The Efficacy of Directional Atherectomy Prior to Stent Implantation.

Coronary stents have improved the short- and long-term outcomes of patients undergoing catheter-based coronary interventions. However, the use of these devices in complex coronary lesions has also created an incessant form of in-stent restenosis that still defies treatment. Plaque burden has been consistently and reproducibly recognized as an important factor that may incite neointimal proliferation after stent implantation. Prospective nonrandomized experience has shown that plaque removal prior to stent implantation using directional atherectomy is a promising approach to reduce restenosis in selected patients. However, the proof of concept awaits the results of the randomized trials. Ultimately, the clinical use (safety and efficacy) of this approach will depend on 1) further improvements on the current directional atherectomy device to make it user friendly; 2) minimizing the incidence of non-Q-wave myocardial infarction with selective use of IIb-IIIa platelet receptor antagonists or distal protection devices; and 3) targeting patients at high risk for restenosis in whom efficient debulking is feasible. This would include patients who have noncalcified lesions in vessels greater than 2.75 mm but less than 3.5 mm in diameter that require a long stent or multiple stents, aorto-ostial lesions, bifurcational lesions, and chronic total occlusions.