资源描述
单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Clinical Trails Review of,Rotational Atherectomy,Contents,Mechanisms,of Rotational Atherectomy,Safety and Efficacy of Rotational Atherectomy,Technical Parameters of Rotational Atherectomy,Management of Rotational Atherectomy Complications,Contents,Mechanisms,of Rotational Atherectomy,Safety and Efficacy of Rotational Atherectomy,Technical Parameters of Rotational Atherectomy,Management of Rotational Atherectomy Complications,Rotablator,mechanisms,Cavusoglu,et al,.,J Vasc Surg 1988;7:292300.,High-speed mechanical RA relies on,plaque ablation and pulverization by,the abrasive diamond-coated burr.,The Rotablator is able to ablate inelastic tissue selectively while maintaining the integrity of elastic due to the principle of differential cutting.,The abraded plaque is pulverized into microparticles, which are 5-10m in diameter. These particles are small enough to passthrough the coronary microcirculation and ultimately undergo phagocytosis in the liver, spleen, and lung.,Roblator,compared,with,common,balloon angioplasty,Effect,of,Balloon Dilatation,and,ROTA,on,vascular wall,A,B,C,Ahn,et al,.,J Vasc Surg 1988;7:292300.,Mechanisms,of Rotational Atherectomy,Safety and Efficacy of Rotational Atherectomy,Technical Parameters of Rotational Atherectomy,Management of Rotational Atherectomy Complications,Contents,Roblator,outcome,Abdel-Wahab,et al,. Catheter Cardiovas Interv 2013;81:285291.,In-hospital events (n = 205),Long-term events (n = 188),Death, n(%),3(1.5),17(9.0),Cardiac, n(%),7(3.7),Noncardiac, n(%),4(2.1),Unknow, n(%),6(3.2),MI, n(%),5(2.4),5(2.7),Q-wave, n(%),2(1.1),Non-Q-wave, n(%),3(1.6),TLR, n(%),0,15(7.9),TVR, n(%),1(0.5),21(11.2),MACE,*, n(%),9(4.4),39(20.7),In-Hospital and Long-Term Outcome,#,#,Median,Follow-Up = 15 Months, Range,=,184 Months.,*,Defined as death, MI and TVR.,Rainer,et al,.,Am J Cardiol 1998;81:552557,.,QCA,of,ROTA, Stent and ROTA + Stent,ROTA,(n = 147),Stent,(n = 103),ROTA + Stent,(n = 56),p,Value,Reference diameter (mm),3.20 0.34,3.36 0.52,3.35 0.48, 0.0001,MLD,Pretreatment (mm),1.01,0.46,1.06,0.57,1.12,0.45,0.4382,Final (mm),2.29,0.55,2.88,0.51,3.21,0.49, 0.0001,Diameter stenosis,Pretreatment (%),68,15,68,16,66,15,0.7584,Final (%),27,17,14,13,4,15, 0.0001,Acute diameter gain (mm),1.28,0.61,1.81,0.66,2.17,0.60, 0.0001,Roblatoroutcome,Rainer,et al,.,Am J Cardiol 1998;81:552557,.,Event-free survival-curves for each of the 3 treatment,modalities during 9-month follow-up,Roblatoroutcome,A strategy of ROTA and DES implantation is a safe and effective treatment option in complex patients with complex calcified lesions.,Long-term revascularisation rates do not differ from the experience with DES in less severe patient and lesion subsets.,ROTA and DES appear to be particularly effective in elderly patients.,Abdel-Wahab,et al,. Catheter Cardiovas Interv 2013;81:285291.,Roblatoroutcome,Dill,et al,. Eur Heart J 2000;21:17591766.,The COBRA Study,A randomized comparison of balloon angioplasty versus rotational atherectomy in complex coronary lesions (COBRA study),T. Dill, U. Dietz, C. W. Hamm, R. Kchler, H.-J. Rupprecht, M. Haude, J. Cyran, C. zbek, K.