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David R. Holmes - One of the best experts on this subject based on the ideXlab platform.
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Clinical Angiographic and Histologic Correlates of Ectasia After Directional Coronary Atherectomy
2016Co-Authors: Nicoletta B. De Cesare, David R. Holmes, Christian C. Haudenschild, Jeffrey J Popma, Stephen G. EllisAbstract:Directional coronary Atherectomy can cause ecta-sia (final area stenosis <O%), presumably due to an excision deeper than the angiographically “nor-mal ” arterial lumen. In a multicenter series in which quantitative coronary arteriography was performed after directional Atherectomy in 382 le-sions (372 patients), ectasia after Atherectomy oc-curred in 50 (13%) lesions. By univariate analysis, ectasia was seen more often within the circumflex coronary artery (p = O.OOS), in complex, probably thrombus-containing lesions (p = O.OlS), and with higher device:artery ratios (p <O.OOl). Ectasia occurred less often in lesions within the right coro-nary artery (p = 0.008). Histologic analysis dem-onstrated adventitia or media, or both, in all pa
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guidewire transection during rotational coronary Atherectomy due to guide catheter dislodgement and wire kinking
Catheterization and Cardiovascular Diagnosis, 1995Co-Authors: Karl Fostersmith, Kirk N Garratt, David R. HolmesAbstract:Rotational coronary Atherectomy is an effective treatment for calcified ostial lesions. We report a case of guidewire transection during rotational Atherectomy of a right coronary artery ostial stenosis. Guide catheter dislodgement appeared to have caused prolapse and kinking of the guidewire. Advancement of the burr over the kinked wire resulted in transection. The wire fragment was retrieved successfully using an inflated fixed-wire balloon catheter. This report illustrates the importance of excellent coaxial guide catheter alignment with rotational Atherectomy and suggests that operators be vigilant to possible damage to the radiolucent rotational Atherectomy guidewire. © 1995 Wiley-Liss, Inc.
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a multicenter randomized trial of coronary angioplasty versus directional Atherectomy for patients with saphenous vein bypass graft lesions
Circulation, 1995Co-Authors: David R. Holmes, Robert D. Safian, Eric J. Topol, Fred Leya, Robert M Califf, Lisa G Berdan, Peter B Berger, Patrick L Whitlow, Allan G Adelman, Mirle A KellettAbstract:Background Directional coronary Atherectomy and percutaneous transluminal coronary angioplasty have both been used in symptomatic patients with coronary saphenous vein bypass graft stenoses. The relative merits of plaque excision and removal versus balloon dilatation remain uncertain. We compared outcomes after directional coronary Atherectomy or angioplasty in patients with de novo bypass graft stenoses. Methods and Results Fifty-four North American and European sites randomized 305 patients with de novo vein graft lesions to Atherectomy (n=149) or angioplasty (n=156). Quantitative coronary angiography at a core laboratory assessed initial and 6-month results. Initial angiographic success was greater with Atherectomy (89.2% versus 79.0%), as was initial luminal gain (1.45 versus 1.12 mm, P<.001). Distal embolization was increased with Atherectomy (P=.012), and a trend was shown toward more non–Q-wave myocardial infarction (P=.09). Although the 6-month net minimum luminal diameter gain was 0.68 mm for ath...
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Directional Atherectomy versus balloon angioplasty for coronary ostial and nonostial left anterior descending coronary artery lesions: Results from a randomized multicenter trial
Journal of the American College of Cardiology, 1995Co-Authors: James D. Boehrer, Michael Mooney, David R. Holmes, Stephen G. Ellis, Karen S. Pieper, Gordon P. Keeler, Darrell L. Debowey, Anthony T. Chapekis, Fred Leya, Ronald S. GottliebAbstract:Objectives. We hypothesized that Atherectomy would be superior to balloon angioplasty for ostial and nonostial left anterior descending coronary artery lesions. Background. Balloon angioplasty of ostial coronary artery lesions has been associated with a lower procedural success rate and a higher rate of complications and of restenosis than angioplasty of nonostial stenoses. Directional coronary Atherectomy has been proposed as an alternative therapy for ostial lesions. Methods. In the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-1), 1, 012 patients were randomized to undergo either procedure; 563 patients had proximal left anterior descending coronary artery lesions, of which 74 were ostial. We compared balloon angioplasty with directional Atherectomy for early and 6-month results for ostial as well as nonostial proximal left anterior descending coronary artery lesions. Results. Directional Atherectomy led to an initially higher gain in minimal lumen diameter for ostial lesions (1.13 vs. 0.56 mm, respectively, p Conclusions. For ostial left anterior descending coronary artery stenoses, both procedures yielded similar rates of initial success and restenosis, but Atherectomy was associated with more non-Q wave myocardial infarction. In this trial the predominant angiographic benefit (increased early gain and less angiographic restenosis) of Atherectomy for the left anterior descending coronary artery was in proximal nonostial lesions. However, the tradeoffs for this angiographic advantage were more in-hospital myocardial infarctions and no decrease in clinical restenosis.
