Mechanisms of acute lumen gain and recurrent restenosis after rotational atherectomy of diffuse in-stent restenosis : quantitative angiographic and intravascular ultrasound study

OBJECTIVES This quantitative angiographic and intravascular ultrasound study determined the mechanisms of acute lumen enlargement and recurrent restenosis after rotational atherectomy (RA) with adjunct percutaneous transluminal coronary angioplasty in the treatment of diffuse in-stent restenosis (ISR). BACKGROUND In-stent restenosis remains significant clinical problem for which optimal treatment is under debate. Rotational atherectomy has become an alternative therapeutic approach for the treatment of diffuse ISR based on the concept of “tissue-debulking.” METHODS Rotational atherectomy with adjunct angioplasty of ISR was used in 45 patients with diffuse lesions. Quantitative coronary angiographic (QCA) analysis and sequential intravascular ultrasound (IVUS) measurements were performed in all patients. Forty patients (89%) underwent angiographic six-month follow-up. RESULTS Rotational atherectomy lead to decrease in maximal are of stenosis from 80 ± 32% before intervention to 54 ± 21% after R (p < 0.0001) as result of significant decrease in intimal hyperplasi cross-sectional are (CSA). The minimal lumen diameter after R remained 15 ± 4% smaller than the burr diameter used, indicating acute neointimal recoil. Additional angioplasty led to further decrease in are of stenosis to 38 ± 12% due to significant increase in stent CSA. At six-month angiographic follow-up, recurrent restenosis rate was 45%. Lesion and stent length, preinterventional diameter stenosis and amount of acute neointimal recoil were associated with higher rate of recurrent restenosis. CONCLUSIONS Rotational atherectomy of ISR leads to acute lumen gain by effective plaque removal. Adjunct angioplasty results in additional lumen gain by further stent expansion and tissue extrusion. Stent and lesion length, severity of ISR and acute neointimal recoil are predictors of recurrent restenosis.