-H. Kuck, J. Berger and R. Erbel,Dill,et al,. Eur Heart J 2000;21:17591766.,KaplanMeier survival curves for,patients,undergoing,Angioplasty,Rotablator,The,COBRA Study,Dill,et al,. Eur Heart J 2000;21:17591766.,Risk differences and 95% CI for,event-free procedural outcome,The,COBRA Study,Dill,et al,. Eur Heart J 2000;21:17591766.,Complex coronary artery lesions can be treated with a high level of success and low complication rates either by PTCA with adjunctive stenting or rotablation. The long-term clinical and angiographic outcome is comparable.,The,COBRA Study,The ROTAXUS trial (9-month),Abdel-Wahab,et al,. J Am Coll Cardiol Intv 2013;6:10,19,.,High-Speed Rotational Atherectomy Before Paclitaxel-Eluting Stent Implantation in Complex Calcified Coronary Lesions,The Randomized ROTAXUS (Rotational Atherectomy Prior to Taxus Stent Treatment for Complex Native Coronary Artery Disease) Trial,Mohamed Abdel-Wahab, Gert Richardt, Heinz Joachim Buttner, Ralph Toelg, Volker Geist, Thomas Meinertz, Joachim Schofer, Lamin King, Franz-Josef Neumann, Ahmed A. Khattab,Abdel-Wahab,et al,. J Am Coll Cardiol Intv 2013;6:,10-19,.,240 patients enrolled between August 2006 and March 2010 at 3 clinical sites in Germany,240 patients analyzed with complete in-hospital follow-up,Angiographic follow-up at 9 months in 80.5% (N=190),Clinical follow-up at 9 months in 96.2% (N=227),1:1 randomization,PTCA + PES,(N=120),Rota + PES,(N=120),2 patients died in-hospital,6 patients withdrew consent,5 patients lost at follow-up,Flow chart of the ROTAXUS trial,The ROTAXUS trial (9-month),result,Abdel-Wahab,et al,. J Am Coll Cardiol Intv 2013;6:,10-19,.,9-Month Follow-Up QCA Data (N = 255 Lesions),ROTA (n = 123),Standard (n = 132),p,Value,Min lumen diameter (mm),In-stent,2.140.63,2.250.62,0.15,In-segment,1.910.57,2.020.65,0.16,Diameter stenosis (%),In-stent,22.0119.92,19.8619.64,0.26,In-segment,27.9218.97,26.991.73,0.44,Late lumen loss (mm),In-stent,0.440.58,0.310.52,0.01,In-segment,0.360.57,0.250.57,0.04,Binary restenosis (%),In-stent,14 (11.4%),14 (10.6%),0.84,In-segment,15 (12.2%),17 (12.9%),0.87,The ROTAXUS trial (9-month),Abdel-Wahab,et al,. J Am Coll Cardiol Intv 2013;6:,10-19,.,ROTA (n = 113),Standard (n = 114),p,Valu,e,Death,5.0%,5.8%,0.78,MI,6.7%,5.8%,0.79,TVR,16.7%,18.3%,0.73,TLR,11.7%,12.5%,0.84,MACE,*,24.2%,28.3%,0.46,Definite ST,(1),(0),-,Events at Follow-up,*,Defined as death, MI and TVR.,The ROTAXUS trial (9-month),Abdel-Wahab,et al,. J Am Coll Cardiol Intv 2013;6:,10-19,.,ROTA + PES was not superior to balloon dilatation + PES in reducing the primary endpoint of late lumen loss at 9 months in patients with complex calcified CAD.,ROTA (probably due to additional vessel trauma) rather decreased the efficacy of PES in reducing neointimal growth.,The superior acute gain obtained by ROTA was counter balanced by an increased late loss resulting in a neutral effect on restenosis.,ROTA remains an important bail-out device for uncrossable or undilatable coronary lesions and can improve overall success of DES implantation,.,The ROTAXUS trial (9-month),Abdel-Wahab,et al,. Abstracts of EuroPCR & AsiaPCR/SingLIVE 2013.,Rotational atherectomy before paclitaxel-eluting stent implantation in complex calcified coronary lesions:,two-year clinical outcome of the randomised ROTAXUS trial,Abdel-Wahab