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randomized trials of directional coronary Atherectomy implications for clinical practice and future investigation
Journal of the American College of Cardiology, 1994Co-Authors: David R. Holmes, Eric J. Topol, Allan G Adelman, Eric A Cohen, Robert M CaliffAbstract:Abstract Objectives . This study compared and contrasted the randomized trials of directional Atherectomy and coronary angioplasty for de novo native coronary artery lesions. Background . The results of two randomized trials, the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) and the Canadian Coronary Atherectomy Trial (CCAT), comparing initial and intermediate-term outcome of directional coronary Atherectomy and conventional coronary angioplasty in de novo native vessels, have been reported. In CAVEAT any coronary artery segment that could be by either technique was included; in CCAT only nonostial proximal left anterior descending coronary artery stenoses were studied. Methods . The primary end point was 6-month angiographic restenosis. Clinical outcome end points at 6 months included death, myocardial infarction, emergency bypass surgery and abrupt closure. Results . Initial angiographic success rates were significantly improved with directional coronary Atherectomy compared with conventional angioplasty (89% vs. 80% for CAVEAT; 98% vs. 91% for CCAT). Also, the initial improvement in minimal lumen diameter and final immediate postprocedural residual diameter stenosis were better with Atherectomy. In CCAT, there was no difference in initial complications; in CAVEAT, non-Q wave myocardial infarction rates and abrupt closure were increased with Atherectomy. Despite improved success rates and better lumen achieved with Atherectomy, in CCAT there was no difference in angiographic restenosis (46% for directional Atherectomy vs. 43% for angioplasty). In CAVEAT, in a prespecified subset analysis involving the proximal left anterior descending coronary artery, restenosis was both significantly and clinically less for directional Atherectomy (51% vs. 63%). For non-left anterior descending coronary artery segments, there was no difference. Conclusions . These studies document the difference between achievement of an excellent initial angiographic result and the longer term issue of clinical restenosis. Widespread use of directional coronary Atherectomy to treat lesions that would be well treated by angioplasty in an attempt to decrease restenosis rates substantially does not appear indicated by the data. In individual lesions, directional Atherectomy should be selected with the view toward optimizing initial results. Further trials are needed to determine whether more aggressive or better targeted directional coronary Atherectomy may improve not only the initial gain but the long-term outcome as well.
Eric J. Topol - One of the best experts on this subject based on the ideXlab platform.
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a multicenter randomized trial of coronary angioplasty versus directional Atherectomy for patients with saphenous vein bypass graft lesions
Circulation, 1995Co-Authors: David R. Holmes, Robert D. Safian, Eric J. Topol, Fred Leya, Robert M Califf, Lisa G Berdan, Peter B Berger, Patrick L Whitlow, Allan G Adelman, Mirle A KellettAbstract:Background Directional coronary Atherectomy and percutaneous transluminal coronary angioplasty have both been used in symptomatic patients with coronary saphenous vein bypass graft stenoses. The relative merits of plaque excision and removal versus balloon dilatation remain uncertain. We compared outcomes after directional coronary Atherectomy or angioplasty in patients with de novo bypass graft stenoses. Methods and Results Fifty-four North American and European sites randomized 305 patients with de novo vein graft lesions to Atherectomy (n=149) or angioplasty (n=156). Quantitative coronary angiography at a core laboratory assessed initial and 6-month results. Initial angiographic success was greater with Atherectomy (89.2% versus 79.0%), as was initial luminal gain (1.45 versus 1.12 mm, P<.001). Distal embolization was increased with Atherectomy (P=.012), and a trend was shown toward more non–Q-wave myocardial infarction (P=.09). Although the 6-month net minimum luminal diameter gain was 0.68 mm for ath...
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randomized trials of directional coronary Atherectomy implications for clinical practice and future investigation
Journal of the American College of Cardiology, 1994Co-Authors: David R. Holmes, Eric J. Topol, Allan G Adelman, Eric A Cohen, Robert M CaliffAbstract:Abstract Objectives . This study compared and contrasted the randomized trials of directional Atherectomy and coronary angioplasty for de novo native coronary artery lesions. Background . The results of two randomized trials, the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) and the Canadian Coronary Atherectomy Trial (CCAT), comparing initial and intermediate-term outcome of directional coronary Atherectomy and conventional coronary angioplasty in de novo native vessels, have been reported. In CAVEAT any coronary artery segment that could be by either technique was included; in CCAT only nonostial proximal left anterior descending coronary artery stenoses were studied. Methods . The primary end point was 6-month angiographic restenosis. Clinical outcome end points at 6 months included death, myocardial infarction, emergency bypass surgery and abrupt closure. Results . Initial angiographic success rates were significantly improved with directional coronary Atherectomy compared with conventional angioplasty (89% vs. 80% for CAVEAT; 98% vs. 91% for CCAT). Also, the initial improvement in minimal lumen diameter and final immediate postprocedural residual diameter stenosis were better with Atherectomy. In CCAT, there was no difference in initial complications; in CAVEAT, non-Q wave myocardial infarction rates and abrupt closure were increased with Atherectomy. Despite improved success rates and better lumen achieved with Atherectomy, in CCAT there was no difference in angiographic restenosis (46% for directional Atherectomy vs. 43% for angioplasty). In CAVEAT, in a prespecified subset analysis involving the proximal left anterior descending coronary artery, restenosis was both significantly and clinically less for directional Atherectomy (51% vs. 63%). For non-left anterior descending coronary artery segments, there was no difference. Conclusions . These studies document the difference between achievement of an excellent initial angiographic result and the longer term issue of clinical restenosis. Widespread use of directional coronary Atherectomy to treat lesions that would be well treated by angioplasty in an attempt to decrease restenosis rates substantially does not appear indicated by the data. In individual lesions, directional Atherectomy should be selected with the view toward optimizing initial results. Further trials are needed to determine whether more aggressive or better targeted directional coronary Atherectomy may improve not only the initial gain but the long-term outcome as well.
