Distal Embolization During Directional Coronary Atherectomy

Directional coronary atherectomy (DCA) with eventual stent implantation seems to be the ideal strategy to treat ostial lesions and lesion with a large plaque burden.1–3 However, non-Q wave myocardial infarction emerged as a major drawback of DCA.1–5 The mechanism of such a complication is not clearly understood, but some evidence exist that platelet aggregation, thrombus formation, and plaque embolization are integral components of this complication.6 Preliminary studies have recently supported the feasible use of the PercuSurge GuardWire™ Temporary Occlusion and Aspiration System (a catheter system designed to contain and retrieve particulate material) for retrieval of plaque debris and prevention of embolization in vein graft intervention.7–9 In the present study, we report 2 cases of DCA performed with the use of the PercuSurge GuardWire, in order to prevent distal embolization, and thus the occurrence of ischemic complications. Case Report 1. A 60-year-old man with previous anterior wall myocardial infarction (MI) and actual stable effort angina underwent coronary angiography and cardiac catheterization. A critical, eccentric stenosis (type B2, according to the ACC/AHA classification) was present in the proximal tract of the left anterior descending coronary artery (LAD) (Figure 1, panel A). Left ventricular ejection fraction was 75% (as assessed with the area-length method, by 2-dimensional echocardiography). We decided to treat this lesion with DCA and stent implantation. An 8 French (Fr) intraaortic balloon pump (Percor, Percor STAT DL, Datascope System, Datascope Corporation, Fairfield, New Jersey) was electively placed percutaneously from the left femoral artery and balloon counterpulsation was initiated before starting angioplasty procedure, provided one-to-one counterpulsation. An 8 Fr sheath was introduced in the right femoral artery. After LAD cannulation with a 8 Fr Viking Optima‚ guiding catheter and before starting DCA, the PercuSurge GuardWire™ was advanced through the lesion, in the distal segment of the LAD, and the balloon (3.0–3.5 mm) was inflated in order to occlude the vessel (Figure 1, panel B). DCA was performed by a 7 Fr Flexi-Cut‚ (Directional Debulking System, Guidant, California) as previously described.5 After DCA (12 cuts), residual stenosis was Case Report 2. A 55-year-old man with previous inferior wall MI and actual stable effort angina, underwent coronary angiography. A total occlusion was present in the proximal tract of the right coronary artery (RCA) (Figure 3, panel A). TIMI flow was 0. Left ventricular ejection fraction (as assessed by 2D echocardiography) was 59%. After crossing the occlusion with a hydrophilic guidewire, we decided to treat this lesion with DCA and eventual stenting. After replacing the hydrophilic guidewire with a high-support one, balloon dilatation (with a 1.5 mm balloon) to facilitate atherectomy was performed. Before starting DCA, the PercuSurge GuardWire™ was advanced in the distal segment of the RCA, and the balloon (3.0 – 3.5 mm) was inflated in order to occlude the vessel (Figure 3, panel B). DCA was performed by a 7 Fr Flexi-Cut‚ (Directional Debulking System, Guidant, CA) as previously described.5 After DCA (20 cuts), residual stenosis was Discussion CK-release and DCA. Non-Q wave MI emerged as a major drawback of DCA, with a greater that twofold increase in CK myocardial isoenzyme band elevations.1–4,10 However, a number of investigators have questioned whether isolated moderate CK-MB increases (

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