M., Khattab A.A., Bttner H.J., Toelg R., Geist V., Neumann , Richardt G.F.J.ranz-Josef Neumann, Ahmed A. Khattab,The ROTAXUS trial (9-month),Abdel-Wahab,et al,. Abstracts of EuroPCR & AsiaPCR/SingLIVE 2013.,ROTA,Standard,p,Valu,e,Death,8.9% (10),8.0%(9),0.81,MI,8.0%,6.3%,0.60,TVR,19.6%,23.2%,0.51,MACE,*,30.4%(34),35.4%(40),0.39,Events at Follow-up,*,Defined as death, MI and TVR.,The ROTAXUS trial (9-month),Abdel-Wahab,et al,. Abstracts of EuroPCR & AsiaPCR/SingLIVE 2013.,Despite high rates of initial angiographic success, nearly one third of the patients had a major adverse cardiac event within a 2-year follow-up period, with no differences between patients treated with or without,ROTA,.,Coronary calcification remains a challenge for current interventional therapies and new therapeutic approaches are needed.,The ROTAXUS trial (9-month),Non-ctrl studies of RA and DES,Trial/,First Author,Year,N,Burr/artery Bur size (mm),Angiographic/ Procedure Success (%),In-hospital,MACE/,Death,(%),MACE/,TLR,(%, FU),ST,(%),Procedural events,(%),Furuichi,et al,2009,95,0.58 0.14,1.48 0.18,99 / 95.8,3.2 / 0,15.8 / 9.5,14.7 mo,Late ST:2.1: definite,2.1: probable,slow-flow:1.0,perforation:1.0,dissection:2.0,Mezilis,et al,2010,150,0.6-0.7,1.25-2.2,98/98,0 / 0,11.3 / 2.2,3y,-,-,Benezet,et al,2011,102,0.56 0.1,1.5 0.2,99/97,2.9 / 0.9,12.7 / 8.8,15 mo,Early ST:,2.9: definite,1.9: probable,dissection:2.9,Dardas,et al,2011,184, 0.6-0.7, 1.25,97.3 / 97.3,0 / 0,14.85 / 2.8,49 mo,-,N/A,Jiang,et al,2012,253,0.55 0.08,1.5-1.75,100/98,2.0 / 0.8,4.4 / 3.2,3y,-,perforation: 0.8,dissection:1.2%,slow-flow:2.0,Abdel-Wahab,et al,2013,205,0.43-0.57,1.5-1.75,98.1 / 95.6,4.4 / 1.5,17.7 / 6.8,15 mo,1.0,slow-flow: 2.0,perforation:1.0,Chiang,et al,2013,67,0.6 0.1,1.60 0.2,100 / 92.5,7.5 / 7.5,17.9 / 10.4,23.3 mo,1.5,-,Furuichi,et al,. EuroIntervention 2009; 5(3):370-374.Mezilis,et al,. J Interv Cardiol 2010; 23(3): 249-253.Benezet,et al,. J Invasive Cardiol 2011; 23(1): 28-32.Dardas,et al,. Hellenic J Cardiol 2011; 52(5):399-406,.,Jiang,et al,. J Zhejiang Univ Sci B 2012; 13(8):645-651.Abdel-Wahab,et al,. CCI 2013; 81(2):285-291.,Chiang,et al,. J Chin Med Assoc 2013; 76(2): 71-77,.,Contents,Mechanisms,of Rotational Atherectomy,Safety and Efficacy of Rotational Atherectomy,Technical Parameters of Rotational Atherectomy,Management of Rotational Atherectomy Complications,Friction between the burr and plaque generates heat. Heat varies with technique from,2.6C,using intermittent ablation and permitting minimal decelerations (4,000 6,000 rpm), to 13.9C using continuous ablation allowing excessive decelerations (14,000 18,000 rpm) in experimental modeling.,Along with microembolization of debris, thermal injury may contribute to increased risk of periprocedural MI and restenosis associated with excessive decelerations.,Modern technique, favoring gradual, intermittent ablation with a pecking motion, aims to minimize decelerations and thermal injury. Slower burr speeds of 140,000 to 150,000 rpm further reduce platelet aggregation associated with RA.,Reisman,et al,. Cathet Cardiovasc Diagn 1998;44:4535.,Whitlow,et al,. Am J Cardiol 2001;87:699705.,Reisman,et al,. Cathet Cardiovasc Diagn 1998;45:20814.,Rotational speed,RA particulate must traverse