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Comparison of histopathologic coronary lesions obtained from directional Atherectomy in stable angina versus acute coronary syndromes
The American journal of cardiology, 1994Co-Authors: Uri Rosenschein, Stephen G. Ellis, Christian C. Haudenschild, Steven J. Yakubov, David W.m. Muller, Ronald J.l. Dick, Eric J. TopolAbstract:The transition of coronary lesions from the stable to unstable state is the pathophysiologic mechanism underlying myocardial infarction and unstable angina pectoris. Angiographic, angioscopic and postmortem pathologic studies suggest that this transition is mainly due to atherosclerotic plaque fissuring and associated thrombus formation.‘.2 The present study examines the tiistopathologic characteristics of the “culprit lesion” obtained during directional coronary Atherectomy of patients with acute coronary syndromes. Directional Atherectomy provides a unique opportunity for studying the composition of unstable lesions in living symptomatic patients. Case histories of consecutive patients referred to the University of Michigan Medical Center for directional coronary Atherectomy after May I, 1989 were analyzed. All patients selected for inclusion in this study had angina, objective evidence of myocardial ischemia and cineangiograms showing 21 lesion with >50% diameter stenosis of an epicardial coronary artery. The unstable group comprised patients who had experienced ischemic pain at rest accompanied by transient ST-T changes on the electrocardiogram, or acute myocardial infarction during the 2-week period preceding directional Atherectomy. The stable group comprised patients who had not had ischemic pain at rest, progressive angina, recent-onset angina or acute myocardial infarction during the 3-month period preceding directional atherectornv. Directional atherectorny was petformed as described previously.3 The Atherectomy device (Devices
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quantitative analysis of factors influencing late lumen loss and restenosis after directional coronary Atherectomy
American Journal of Cardiology, 1993Co-Authors: Jeffrey J Popma, David R. Holmes, Eric J. Topol, Patrick L Whitlow, Martin B Leon, Nicoletta De Cesare, Cass A Pinkerton, Spencer B King, Dean J Kereiakes, Stephen G. EllisAbstract:Abstract Although encouraging initial results have been demonstrated after directional Atherectomy, the mechanisms and predictors of late lumen loss and restenosis after this procedure have not been evaluated. To examine these issues, clinical and angiographic follow-up were obtained in 262 (96%) and 212 (77%) of 274 patients undergoing successful directional coronary Atherectomy. Symptom recurrence developed in 87 (33%) patients and angiographic restenosis was found in 93 (44%). Restenosis was highest in restenotic lesions in saphenous vein grafts (78% [95% confidence interval (CI): 56 to 100%]) and lowest in new-onset lesions in the left anterior descending (27% [95% CI: 15 to 39%]) and circumflex (14% [95% CI: 0 to 43%]) coronary arteries. Residual lumen diameter immediately after Atherectomy was smaller in re-stenotic lesions (p = 0.002) and in lesions ≥10 mm in length (p = 0.02). Late lumen loss was associated with the minimal lumen diameter immediately after Atherectomy (p
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a comparison of directional Atherectomy with coronary angioplasty in patients with coronary artery disease
The New England Journal of Medicine, 1993Co-Authors: Eric J. Topol, Fred Leya, Patrick L Whitlow, Martin B Leon, Cass A Pinkerton, Patrick W Serruys, B Hofling, Charles A Simonton, Ronald Masden, David O WilliamsAbstract:Background Directional coronary Atherectomy is a new technique of coronary revascularization by which atherosclerotic plaque is excised and retrieved from target lesions. With respect to the rate of restenosis and clinical outcomes, it is not known how this procedure compares with balloon angioplasty, which relies on dilation of the plaque and vessel wall. We compared the rate of restenosis after angioplasty with that after Atherectomy. Methods At 35 sites in the United States and Europe, 1012 patients were randomly assigned to either Atherectomy (512 patients) or angioplasty (500 patients). The patients underwent coronary angiography at base line and again after six months; the paired angiograms were quantitatively assessed at one laboratory by investigators unaware of the treatment assignments. Results Stenosis was reduced to 50 percent or less more often with Atherectomy than with angioplasty (89 percent vs. 80 percent, P<0.001), and there was a greater immediate increase in vessel caliber (1.05 vs. 0....
Jeffrey J Popma - One of the best experts on this subject based on the ideXlab platform.
