Early experience of directional coronary atherectomy: clinical results, complications and histopathological findings.

Objective: To report the early experience, clinical results and histopathologic findings of Directional Coronary Atherectomy from a UK centre experienced in coronary angioplasty.
Design: Prospective study of the first 45 Directional Coronary Atherectomy (DCA) procedures using the Simpson coronary atherectomy device.
Results: Forty-five procedures were performed in 33 male and 5 female patients (mean age, 55.1 years). Directional Coronary Atherectomy was performed to 50 lesions (39 de novo, 11 restenosis; 44 left anterior descending, 3 right, 2 circumflex coronary arteries and 1 saphenous vein graft). Clinical and primary angiographic success was achieved in 43 of 45 cases (95.5%) and in 47 of 50 lesions (94%) after DCA alone. Before DCA the mean diameter stenosis was 88.7% (range, 50-100%) but following DCA (and percutaneous coronary angioplasty (PTCA) if necessary) the mean diameter stenosis was 3.5% (range, 0-15%; P < 0.001). Complications included occlusive dissection requiring coronary artery bypass surgery in two patients; abrupt closure of right coronary artery in one patient successfully reopened by PTCA and thrombolysis, complicated by excessive blood loss; reversible coronary artery spasm due to minor nose-cone trauma in four patients and temporary side branch loss in one patient. There were no coronary artery perforations, guide catheter complications, peripheral vascular trauma or deaths. On average 5.6 specimens (range, 1-18) were removed per case. Histology showed fibrous intimal plaque in 98%, media in 39% and adventitia in 7%. Neo-intimal hyperplasia was found in all restenosis lesions but also in 30% of de novo lesions.
Conclusions: This small initial series indicates that directional coronary atherectomy is an effective and safe procedure for the treatment of obstructive coronary artery disease in carefully selected patients. With care, a high success rate can be achieved even during a learning phase. The technique is particularly effective for morphologically complex lesions that are unfavourable for PTCA. The procedure is unlike PTCA and requires additional training if pitfalls are to be avoided, high success rates achieved and complication rates kept low.