Rotastenting for “Complex Lesions”: Benefit Unlikely with Bare Metal Stents

In the paper by Lee and colleagues (see pages 406–409), the authors seek to establish whether stenting after coronary rotational atherectomy (RA) for “complex lesions” offers any advantage over rotational atherectomy plus adjunctive PTCA alone.1 It presents an interesting, albeit retrospective, comparison of outcomes obtained by patients undergoing these two different treatment modalities. Although the two groups appear to be well-matched for their baseline clinical and angiographic characteristics — in particular, lesion calcification and length and vessel size, the study is non-randomized and inevitably open to bias. For example, it is not clear why some patients with “complex lesions” received rotastenting, whereas others simply got adjunctive PTCA and no mention is made as to the type of stent being used nor what was the proportion of multiple/overlapping stents to single, long stents placed in these long lesions. Moreover, IVUS was not used to detect suboptimal stent deployment and relatively modest stent-balloon inflation pressures were used. Late angiographic follow-up was not performed and this is essential if any conclusions are to be made about comparative restenosis rates between the two strategies. Because the lesions in both groups were long (93–95% were > 20 mm) and the average stent length was 31.6 +/- 9.3 mm, it is not surprising that the clinical outcomes were similar in the two groups (TLR: 20% RA + stent versus 24% RA + PTCA). Complex lesions (including long lesions) treated by rotational atherectomy and adjunctive PTCA are likely to have high TVR and angiographic restenosis rates (DART 30.5% and 50.5%; ERBAC 42% and 57%; COBRA 25% and 42%)2–4 as are long segments of vessels stented without IVUS guidance (TULIP 14% and 45%).5 Perhaps not surprisingly therefore, simply replacing long segment RA + PTCA with long segment bare-metal stenting is unlikely to be clinically helpful. Moreover, studies suggest that RA prior to bare-metal stent implantation offers little advantage to simple predilatation with PTCA. For example, the SPORT trial reported 6-month TVR rates of 18% versus 15% respectively,6 and a small randomized trial by Kwon et al.7 reported similar angiographic restenosis and TVR rates in patients with diffuse lesions in 2.0–2.9 mm vessels undergoing RA + stenting versus PTCA + stenting (33% versus 31% and 24% versus 15%; p = ns). It would be more important, relevant and interesting to know whether a combination of debulking prior to drug-eluting stent implantation had any advantage over rotastenting using bare metal stents or to drug-eluting stent implantation alone. A multicentre, randomized controlled clinical trial by enthusiastic interventionists experienced in rotational atherectomy, with at least an IVUS substudy and follow-up angiography would be of practical value.

1. Lee SW, Hong MK, Lee CW, et al. Early and late clinical outcomes after rotational atherectomy with stenting versus rotational atherectomy with balloon angioplasty for complex coronary lesions. J Invas Cardiol 2004;16:406–409. 2. Mauri L, Reisman M, Buchbinder M, et al. Comparison of rotational atherectomy with conventional balloon angioplasty in the prevention of restenosis of small coronary arteries: results of the Dilatation vs Ablation Revascularization Trial Targeting Restenosis (DART). Am Heart J 2003;145:847–854. 3. Reifart N, Vandormael M, Krajcar M, et al. Randomized comparison of angioplasty of complex coronary lesions at a single center – Excimer laser, Rotational Atherectomy and Balloon Angioplasty Comparison (ERBAC) study. Circulation 1997;96:91–98. 4. Dill T, Dietz U, Hamm CW et al. A randomized comparison of balloon angioplasty versus rotational atherectomy in complex coronary lesions (COBRA study). Eur Heart J 2000;21:1727–1729. 5. Oemrawsingh PV, Mintz GS, Schalij MJ, et al. Intravascular ultrasound guidance improves angiographic and clinical outcome of stent implantation for long coronary artery stenosis: final results of a randomized comparison with angiographic guidance (TULIP Study). Circulation 2003;107:62–67. 6. Buchbinder M, Fortuna R, Sharma SK, et al. Debulking prior to stenting improves acute outcomes: early results from the SPORT trial. J Am Coll Cardiol 2000;35(Suppl A):9A. 7. Kwon K, Choi D, Choi SH, et al. Coronary stenting after rotational atherectomy in diffuse lesions of the small coronary artery: comparison with balloon angioplasty before stenting. Angiology 2003;54:423–31.