The dinosaur that still roars Blankenship, James C.
Catheterization and cardiovascular interventions,
November 1, 2021, 2021-11-01, 2021-11-00, 20211101, Volume:
98, Issue:
5
Journal Article
Peer reviewed
Key Points
Rotational atherectomy (RA) and orbital atherectomy (OA) are both effective in ablating calcified lesions in preparation for coronary stenting. It remains unclear, which is superior.
This ...meta‐analysis of eight non‐randomized studies comparing OA and RA finds that RA causes fewer dissections and perforations but OA is associated with fewer myocardial infarctions, mortalities, and target vessel revascularizations.
Limitations of this meta‐analysis prevent any firm conclusions about which are superior. Experience with one device or the other may be more important than which is chosen.
Ellis type 4 coronary artery perforation (CAP4), also referred to as Ellis type 3 cavity‐spilling perforation, is a rare but life‐threatening complication of percutaneous coronary intervention ...characterized by extravasation of blood into a cardiac chamber, anatomic cavity, or coronary sinus or vessel. CAP4 is uncommon, accounting for 1.9% to 3.0% of all CAP. Only 11 cases of CAP4 have been reported in detail; we report an additional two cases and review prior reports of this rare complication. Our first case highlights a patient with chronic anginal symptoms due to a 75% concentric stenotic lesion in the mid‐LAD. Revascularization was complicated by perforation during pre‐dilation with robust contrast extravasation into the left ventricle. Successful postperforation hemostasis was achieved with heparin reversal and covered stent placement. The second case demonstrates another major mechanism of CAP4: wire perforation. During intervention, the absence of blood flow distal to the lesion in the setting of an ST segment elevation myocardial infarction obscured the course of the nonhydrophilic floppy wire leading to perforation that was managed conservatively.
In our scoping review, we found that the majority of CAP4 occurred in the LAD. The most frequently involved cavity was the left ventricle—other cavities involved were the right ventricle and coronary veins. Common etiologies of CAP4 included guidewire perforation (62%) and balloon dilation (31%). Perforation was managed with reversal of anticoagulation in 46% of cases, prolonged balloon inflation in 54% of cases, and covered stent deployment in 15% of cases. No patients required surgical repair or pericardiocentesis and perforations were successfully sealed in all cases. In‐hospital mortality was 0%.
Because the ACC/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are currently unavailable in North America are discussed in the ...text without a specific COR. For studies performed in large numbers of subjects outside North America, a writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and relevance to the ACC/AHA target population to determine whether the findings should inform a specific recommendation.\n Sabik Content Reviewer--ACC Surgeons' Scientific Council Cleveland Clinic--Department Chair, Thoracic and Cardiovascular Surgery Edwards Lifesciences Medtronic None Abbott Laboratoriesdagger Edwards Lifesciencesdagger None Vikas Saini Content Reviewer The Lown Institute--President None None None None Frank W. Sellke Content Reviewer--ACC/AHA Task Force on Practice Guidelines Brown Medical School and Lifespan--Chief of Cardiothoracic Surgery None None The Medicines Company None William S. Weintraub Content Reviewer Christiana Care Health System--Section Chief, Cardiology Bristol-Myers Squibb Daiichi-Sankyo Eli Lilly None None None Christopher J. White Content Reviewer Ochsner Health System--Director, John Ochsner Heart and Vascular Institute None None None St. Jude Medical (DSMB) Sankey V. Williams Content Reviewer--ACP University of Pennsylvania Health System--Professor of General Medicine None None None None Poh Shuan Daniel Yeo Content Reviewer--AIG Tan Tock Seng Hospital, Department of Cardiology--Cardiologist None None None Boston Scientificdagger Merckdagger Schering-Ploughdagger * No reviewer had a relevant ownership, partnership, or principal position to report.
Key Points
One‐third of interventionalists still use dedicated left and right coronary catheters for diagnostic angiography with radial access, despite some evidence that a single “universal” ...catheter strategy is superior.
This meta‐analysis of seven randomized controlled studies of one‐ versus two‐catheter strategies with radial access showed no differences in procedural time, fluoroscopy time, or contrast use. Use of an additional catheter was more frequent with the one‐catheter strategy but radial spasm was more common with a two‐catheter strategy.
This meta‐analysis did not address cost, complication rates, or radial occlusion rates. Differences in these factors, if found in future studies, may yet prove one strategy or the other to be superior.
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