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Clinical Angiographic and Histologic Correlates of Ectasia After Directional Coronary Atherectomy
2016Co-Authors: Nicoletta B. De Cesare, David R. Holmes, Christian C. Haudenschild, Jeffrey J Popma, Stephen G. EllisAbstract:Directional coronary Atherectomy can cause ecta-sia (final area stenosis <O%), presumably due to an excision deeper than the angiographically “nor-mal ” arterial lumen. In a multicenter series in which quantitative coronary arteriography was performed after directional Atherectomy in 382 le-sions (372 patients), ectasia after Atherectomy oc-curred in 50 (13%) lesions. By univariate analysis, ectasia was seen more often within the circumflex coronary artery (p = O.OOS), in complex, probably thrombus-containing lesions (p = O.OlS), and with higher device:artery ratios (p <O.OOl). Ectasia occurred less often in lesions within the right coro-nary artery (p = 0.008). Histologic analysis dem-onstrated adventitia or media, or both, in all pa
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clinical and angiographic outcome after directional coronary Atherectomy a qualitative and quantitative analysis using coronary arteriography and intravascular ultrasound
American Journal of Cardiology, 1993Co-Authors: Jeffrey J Popma, Gary S. Mintz, Kenneth M. Kent, Lowell F. Satler, Augusto D Pichard, Ya Chien Chuang, Fadi Matar, Theresa A Bucher, Alan J Merritt, Martin B LeonAbstract:To assess clinical and angiographic outcome after directional coronary Atherectomy, the clinical course of 306 patients undergoing this procedure was reviewed. Directional Atherectomy was successful in 290 (94.8%) procedures; complications developed in 8 (2.6%) patients. After Atherectomy, percent diameter stenosis was reduced from 71 ± 14 to 14 ± 14% (p 30%. Intravascular ultrasound was also performed in 57 patients after directional Atherectomy and demonstrated that a significant amount of residual plaque mass remained in lesions with a calcium arc ≥90° (17 ± 5 mm2 vs 12 ± 5 mm2 in lesions without calcium; p = 0.007). During the 11 ± 6 month follow-up period, 69 (28.3%) patients developed recurrent clinical events (death, 5; Q wave myocardial infarction, 8; coronary bypass surgery, 31; coronary angioplasty, 36). Using a proportional hazards model, independent predictors of late clinical events included diabetes mellitus (relative risk [RR] = 1.95; p <0.05), unstable angina (RR = 2.78; p <0.005) and a prior history of restenosis (RR = 2.21; p <0.01). We conclude that directional Atherectomy is associated with high procedural success rates and infrequent complications in selected lesion subsets, although the degree of plaque resection may be limited if extensive calcium is present. Late clinical events develop in some (28%) patients after directional Atherectomy, related to certain preprocedural clinical risk factors.
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Preliminary experience with adjunct directional coronary Atherectomy after high-speed rotational Atherectomy in the treatment of calcific coronary artery disease
The American journal of cardiology, 1993Co-Authors: Gary S. Mintz, Jeffrey J Popma, Augusto D. Richard, Kenneth M. Kent, Lowell F. Satler, Martin B LeonAbstract:A high-speed rotational Atherectomy was performed followed by adjunct directional Atherectomy in 10 patients with symptomatic coronary artery disease and calcified target lesions and the results were evaluated using quantitative coronary arteriography and intravascular ultrasound. Target lesion calcium is common in obstructive coronary artery disease. High-speed rotational coronary Atherectomy preferentially abrades noncompliant atherosclerotic plaque material, especially calcium, but often requires adjunct balloon angioplasty to achieve optimal lumen dimensions. Directional coronary Atherectomy has limited efficacy in heavily calcified plaque; usually, it is a definitive primary procedure in large arteries with noncalcified target lesions. Neither of these devices alone is effective in treating calcified target lesions in large coronary arteries. Before intervention, after rotational and adjunct directional Atherectomy, these measurements were obtained: quantitative coronary arteriographic measurements of minimal lumen diameter and percent diameter stenosis and intravascular ultrasound measurements of external elastic membrane, lumen, and plaque + media crosssectional areas; percent cross-sectional narrowing; minimal lumen diameter; and target-lesion arc of calcium. With use of quantitative coronary arteriography, the preintervention minimal lumen diameter measured 0.7 ± 0.4 mm, increased to 1.5 ± 0.5 mm after rotational Atherectomy (p = 0.0013) and to 2.5 ± 0.3 mm after adjunct directional Atherectomy (p < 0.001). The preintervention percent diameter stenosis measured 78 ± 15%, decreased to 50 ± 17% after rotational Atherectomy (p = 0.0011), and to 17 ± 11% (p < 0.001) after adjunct directional coronary Atherectomy. The 9 patients studied by intravascular ultrasound had arcs of target lesion calcification that measured 271 ± 92 ° before intervention, decreased to 210 ± 120 ° after rotational Atherectomy (p = 0.046) and to 163 ± 122 ° after adjunct directional Atherectomy (p = 0.0015), with distinct directional Atherectomy cuts into calcium. Before intervention, target lesion external elastic membrane area measured 20.4 ± 2.3 mm2, lumen area measured 1.5 ± 0.6 mm2, plaque + media area measured 18.9 ± 2.3 mm2, and percent cross-sectional narrowing measured 93 ± 3. After rotational Atherectomy, target lesion external elastic membrane area measured 21.2 ± 2.3 mm2 (p = NS), lumen area increased to 4.4 ± 1.0 mm2 (p < 0.001), plaque + media area decreased to 16.8 ± 2.8 mm2 (p = 0.072), and percent cross-sectional narrowing decreased to 79 ± 7 (p = 0.0024). After adjunct directional Atherectomy, target lesion external elastic membrane area measured 23.5 ± 2.9 mm2 (p = NS), lumen area increased further to 7.7 ± 1.2 mm2 (p < 0.001), plaque + media area decreased further to 15.8 ± 3.0 mm2 (p = 0.063), and percent cross-sectional narrowing decreased even more, to 67 ± 6 (p < 0.001). Rotational Atherectomy appears to alter the calcified plaque to render it susceptible to the directional Atherectomy device. Thus, there seems to be a synergistic relation between high-speed rotational and adjunct directional Atherectomy in treating calcified coronary artery target lesions.
