Can a coronary atherectomy and stent be performed as part of the same procedure?

Coronary Atherectomy and Stent Placement Can Be Performed in the Same Procedure

Yes, coronary atherectomy and stent placement can be performed as part of the same procedure, and this combined approach is often used for complex calcified coronary lesions to improve procedural success and outcomes. 1

Rationale for Combined Approach

Indications for Atherectomy Before Stenting

• Heavily calcified lesions: Plaque modification with rotational atherectomy is particularly useful for fibrotic or heavily calcified lesions that might not be crossed by a balloon catheter or adequately dilated before stent implantation 1
• Lesion preparation: Atherectomy can favorably modify calcified plaques to facilitate stent delivery and expansion 2
• Procedural success: The combination improves the likelihood of successful stent delivery and optimal stent expansion in complex lesions 1

Types of Atherectomy Devices

1. Rotational atherectomy (Class IIa, Level of Evidence: B-R) - Most established and commonly used 1
2. Orbital atherectomy (Class IIb, Level of Evidence: B-NR) 1
3. Directional coronary atherectomy (DCA) 1
4. Balloon atherotomy (Class IIb, Level of Evidence: B-NR) 1
5. Laser angioplasty (Class IIb, Level of Evidence: B-NR) 1
6. Intracoronary lithotripsy (Class IIb, Level of Evidence: B-NR) 1

Procedural Considerations

When to Consider the Combined Approach

• Presence of calcium deposits thicker than 500 μm
• Calcium involving an arc of the vessel >270° on intravascular imaging 1
• Lesions that cannot be adequately crossed or dilated with conventional balloon angioplasty 1
• Complex calcified native coronary lesions 2

Procedural Steps

1. Perform atherectomy to modify the calcified plaque
2. Follow with balloon angioplasty if needed
3. Deploy stent in the same procedure
4. Optimize stent expansion with post-dilation if necessary

Clinical Outcomes

Benefits

• Higher strategy success rate compared to stenting alone in complex calcified lesions (92.5% vs. 83.3%) 2
• Improved acute lumen gain initially 2
• Facilitates stent delivery in challenging anatomy 1

Limitations

• May be associated with higher in-stent late lumen loss at 9 months compared to stenting alone (0.44 mm vs. 0.31 mm) 2
• No significant reduction in binary restenosis rates compared to stenting alone 2, 3
• Higher procedural complexity and potentially longer procedure time

Safety Considerations

• In-hospital major adverse cardiac events rate of approximately 4.4% with rotational atherectomy followed by drug-eluting stent implantation 4
• Long-term target lesion revascularization rates of approximately 6.8% 4
• Low risk of stent thrombosis (approximately 1%) 4

Important Caveats

• Patient selection is crucial: The combined approach is most beneficial in patients with complex calcified lesions that would be difficult to treat with stenting alone
• Operator experience matters: These procedures should be performed by experienced operators familiar with both atherectomy techniques and stent implantation
• Device selection: The choice of atherectomy device should be based on lesion characteristics and operator familiarity
• Despite improved acute results, routine lesion preparation using rotational atherectomy before drug-eluting stent implantation has not been shown to reduce late lumen loss at 9 months 2

Conclusion

Coronary atherectomy followed by stent implantation in the same procedure is a well-established approach for treating complex calcified coronary lesions. The combined strategy improves procedural success by facilitating stent delivery and expansion, though it has not consistently demonstrated superiority in reducing restenosis rates compared to stenting alone.