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CLINICAL STUDY: INTERVENTIONAL CARDIOLOGY

A synergistic approach to optimal stenting

Directional coronary atherectomy prior to coronary artery stent implantation—the AtheroLink registry

Hans-Wilhelm Höpp, MD^*, Frank Michael Baer, MD^*, Cem Özbek, MD, Karl Heinz Kuck, MD, Bruno Scheller, MD for the AtheroLink Study Group

^* Klinik III für Innere Medizin der Universität zu Köln, Cologne, Germany
Universitätskliniken des Saarlandes, Homburg/Saar, Homburg, Germany
Allgemeines Krankenhaus St. Georg, Hamburg, Germany

Manuscript received January 12, 1999; revised manuscript received May 16, 2000, accepted July 12, 2000.

Reprint requests and correspondence: Dr. Hans-Wilhelm Höpp, Klinik III für Innere Medizin, Universität zu Köln, Joseph-Stelzmann-Str. 9, D-50924 Köln, Germany
hans.hoepp{at}medizin.uni-koeln.de

OBJECTIVES

The AtheroLink registry sought to observe the effect of plaque burden reduction by directional coronary atherectomy (DCA) prior to stenting on acute lesion minus rate, on the clinical success rate and on the incidence of in-stent restenosis six months after intervention.

BACKGROUND

Although coronary stenting has reduced restenosis, its effect has been less favorable in complex lesions with a high plaque burden that results from suboptimal stent expansion. Therefore, plaque removal by DCA may improve the results of coronary stenting.

METHODS

A total of 167 patients with >60% stenosis in a native coronary artery of 2.8 to 4.0 mm in diameter were enrolled in 10 study centers on an intention-to-treat basis. All patients underwent DCA aimed at an optimal result (residual diameter stenosis <20%) followed by stenting. Angiographic follow-up was performed in 120 (71.8%) patients at 5.3 ± 2.8 months.

RESULTS

Lesion success was achieved in 164/167 (98.2%) patients, and the clinical success rate was 95.2% (159/167 patients). The overall restenosis rate in the 120 patients with angiographic follow-up was 10.8% (13/120). Incidence of restenosis was lower (8.4%) in patients with optimal stent deployment following DCA compared to patients with a persisting caliber reduction >15% (restenosis rate 15.3.%) and restenosis occurred with a significantly higher frequency (p < 0.04) in distal lesions (37.5%) compared to proximal stenoses (9.0%).

CONCLUSIONS

This observational multicenter registry points to a potential reduction in restenosis by a synergistic approach of DCA and stenting performed under routinely accessible angiographic guidance. Therefore, multicenter-based randomized clinical trials are clearly warranted to finally clarify the validity of this complex approach versus conventional angioplasty plus stenting.

Abbreviations and Acronyms   CK-MB = creatine kinase-MB fraction   DCA = directional coronary atherectomy   IVUS = intravascular ultrasound   MLD = minimal lumen diameter   PTCA = percutaneous transluminal coronary angioplasty   QCA = quantitative coronary angiography   RfD = reference diameter

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