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quantitative analysis of factors influencing late lumen loss and restenosis after directional coronary Atherectomy
American Journal of Cardiology, 1993Co-Authors: Jeffrey J Popma, David R. Holmes, Eric J. Topol, Patrick L Whitlow, Martin B Leon, Nicoletta De Cesare, Cass A Pinkerton, Spencer B King, Dean J Kereiakes, Stephen G. EllisAbstract:Abstract Although encouraging initial results have been demonstrated after directional Atherectomy, the mechanisms and predictors of late lumen loss and restenosis after this procedure have not been evaluated. To examine these issues, clinical and angiographic follow-up were obtained in 262 (96%) and 212 (77%) of 274 patients undergoing successful directional coronary Atherectomy. Symptom recurrence developed in 87 (33%) patients and angiographic restenosis was found in 93 (44%). Restenosis was highest in restenotic lesions in saphenous vein grafts (78% [95% confidence interval (CI): 56 to 100%]) and lowest in new-onset lesions in the left anterior descending (27% [95% CI: 15 to 39%]) and circumflex (14% [95% CI: 0 to 43%]) coronary arteries. Residual lumen diameter immediately after Atherectomy was smaller in re-stenotic lesions (p = 0.002) and in lesions ≥10 mm in length (p = 0.02). Late lumen loss was associated with the minimal lumen diameter immediately after Atherectomy (p
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Transcatheter device synergy: preliminary experience with adjunct directional coronary Atherectomy following high-speed rotational Atherectomy or excimer laser angioplasty in the treatment of coronary artery disease.
Catheterization and cardiovascular diagnosis, 1993Co-Authors: Gary S. Mintz, Jeffrey J Popma, Kenneth M. Kent, Lowell F. Satler, August D Pichard, Julie A. Kovach, Martin B LeonAbstract:We performed high-speed rotational Atherectomy followed by adjunct directional Atherectomy in 10 patients and excimer laser angioplasty followed by directional Atherectomy in 6 patients and evaluated the results using quantitative coronary arteriography and intravascular ultrasound. Quantitative coronary arteriographic measurements of minimal lumen diameter and % diameter stenosis and intravascular ultrasound measurements of external elastic membrane, lumen, and plaque + media cross-sectional areas; % cross-sectional narrowing; minimal lumen diameter; and target-lesion arc of calcium were made pre-intervention, after rotational Atherectomy or excimer laser angioplasty, and after adjunct directional Atherectomy. Rotational Atherectomy: Using quantitative coronary arteriography, the pre-intervention minimum lumen diameter measured 0.7 +/- 0.4 mm, increased to 1.5 +/- 0.5 mm after rotational Atherectomy, and to 2.5 +/- 0.3 mm after adjunct directional Atherectomy. The pre-intervention % diameter stenosis measured 78 +/- 15%, decreased to 50 +/- 17% after rotational Atherectomy, and to 17 +/- 11% after adjunct directional coronary Atherectomy. Intravascular ultrasound showed arcs of target lesion calcification that measured 271 +/- 92 degrees pre-intervention, decreased to 210 +/- 120 degrees after rotational Atherectomy, and to 163 +/- 122 degrees after adjunct directional Atherectomy, with distinct directional Atherectomy cuts into calcium. Pre-intervention, target lesion external elastic membrane area measured 20.4 +/- 2.3 mm2, lumen area measured 1.5 +/- 0.6 mm2, plaque + media are measured 18.9 +/- 2.3 mm2, and % cross-sectional narrowing measured 93 +/- 3.(ABSTRACT TRUNCATED AT 250 WORDS)
Martin B Leon - One of the best experts on this subject based on the ideXlab platform.
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association between prior cytomegalovirus infection and the risk of restenosis after coronary Atherectomy
The New England Journal of Medicine, 1996Co-Authors: Yi Fu Zhou, Martin B Leon, Myron A Waclawiw, Jeffery J Popma, Toren Finkel, Stephen E EpsteinAbstract:Background Restenosis occurs commonly after coronary angioplasty and Atherectomy, but the causes of restenosis are poorly understood. Recently, it has been found that cytomegalovirus (CMV) DNA is present in restenotic lesions from Atherectomy specimens. This and other evidence suggest that CMV may have a role in the process of restenosis. Methods We prospectively studied 75 consecutive patients undergoing directional coronary Atherectomy for symptomatic coronary artery disease. Before Atherectomy was performed, we measured blood levels of anti-CMV IgG antibodies to determine whether previous exposure to CMV increased the risk of restenosis, as determined by coronary angiography performed six months after Atherectomy. Results After Atherectomy, the mean (±SD) minimal luminal diameter of the target vessel was greater in the 49 patients who were seropositive for CMV than in the 26 patients who were seronegative (3.18±0.51 mm vs. 2.89±0.45 mm, P = 0.01). After six months, however, the seropositive patients ha...
