Clinical Study On Planned Rotational Atherectomy Guided By Intravascular Ultrasound For Highly Calcified Coronary Lesions

Objective:1. To study the safety andefficacy of RotationalAtherectomy (RA) combined with drug-eluting stent (DES)in patients with highly calcified coronary lesions and the major influencing factors of major adverse cardiaccerebrovascular events (MACCE) in 1-year follow-up.2. To evaluate the efficacy of Planned RA and RA guided by intravascular ultrasound (IVUS) on highlycalcified coronary lesions.Methods:1. One hundred and forty-three patients with highlycalcified coronary lesions who underwent RA combined with DES in our hospital were enrolled in this study. The clinical data, procedural characters, angiographic and ultrasonic data before and after intervention, perioperative complications, MACCE and the influencing factors were analyzedretrospectively.2.A total of one hundred and thirty-seven coronary artery disease (CAD) patients treated by RA in our hospital from 2010-04to2014-09 were retrospectively studied. The ischemic related lesions were alldefined as highly calcified coronary lesions. The patientswere divided into 2 groups:Planned RA group (the initial use of RA without previous device failure), n=81 and Provisional RA group, (RA use following any device failure such as incomplete expansion of balloon or the inability to cross a lesion with any device), n=56. The procedural features, complications, in-hospital and 1 year occurrencerates of majoradverse cardiaccerebral vascularevents (MACCE)were compared between 2 groups.3.One hundred and fifty-sixpatients with highlycalcified coronary lesions underwent RA in our hospital were retrospectively analyzed from June 2004 to June 2014 There were 63 patients in RA with IVUS guided group and 93 in RA without IVUS guided group. Procedural characters, operation related complications, and MACCE rate in 1 year were analysed.Results:1.Thesuccess rate of RA combined with DES was 97.2% in patients with calcified coronary lesions. The incidence of MACCE in 1-year follow-up was 13.3%. Leftmain stenosis, provisional RA, LVEF>40%, postdilatation, and minimum stent lumen area were the major influencing factors of MACCE (HR:7.249,95% CI:1.501?35.459,P=0.014; HR:9.466,95% CI:2.219?40.375,P=0.002; HR:0.064,95% CI:0.011?0.385,P=0.003; HR:0.232,95% CI.0.069?0.785,P=0.019; HR:0.538,95% CI:0.374-0.774,P=0.001). The minimumdiameterstenosis was significantly larger while the minimum diameter stenosis rate was significantly lower after DES than before DES.2. Compared with Provisional RA group, Planned RA group had the less predilatation balloonapplication,(P< 0.001) and the higher maximum post-dilatationpressure (P=0.004); lower rate of perioperation complication (14.8%vs 32.1%), P=0.016;higher rate of acute lumen gain (128.52±75.77)% vs (77.12± 27.01)%, P=0.004; lower MACCEoccurrencerate(7.3%vs23.6%) at 1 year follow-up period,P=0.006.Cox regression analysis presented that the following indexes wererelated to MACCEoccurrence within 1 year of RA treatment:balloon dilatation before RA(HR:8.166,95% CII.872-35.614,P=0.005),leftmain disease (HR:13.649,95% CI:2.983?62.440, P=0.001),minimum post-operative lumen area (HR:0.583,95%CI:0.378?0.879,P=0.010), post-dilatation (HR:0.066,95% CI:0.013?0.332, P=0.001) and EF>40% (HR:0.019,95% C:I0.002?0.158, P=0.000).3. There were no significantly differences in base clinical characters, such as calcified degree, lesion type, between IVUS guided and non-IVUS groups. But compared with non-IVUS guided group, LM lesion was more in IVUS guided group (44.4% vs.21.5%,P=0.020).Compared with non-IVUS guided group, there were lower but more effective predilatation (9.5% vs.61.3%,P=0.000), stronger post dilatation(18.7±3.7 vs.16.4±2.8,P=0.000), decreased complication rate (15.9% vs. 31.2%,P=0.030), and larger acute lumen gain in IVUS guided group. The independent predictors for 1 year MACCE were non-IVUS guided(HR:4.667,95%CI:1.022?21.310,P=0.047),unprotected leftmainstenosislesion(HR:6.019,95% CI: 1.541?23.513,P=0.010), chronic total occlusion lesion(HR):3.317,95% CI: 1.126?9.774,P=0.030),predilatation before RA (HR:3.746,95% CI: 1.078?13.011,P=0.038), and minimum lumen area(HR:0.626, 95%CI:0.460?0.850,P=0.003).Conclusion:1.The success rate of RA combined with DES is high in patients with highlycalcified coronary lesions and their long-term clinical follow-up outcomes are perfect.2. Planned RA had the lower MACCEoccurrence rate at 1 year follow-up period, this might be related to less operationcomplication and the more optimal lumen debulking result before stenting.3. RA guided by IVUS is associated with lower 1 year MACCE rate, since by IVUS guiding there are more effective pre-dilatation and post-dilatation, more less operation complication, and more optimal acute lumen gain.