coronary microvasculature before clearance by the reticuloendothelial system. Microvascular obstruction can cause reduced contractility in subtended myocardium, slow-flow/no-reflow, and MI.,98% particles are 5,000 rpm,Final polishing,run,Contents,Mechanisms,of Rotational Atherectomy,Safety and Efficacy of Rotational Atherectomy,Technical Parameters of Rotational Atherectomy,Management of Rotational Atherectomy Complications,C,linical,complications common to,PCI (including,vascular access complications, stroke, MI, urgent,CABG,and,death).,Angiographic complications,(,including,dissection, perforation, short-term,closure, side,branch loss, and the slow-flow/no-reflow,phenomenon).,V,asospasm,(1.6% to 6.6%) and burr,entrapment,(0.5% to 1%).,Cavusoglu,et al,. Catheter Cardiovasc Interv 2004;62:485498.,Common complications,Trial/,First Author,Year,N,Death,(%),MI,(%),Urgent CABG,(%),Vascular,(%),Dissection,(%),ROTAXUS,2013,120,1.7,1.7,0.8,5.8,3.3,Abdel-Wahab,et al,2013,205,1.5,2.4,4.4,Naito,et al,2012,233,0.0,1.3,1.7,Benezet,et al,2011,102,1.0,1.0,2.9,Dardas,et al,2011,184,0.0,Garcia de Lara,et,al,2010,50,4.0,14.0,0.0,2.0,Rathore,et al,2010,391,1.0,6.9,0.0,5.9,Vaquerizo,et al,2010,63,0.0,3.2,0.0,1.6,Furuichi,et al,2009,95,0.0,3.2,2.1,Clavijo,et al,2006,81,0.0,19.8,1.9,Reported Complications (1),Abdel-Wahab,et al,. J Am Coll Cardiol Intv 2013;6:10-19.,Abdel-Wahab,et al,.,CCI,2013;81: 285-291.,Naito R,et al,. Int Heart J 2012;53:14953.,Benezet,et al,. J Invasive Cardiol 2011;23:2832.,Dardas,et al,. Hellenic J Cardiol 2011;52:399406.,Garcia de Lara et al. Rev Esp Cardiol 2010;63:10710.,Rathore et al. Catheter Cardiovasc Interv 2010;75:91927.,Vaquerizo et al. J Interv Cardiol 2010;23:2408.,Furuichi et al. EuroIntervention 2009;5:3704.,Clavijo et al. Catheter Cardiovasc Interv 2006; 68:8738.,Reported Complications (2),Trial/,First Author,Year,N,Perforation,(%),Acute Closure,(%),Side Branch,Loss (%),Slow Flow/,No,Reflow,(%),ROTAXUS,2013,120,1.7,0.0,Abdel-Wahab,et al,2013,205,0.5,2.0,Naito,et al,2012,233,0.4,Benezet,et al,2011,102,0.0,Dardas,et al,2011,184,Garcia de Lara,et,al,2010,50,2.0,2.0,4.0,0.0,Rathore,et al,2010,391,2.0,0.3,3.6,2.6,Vaquerizo,et al,2010,63,1.6,Furuichi,et al,2009,95,1.1,1.1,Clavijo,et al,2006,81,Abdel-Wahab,et al,. J Am Coll Cardiol Intv 2013;6:10-19.,Abdel-Wahab,et al,.,CCI,2013;81: 285-291.,Naito R,et al,. Int Heart J 2012;53:14953.,Benezet,et al,. J Invasive Cardiol 2011;23:2832.,Dardas,et al,. Hellenic J Cardiol 2011;52:399406.,Garcia de Lara et al. Rev Esp Cardiol 2010;63:10710.,Rathore et al. Catheter Cardiovasc Interv 2010;75:91927.,Vaquerizo et al. J Interv Cardiol 2010;23:2408.,Furuichi et al. EuroIntervention 2009;5:3704.,Clavijo et al. Catheter Cardiovasc Interv 2006; 68:8738.,Clinical considerations,Generally, RA should be used in severe calcified lesions, lesions with bulky plaques or that are unfavorable for stent deployment.,High,pressure post dilation remains necessary in patients treated with RA and DES because the stiff vessel wall probably affects the expansion of stent as well as the release of drug even after ablation,.,In addition to RA, cutting balloon (CB) and AngioSculpt scoring balloon are proposed to treat moderate or severe calcified lesions,.,
展开阅读全文