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clinical and angiographic outcome after directional coronary Atherectomy a qualitative and quantitative analysis using coronary arteriography and intravascular ultrasound
American Journal of Cardiology, 1993Co-Authors: Jeffrey J Popma, Gary S. Mintz, Kenneth M. Kent, Lowell F. Satler, Augusto D Pichard, Ya Chien Chuang, Fadi Matar, Theresa A Bucher, Alan J Merritt, Martin B LeonAbstract:To assess clinical and angiographic outcome after directional coronary Atherectomy, the clinical course of 306 patients undergoing this procedure was reviewed. Directional Atherectomy was successful in 290 (94.8%) procedures; complications developed in 8 (2.6%) patients. After Atherectomy, percent diameter stenosis was reduced from 71 ± 14 to 14 ± 14% (p 30%. Intravascular ultrasound was also performed in 57 patients after directional Atherectomy and demonstrated that a significant amount of residual plaque mass remained in lesions with a calcium arc ≥90° (17 ± 5 mm2 vs 12 ± 5 mm2 in lesions without calcium; p = 0.007). During the 11 ± 6 month follow-up period, 69 (28.3%) patients developed recurrent clinical events (death, 5; Q wave myocardial infarction, 8; coronary bypass surgery, 31; coronary angioplasty, 36). Using a proportional hazards model, independent predictors of late clinical events included diabetes mellitus (relative risk [RR] = 1.95; p <0.05), unstable angina (RR = 2.78; p <0.005) and a prior history of restenosis (RR = 2.21; p <0.01). We conclude that directional Atherectomy is associated with high procedural success rates and infrequent complications in selected lesion subsets, although the degree of plaque resection may be limited if extensive calcium is present. Late clinical events develop in some (28%) patients after directional Atherectomy, related to certain preprocedural clinical risk factors.
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Preliminary experience with adjunct directional coronary Atherectomy after high-speed rotational Atherectomy in the treatment of calcific coronary artery disease
The American journal of cardiology, 1993Co-Authors: Gary S. Mintz, Jeffrey J Popma, Augusto D. Richard, Kenneth M. Kent, Lowell F. Satler, Martin B LeonAbstract:A high-speed rotational Atherectomy was performed followed by adjunct directional Atherectomy in 10 patients with symptomatic coronary artery disease and calcified target lesions and the results were evaluated using quantitative coronary arteriography and intravascular ultrasound. Target lesion calcium is common in obstructive coronary artery disease. High-speed rotational coronary Atherectomy preferentially abrades noncompliant atherosclerotic plaque material, especially calcium, but often requires adjunct balloon angioplasty to achieve optimal lumen dimensions. Directional coronary Atherectomy has limited efficacy in heavily calcified plaque; usually, it is a definitive primary procedure in large arteries with noncalcified target lesions. Neither of these devices alone is effective in treating calcified target lesions in large coronary arteries. Before intervention, after rotational and adjunct directional Atherectomy, these measurements were obtained: quantitative coronary arteriographic measurements of minimal lumen diameter and percent diameter stenosis and intravascular ultrasound measurements of external elastic membrane, lumen, and plaque + media crosssectional areas; percent cross-sectional narrowing; minimal lumen diameter; and target-lesion arc of calcium. With use of quantitative coronary arteriography, the preintervention minimal lumen diameter measured 0.7 ± 0.4 mm, increased to 1.5 ± 0.5 mm after rotational Atherectomy (p = 0.0013) and to 2.5 ± 0.3 mm after adjunct directional Atherectomy (p < 0.001). The preintervention percent diameter stenosis measured 78 ± 15%, decreased to 50 ± 17% after rotational Atherectomy (p = 0.0011), and to 17 ± 11% (p < 0.001) after adjunct directional coronary Atherectomy. The 9 patients studied by intravascular ultrasound had arcs of target lesion calcification that measured 271 ± 92 ° before intervention, decreased to 210 ± 120 ° after rotational Atherectomy (p = 0.046) and to 163 ± 122 ° after adjunct directional Atherectomy (p = 0.0015), with distinct directional Atherectomy cuts into calcium. Before intervention, target lesion external elastic membrane area measured 20.4 ± 2.3 mm2, lumen area measured 1.5 ± 0.6 mm2, plaque + media area measured 18.9 ± 2.3 mm2, and percent cross-sectional narrowing measured 93 ± 3. After rotational Atherectomy, target lesion external elastic membrane area measured 21.2 ± 2.3 mm2 (p = NS), lumen area increased to 4.4 ± 1.0 mm2 (p < 0.001), plaque + media area decreased to 16.8 ± 2.8 mm2 (p = 0.072), and percent cross-sectional narrowing decreased to 79 ± 7 (p = 0.0024). After adjunct directional Atherectomy, target lesion external elastic membrane area measured 23.5 ± 2.9 mm2 (p = NS), lumen area increased further to 7.7 ± 1.2 mm2 (p < 0.001), plaque + media area decreased further to 15.8 ± 3.0 mm2 (p = 0.063), and percent cross-sectional narrowing decreased even more, to 67 ± 6 (p < 0.001). Rotational Atherectomy appears to alter the calcified plaque to render it susceptible to the directional Atherectomy device. Thus, there seems to be a synergistic relation between high-speed rotational and adjunct directional Atherectomy in treating calcified coronary artery target lesions.
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quantitative analysis of factors influencing late lumen loss and restenosis after directional coronary Atherectomy
American Journal of Cardiology, 1993Co-Authors: Jeffrey J Popma, David R. Holmes, Eric J. Topol, Patrick L Whitlow, Martin B Leon, Nicoletta De Cesare, Cass A Pinkerton, Spencer B King, Dean J Kereiakes, Stephen G. EllisAbstract:Abstract Although encouraging initial results have been demonstrated after directional Atherectomy, the mechanisms and predictors of late lumen loss and restenosis after this procedure have not been evaluated. To examine these issues, clinical and angiographic follow-up were obtained in 262 (96%) and 212 (77%) of 274 patients undergoing successful directional coronary Atherectomy. Symptom recurrence developed in 87 (33%) patients and angiographic restenosis was found in 93 (44%). Restenosis was highest in restenotic lesions in saphenous vein grafts (78% [95% confidence interval (CI): 56 to 100%]) and lowest in new-onset lesions in the left anterior descending (27% [95% CI: 15 to 39%]) and circumflex (14% [95% CI: 0 to 43%]) coronary arteries. Residual lumen diameter immediately after Atherectomy was smaller in re-stenotic lesions (p = 0.002) and in lesions ≥10 mm in length (p = 0.02). Late lumen loss was associated with the minimal lumen diameter immediately after Atherectomy (p
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Transcatheter device synergy: preliminary experience with adjunct directional coronary Atherectomy following high-speed rotational Atherectomy or excimer laser angioplasty in the treatment of coronary artery disease.
