PCI. Severe coronary artery calcification is associated with lower procedural success rates, as it may impede stent delivery. The inability to fully dilate a resistant lesion can lead to suboptimal stent expansion, thereby increasing the rates of in-stent restenosis and stent thrombosis.

Although the gold standard for the treatment of severe left main disease is CABG, PCI can be used in selected patients, including those who are at high risk for complications with surgical revascularization. Severe calcification of the left main artery represents a complex lesion subset because routine balloon predilation may not fully prepare the lesion for optimal stent expansion. Repeated and prolonged high-pressure balloon inflation of the non-dilatable lesion may cause ischemia, leading to hemodynamic and electrical instability, given the large distribution of myocardium that the left main artery subtends. Furthermore, in-stent restenosis or stent thrombosis that may result from suboptimal stent expansion in the left main artery can lead to catastrophic consequences, including large MI and death.

Rotational Atherectomy of the Left Main Artery

Coronary atherectomy is a valuable tool for plaque modification of severe coronary artery calcification, thereby facilitating stent delivery and optimal stent expansion. Rotational atherectomy (Rotablator Rotational Atherectomy System, Boston Scientific) has been used for more than 20 years to treat calcified lesions. The mechanism of action is differential cutting, in which the crown ablates calcified tissue but not healthy elastic tissue.

In a study of 50 consecutive patients with high surgical risk who underwent rotational atherectomy for complex calcified left main disease, the angiographic success rate was 96% and the in-hospital MACE rate was 10%, according to data by Sulimov and colleagues published in Cardiovascular Revascularization Medicine. Drug-eluting stents were implanted in 86% of cases. Twelve-month survival rates from cardiac death and target lesion revascularization in this study were 87.6% and 13.3%, respectively. Cardiac death-free survival at 12 months was higher in patients with stable angina compared with patients with ACS (94% vs. 72.7%; P = .01), according to the findings.

Orbital Atherectomy of the Left Main Artery

Figure A. Heavily calcified ostial left main coronary artery stenosis in an 89-year-old female.

Figure B. Final angiographic image after atherectomy and implantation of a 5 mm x 18 mm bare-metal stent.

Images provided by Michael S. Lee, MD, FACC, FSCAI; printed with permission.

Orbital atherectomy (Diamondback 360 Peripheral Orbital Atherectomy System, Cardiovascular Systems Inc.) is a novel atherectomy device. The mechanism of action is differential sanding, whereby the eccentrically mounted, 30-µm diamond-coated crown rotates over the ViperWire (Cardiovascular Systems Inc.) and laterally expands due to centrifugal force. The crown rotates at 80,000 rpm at low speed and 120,000 rpm at high speed.

Data on orbital atherectomy of the left main artery are limited. In a subanalysis study of 443 patients, 10 patients underwent orbital atherectomy for protected left main CAD, according to data from my colleagues and I in press in the Journal of Invasive Cardiology. At 2 years, there was no significant difference in MACE in the left-main and non-left-main groups (30% vs. 19.1%; P = .36). Cardiac death was low in both groups (0% vs. 4.4%; P = .99). MI occurred within 30 days in both groups (10% vs. 9.7%; P = .99). Severe dissection, perforation, persistent slow-flow and persistent no-reflow did not occur in the left-main group. Abrupt closure occurred in one patient in the left-main group. In a retrospective study of 14 patients who underwent orbital atherectomy for unprotected left-main CAD, no patient experienced cardiac death, MI, stroke or TLR at 30-day follow-up, according to data from my colleagues and I in press in the Journal of Invasive Cardiology.

Conclusion

Severely calcified left main CAD represents one of the most challenging lesion subsets. Plaque modification with coronary atherectomy is safe and effective and can help facilitate stent delivery and optimal stent expansion. Randomized trials are needed to determine the ideal revascularization strategy for severely calcified left main disease.

• References:
• Lee MS, et al. Catheter Cardiovasc Interv. 2016;doi:10.1002/ccd.26395.
• Lee MS, et al. J Invasive Cardiol. 2016 (in press).
• Lee MS, et al. J Invasive Cardiol. 2016 (in press).
• Sulimov DS, et al. Cardiovasc Revasc Med. 2015;doi:10.1016/j.carrev.2015.05.002.

• For more information:
• Michael S. Lee, MD, FACC, FSCAI, is an interventional cardiologist and associate professor of medicine at UCLA Medical Center. He can be reached at 100 Medical Plaza, Suite 630, Los Angeles, CA 90095; email: mslee@mednet.ucla.edu.

Disclosure: Lee reports receiving speaker honoraria/consultant fees from Cardiovascular Systems Inc.