Clinical Outcomes of Rotational Atherectomy in Heavily Calcified Lesions: Evidence From the Largest Cardiac Center in Thailand

Abstract

Background: Evidence regarding the clinical outcomes of rotational atherectomy (RA) in middle-income countries is limited. We analyzed the clinical outcomes of patients with heavily calcified coronary lesions who underwent RA-assisted percutaneous coronary intervention (PCI) and explored the risks for developing major adverse cardiovascular and cerebrovascular events (MACCE).

Methods: This is a single-center, retrospective cohort analysis that enrolled consecutive patients who underwent RA-assisted PCI at the largest tertiary hospital in Thailand. The primary endpoint is the incidence of MACCE during the first-year follow-up. MACCE consists of cardiac death, ischemic stroke, definite stent thrombosis, target lesion revascularization, and target vessel revascularization.

Results: From January 2015 to December 2018, 616 patients (663 lesions) were enrolled. The mean age was 72.8 ± 9.7 years, 292 (47.4%) patients were female and 523 (84.9%) completed one-year follow-up. Drug-eluting stents were deployed in 606 (91.4%) lesions. The RA success rate - defined as when the operator successfully passed the burr across the target lesion - was 99.4% and the angiographic success rate was 94.8%. 130 (21.4%) procedures developed periprocedural complications. The cumulative MACCE rate at 30-days was 1.5% and at 1-year was 6.3%. The in-hospital mortality rate was 1.1% and the cardiac death rate was 1.6%. Independent risk factors for developing MACCE included the use of an intra-aortic balloon pump (hazard ratio [HR] 3.96, 95% confidence interval [CI] 1.54-10.21; P = 0.004), a history coronary artery bypass graft (HR 2.30, 95% CI 1.01-5.25; P = 0.048), and increased serum creatinine (HR 1.16, 95% CI 1.04-1.30; P = 0.008).

Conclusions: RA is an effective revascularization technique for heavily calcified lesions. This study demonstrates a high success rate and good short- to intermediate-term results of RA-assisted PCI in middle-income countries which are similar to high-income countries. Nevertheless, the rate of periprocedural complications remains high.

Keywords: Debulking the calcified lesion; major adverse cardiovascular and cerebrovascular events; percutaneous coronary intervention.

Figure 1

Impact of the clinical presentation and the use of intravascular imaging on the occurrence of MACCE. (A) The clinical presentation of the patients. ACS was the combination of non-ST elevation ACS and ST-segment elevation myocardial infarction. (B) Intravascular imaging consisted of intravascular ultrasound or optical coherence tomography. ACS – acute coronary syndrome; CAD – coronary artery disease; MACCE – major adverse cardiovascular and cerebrovascular events.

Figure 2

Intraprocedural and periprocedural complications. (A) intraprocedural complications that occurred during RA. (B) periprocedural complications post-RA. MI – myocardial infarction; RA – rotational atherectomy.

Figure 3

Major adverse cardiovascular and cerebrovascular events (MACCE) during follow-up. (A) MACCE during 30-days follow-up. (B) MACCE during one-year follow-up.

Figure 4

Multivariate analysis adjusted for the independent risk of developing MACCE. CABG – coronary artery bypass graft; 95% CI – 95% confidence interval; HR – hazard ratio. * 14.3% of serum Cr values were imputed.