Coronary atherectomy is effective in treating severe coronary lesions—but it’s hardly used

A review published in Circulation: Cardiovascular Interventions Jan. 24 suggests adjunctive coronary atherectomy (CA) is a clinically useful and effective tool for treating severely calcified coronary lesions (SCCL)—but, in reality, it’s rarely used.

The paper, penned by Nirat Beohar, MD, of Columbia University Medical Center, and colleagues, explored the idea of CA in patients with SCCL, who face worse outcomes and mortality odds than their peers without coronary calcification. The global incidence of SCCL is on the up and up, too, increasing in conjunction with a rising prevalence of risk factors like diabetes and chronic renal insufficiency.

Coronary atherectomy is one option for treating SCCL, and it can count better lesion preparation and improved stent delivery, expansion and acquisition among its advantages. But CA is also longer and more expensive than some of its counterparts.

“There are no studies evaluating the temporal trends and variability in CA and the associated clinical outcomes or those that define what the optimal rate of CA should be,” Beohar et al. wrote in Circulation. “Therefore, the present study aims to assess the trends in the frequency of overall usage, interhospital variability and outcomes with CA among a large cohort of patients undergoing PCI.”

That cohort included 3,864,377 patients from the National Cardiovascular Data Registry CathPCI Registry, all of whom underwent percutaneous coronary intervention (PCI) between July of 2009 and December of 2016. The authors analyzed patients based on their experiences with either rotational or orbital CA, considering a primary outcome of in-hospital major adverse cardiac events (MACE) including stroke, periprocedural MI and all-cause death.

Just 1.7% of PCI patients were treated using CA—65,033 cases in total—and those treated with CA were more often older, male and had a history of MI, diabetes, PCI or coronary artery bypass grafting (CABG). Nearly 35% of the hospitals that offered PCI didn’t perform any CA.

Use of CA did increase over time, though, from 1.1% of cases in the third quarter of 2009 to 3% of cases in the fourth quarter of 2016. That’s a 5% quarterly increase in the odds of CA, and people treated with the method saw a temporal decline in MACE and MI. In Beohar et al.’s adjusted analyses, increasing hospital CA volume was linked to a 15% lower risk of mortality and 33% lower risk of PCI failure or complications requiring CABG.

The authors did report those positives were offset by a small 18% increase in patients’ likelihood of experiencing coronary perforation.

In a related editorial, S. Chiu Wong, of Weill Cornell Medicine in New York, said the demand for percutaneous treatment of SCCL is “only likely to rise” in the coming years as global demographics shift.

“The lesion modification rendered by CA certainly eases equipment delivery and optimizes stent expansion,” Wong wrote. “This study emphasizes the importance of familiarity with all devices, old and new, in the catheterization laboratory. This is a responsibility not only of the operators but also the institution support team. Like any craft or technique, practice makes perfect.”

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