Catheterization and cardiovascular diagnosis, 1993Co-Authors: Gary S. Mintz, Jeffrey J Popma, Kenneth M. Kent, Lowell F. Satler, August D Pichard, Julie A. Kovach, Martin B LeonAbstract:We performed high-speed rotational Atherectomy followed by adjunct directional Atherectomy in 10 patients and excimer laser angioplasty followed by directional Atherectomy in 6 patients and evaluated the results using quantitative coronary arteriography and intravascular ultrasound. Quantitative coronary arteriographic measurements of minimal lumen diameter and % diameter stenosis and intravascular ultrasound measurements of external elastic membrane, lumen, and plaque + media cross-sectional areas; % cross-sectional narrowing; minimal lumen diameter; and target-lesion arc of calcium were made pre-intervention, after rotational Atherectomy or excimer laser angioplasty, and after adjunct directional Atherectomy. Rotational Atherectomy: Using quantitative coronary arteriography, the pre-intervention minimum lumen diameter measured 0.7 +/- 0.4 mm, increased to 1.5 +/- 0.5 mm after rotational Atherectomy, and to 2.5 +/- 0.3 mm after adjunct directional Atherectomy. The pre-intervention % diameter stenosis measured 78 +/- 15%, decreased to 50 +/- 17% after rotational Atherectomy, and to 17 +/- 11% after adjunct directional coronary Atherectomy. Intravascular ultrasound showed arcs of target lesion calcification that measured 271 +/- 92 degrees pre-intervention, decreased to 210 +/- 120 degrees after rotational Atherectomy, and to 163 +/- 122 degrees after adjunct directional Atherectomy, with distinct directional Atherectomy cuts into calcium. Pre-intervention, target lesion external elastic membrane area measured 20.4 +/- 2.3 mm2, lumen area measured 1.5 +/- 0.6 mm2, plaque + media are measured 18.9 +/- 2.3 mm2, and % cross-sectional narrowing measured 93 +/- 3.(ABSTRACT TRUNCATED AT 250 WORDS)
Patrick L Whitlow - One of the best experts on this subject based on the ideXlab platform.
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a multicenter randomized trial of coronary angioplasty versus directional Atherectomy for patients with saphenous vein bypass graft lesions
Circulation, 1995Co-Authors: David R. Holmes, Robert D. Safian, Eric J. Topol, Fred Leya, Robert M Califf, Lisa G Berdan, Peter B Berger, Patrick L Whitlow, Allan G Adelman, Mirle A KellettAbstract:Background Directional coronary Atherectomy and percutaneous transluminal coronary angioplasty have both been used in symptomatic patients with coronary saphenous vein bypass graft stenoses. The relative merits of plaque excision and removal versus balloon dilatation remain uncertain. We compared outcomes after directional coronary Atherectomy or angioplasty in patients with de novo bypass graft stenoses. Methods and Results Fifty-four North American and European sites randomized 305 patients with de novo vein graft lesions to Atherectomy (n=149) or angioplasty (n=156). Quantitative coronary angiography at a core laboratory assessed initial and 6-month results. Initial angiographic success was greater with Atherectomy (89.2% versus 79.0%), as was initial luminal gain (1.45 versus 1.12 mm, P<.001). Distal embolization was increased with Atherectomy (P=.012), and a trend was shown toward more non–Q-wave myocardial infarction (P=.09). Although the 6-month net minimum luminal diameter gain was 0.68 mm for ath...
