| Background:Highly calcified coronary lesions respond poorly to conventional percutaneous coronary intervention (PCI) and result in higgher rates of suboptimal stent expansion.Previous study showed that rotational atherectomy (RA) combined with Cutting Balloon may act synergistically in plaque preparation in severely calcified lesions and can optimal stent expansion, however, there is limited evidence to support these claims. Moreover, factors associated with suboptimal stent expansion in highly calcified lesions have not been fully explored.Objective:1. To evaluate the factors affecting optimal stent expansion in calcified lesions treated by aggressive plaque modification with RA and a CB by quantification coronary angiography (QCA)and intravascular ultrasound (IVUS).2. To evaluate the factors affecting optimal stent expansion in calcified lesions treated by aggressive plaque modification with RA and CB by optical coherence tomography(OCT).Methods:1. From May 2013 to Dec. 2015, 92 patients with moderate to severe coronary calcified lesions underwent rotational atherectomy and intravascular ultrasound imaging at Chinese PLA General Hospital (Beijing,China) were included in this study.They were divided into a rotational atherectomy combined with cutting balloon(RACB) group (46 patients treated with RA followed by CB angioplasty) and an RA group (46 patients treated with RA followed by plain balloon angioplasty). Another 40 patients with similar severity of their calcified lesions treated with plain old balloon angioplasty (POBA) were demographically matched to the other groups and defined as the POBA group. All patients received a drug-eluting stent after plaque preparation.Lumen diameter and lumen diameter stenosis (LDS) were measured by quantitative coronary angiography at baseline, after RA, after dilatation, and after stenting. Optimal stent expansion was defined as the final LDS < 10%.2. Nine patients with moderate to severe coronary calcified lesions underwent RA combined with CB, and OCT at Chinese PLA General Hospital were included in this study. OCT was performed after plaque preparation with RA and CB, and after stent implantation. Analyzed OCT imagings and recorded the lumen area, calcium arc,calcium length, calcium thick, calcium nodule, the soft tissue thick in the surface of calcium. After stent implantation, measure the stent area, stent under expansion, strut malposition, and tissue prolapse. The 9 lesions were separated into 148 segments, and every segment was 2mm. Multivariate logistic regression was used to determine independent factors associated with the presence of sub-optimal stent expansion and stent malposition.Results:1. The initial and post-RA LDS values were similar among the three groups. However,after dilatation, the LDS significantly decreased in the RACB group (from 54.5% ± 8.9%to 36.1%±7.1%) but only moderately decreased (from 55.7% ± 7.8% to 46.9% ± 9.4%)in the RA group (time × group, P < 0.001). After stenting, there was a higher rate of optimal stent expansion in the RACB group (71.7% in the RACB group, 54.5% in the RA group, and 15% in the POBA group, P < 0.001), and the final LDS was significantly diminished in the RACB group compared to the other two groups (6.0%± 2.3%,10.8%±3.3%, 12.7%±2.1%,P<0.001).2. An LDS ? 40% after plaque preparation (OR = 2.994, 95% Cl: 1.297, 6.911) was associated with optimal stent expansion, which also had a positive correlation with the appearance of a calcified ring split (r = 0.581, P <0.001).3. In the 105 segments with calcified lesion evaluated by OCT,the mean lumen CSA was 2.4 ± 0.76 mm2,the calcified arc was 164.3 ± 86.4°,the calcified length was 1.72 ± 0.39 mm, the calcium thick was 0.47 ± 0.18 mm,and the soft tissue thick cover the calcium was 0.15±0.14mm,and there were 42 segments appear the calcium crack. After stent implantation, there were 29 segments (27.6%) with stent under expansion, 29 (27.6%) segments with stent malposition, and 24 segments with tissue prolapse (22.9%).4. The appearance of calcium crack (OR=0.160, 95%CI: 0.050, 0.516), and large lumen area (OR=1.87, 95%CI: 1.021,3.425) after the plaque preparation were the main predict factor for optimal stent expansion. The extensive calcium arc (OR= 1.006,95%CI: 1.001, 1.011 ) was the predict factor for stent malposition.The calcium arc(OR=1.008, 95%CI: 1.002, 1.015) and the soft tissue thick (OR=0.000, 95%CI: 0.000,0.001) on the surface of the calcium were associated with the appearance of the calcium crack.Conclusion:1.Aggressive plaque modification with RA and CB achieve more optimal stent expansion in severe coronary calcified lesions.2. An LDS ? 40% after plaque modification was a predictive factor for optimal stent expansion in calcified lesions. This parameter was also associated with the presence of calcified ring split.3. Evaluated by OCT,aggressive plaque modification with RA and CB achieve a high percentage of optimal stent expansion in calcified lesions.4. In severe coronary calcified lesions, the calcium crack after the plaque preparation maybe benefit for optimal stent expansion. The calcium arc and the soft tissue thick on the surface of the calcium, evaluated by OCT, are associated with the appearance of the calcium crack. |
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