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quantitative analysis of factors influencing late lumen loss and restenosis after directional coronary Atherectomy
American Journal of Cardiology, 1993Co-Authors: Jeffrey J Popma, David R. Holmes, Eric J. Topol, Patrick L Whitlow, Martin B Leon, Nicoletta De Cesare, Cass A Pinkerton, Spencer B King, Dean J Kereiakes, Stephen G. EllisAbstract:Abstract Although encouraging initial results have been demonstrated after directional Atherectomy, the mechanisms and predictors of late lumen loss and restenosis after this procedure have not been evaluated. To examine these issues, clinical and angiographic follow-up were obtained in 262 (96%) and 212 (77%) of 274 patients undergoing successful directional coronary Atherectomy. Symptom recurrence developed in 87 (33%) patients and angiographic restenosis was found in 93 (44%). Restenosis was highest in restenotic lesions in saphenous vein grafts (78% [95% confidence interval (CI): 56 to 100%]) and lowest in new-onset lesions in the left anterior descending (27% [95% CI: 15 to 39%]) and circumflex (14% [95% CI: 0 to 43%]) coronary arteries. Residual lumen diameter immediately after Atherectomy was smaller in re-stenotic lesions (p = 0.002) and in lesions ≥10 mm in length (p = 0.02). Late lumen loss was associated with the minimal lumen diameter immediately after Atherectomy (p
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a comparison of directional Atherectomy with coronary angioplasty in patients with coronary artery disease
The New England Journal of Medicine, 1993Co-Authors: Eric J. Topol, Fred Leya, Patrick L Whitlow, Martin B Leon, Cass A Pinkerton, Patrick W Serruys, B Hofling, Charles A Simonton, Ronald Masden, David O WilliamsAbstract:Background Directional coronary Atherectomy is a new technique of coronary revascularization by which atherosclerotic plaque is excised and retrieved from target lesions. With respect to the rate of restenosis and clinical outcomes, it is not known how this procedure compares with balloon angioplasty, which relies on dilation of the plaque and vessel wall. We compared the rate of restenosis after angioplasty with that after Atherectomy. Methods At 35 sites in the United States and Europe, 1012 patients were randomly assigned to either Atherectomy (512 patients) or angioplasty (500 patients). The patients underwent coronary angiography at base line and again after six months; the paired angiograms were quantitatively assessed at one laboratory by investigators unaware of the treatment assignments. Results Stenosis was reduced to 50 percent or less more often with Atherectomy than with angioplasty (89 percent vs. 80 percent, P<0.001), and there was a greater immediate increase in vessel caliber (1.05 vs. 0....
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abrupt vessel closure after directional coronary Atherectomy
Journal of the American College of Cardiology, 1992Co-Authors: Jeffrey J Popma, Donald S Baim, David R. Holmes, Eric J. Topol, Tomoaki Hinohara, Patrick L Whitlow, Cass A Pinkerton, Spencer B King, Dean J Kereiakes, Geoffrey O HartzlerAbstract:From October 1, 1986 to December 31, 1989 directional coronary Atherectomy was performed during 1,020 procedures (1,140 lesions) at 14 clinical centers. Abrupt vessel closure, defined as a total coronary occlusion or subtotal occlusion associated with clinical evidence of myocardial ischemia, occurred in 43 procedures (4.2%). It developed in the catheterization laboratory in 34 patients, but was delayed 1 to 96 h after directional Atherectomy in 9 patients. By univariate analysis the incidence of abrupt closure was higher in directional Atherectomy of de novo lesions (p less than 0.001), lesions in the right coronary artery (p = 0.001) and diffuse lesions (p = 0.04). The incidence of abrupt closure tended to be lower in directional Atherectomy of saphenous vein grafts as opposed to native coronary arteries (1.6% vs. 4.4%; p = 0.08). Clinical findings during abrupt closure included severe angina in 26 patients, myocardial infarction in 17 patients, hypotension in 5 patients and death in 2 patients. Balloon angioplasty was attempted in 32 patients after abrupt vessel closure. In 16 patients balloon angioplasty resulted in initial resolution of the closure episode, although 1 patient died 96 h after the procedure. Fifteen of 16 patients without initial improvement after balloon angioplasty underwent coronary bypass operation; 9 additional patients with abrupt closure were referred directly for bypass operation. It is concluded that abrupt vessel closure develops relatively infrequently after directional coronary Atherectomy. In the absence of severe coronary dissection, abrupt closure after directional Atherectomy may be effectively managed with balloon angioplasty in some cases, although coronary bypass operation is often required.
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clinical angiographic and procedural correlates of quantitative coronary dimensions after directional coronary Atherectomy
Journal of the American College of Cardiology, 1991Co-Authors: Jeffrey J Popma, David R. Holmes, Stephen G. Ellis, Eric J. Topol, Patrick L Whitlow, Nicoletta De Cesare, Cass A Pinkerton, Spencer B King, Ziyad M B Ghazzal, Kirk N GarrattAbstract:To define the clinical, angiographic and procedural correlates of quantitative coronary dimensions after directional coronary Atherectomy, 400 lesions in 378 patients were analyzed with use of qualitative morphologic and quantitative angiographic methods. Successful Atherectomy, defined by a <75% residual area stenosis, tissue retrieval and the absence of in-hospital ischemic complications, was performed in 351 lesions (87.7%). After Atherectomy, minimal cross-sectional area increased from 1.2 ± 1.1 to 6.6 ± 4.4 mm2(p < 0.001) and percent area stenosis was reduced from 87 ± 10% to 31 ± 42% (p < 0.001). By univariate analysis, device size (p < 0.001) and left circumflex artery lesion location (p = 0.004) were associated with a larger final minimal cross-sectional area. Conversely, restenotic lesion (p = 0.002), lesion length ≥ 10 mm (p = 0.018) and lesion calcification (p = 0.035) were quantitatively associated with a smaller final minimum cross-sectional area. With use of stepwise multivariate analysis to control for the reference area, Atherectomy device size (p = 0.003) and left circumflex lesion location (p = 0.007) were independently associated with a larger final minimal cross-sectional area, whereas restenotic lesion (p = 0.010), diffuse proximal disease (p = 0.033), lesion length ≥ 10 mm (p = 0.026) and lesion calcification (p = 0.081) were significantly correlated with a smaller final minimal cross-sectional area. The number of specimens excised, the number of Atherectomy passes and Atherectomy balloon inflation pressure did not correlate with the final minimal cross-sectional area. Thus, directional Atherectomy results in marked improvement of coronary lumen dimensions, at least in part correlated with the presence of certain clinical, angiographic and procedural factors at the time of Atherectomy.