Auflistung nach Autor:in "Mankerious, Nader"

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Rotational atherectomy of heavily calcified coronary lesions
(2025) Mankerious, Nader
Coronary artery calcifications precent in about one fifith of all percutaneous coronary intervention (PCI) procedures [1]. Despite considerable advancements in PCI tools and techniques, coronary calcification remain a significant clinical challenge [2]. Heavily calcified lesions predispose to suboptimal final PCI results [3, 4], underscoring the need for enhanced strategies and tools to adress this challenge. Modified baloons (MB) (cutting and scoring balloons) serve as valuable tools for modifying calcified lesions prior to stent implantation [7]. Nevertheless, these strategies do not achieve optimal plaque modification in over 12% of cases [10, 11]. This highlights the role of rotational atherectomy (RA), which ablates the calcified plaque into small particles (<10 μm), reducing the calcium burden of the lesion and facilitating stent delivery and expansion, potentially improving the long-term performance of drug-eluting stent (DES) [12]. Procedural complications are known to be more frequent among the RA PCIs performed in heavily calcified lesions compared to other PCIs conducted in mild or non-calcified lesions without the use of RA [13]. The SYNTAX score is an anatomically based tool reflecting the cumulative complexity of the coronary tree, taking into account their specific locations and characteristics [15]. We hypothesized that determining the SYNTAX score for the target vessel in the context of RA may serve as a predictive tool for the likelihood of in-hospital adverse outcomes by predicting the technical difficulties faced during the PCI. We have developed the new concept of target vessel SYNTAX score (tvSS) to adress this point. Our analysis aimed to explore the predictors of in-hospital adverse outcomes after RA and to test the target vessel SYNTAX score (tvSS) as a potential causal variable [46]. Patients receiving RA were divided into two groups according to the occurrence of in-hospital adverse outcomes. Median TvSS was significantly higher in patients with vs. without in-hospital adverse outcomes. A tvSS cut-off value of 15 showed 73% sensitivity and 62% specificity for predicting in-hospital adverse outcomes. Moreover, a tvSS ≥15, bailout RA, reduced LVEF, as well as diabetes mellitus, emerged as independent predictors of in-hospital adverse outcomes. After one year follow-up, there was no significant difference between patients with vs. without in-hospital adverse outcomes regarding the rates of composite MACE, all-cause death, MI and TVR. Coronary bifurcation lesions present complex anatomical challenges in the field of interventional cardiology, observed in up to 20% of all PCI cases [18, 19]. They are complex anatomical structures where the main vessel and the side branch (SB) are interpolated within a bifurcation segment [20]. SB compromise is an early described complication during PCI of bifurcation lesions [22]. Main vessel plaques can cause plaque shift leading to side branch compromise [25]. However, the plaque nature including the presence of calcification is also an important predictor of the side branch compromise [26, 27]. The PREPARE-CALC multicenter randomized controlled trial investigated lesion preparation strategies for severely calcified coronary lesions, comparing the use of a MB versus RA, followed by implantation of biodegradable polymer sirolimus eluting stent [11]. We conducted an as-treated subgroup analysis of bifurcation lesions from the PREPARE–CALC trial [47]. We compared outcomes of different modification techniques of severly calcified bifurcation lesion. At the end of the procedure, the SB remained significantly compromised in 15 lesions in MB (32%) and in 5 lesions (7%) in RA group. Fluoroscopy time and procedural duration were significantly higher in RA group. Large coronary dissections were more frequently observed in MB group. In-hospital outcome was similar between both groups. Additionally, we analyzed the evolution of cardiac biomarkers in patients with (n=20) and without (n=84) compromised SB at the end of the procedure until 24 hours. The median value of CK-MB was significantly higher at 16H post-PCI in compromised SB patients with a trend towards higher Troponin T. CTO is observed in approximately one-fifth of all PCI [28]. Heavily calcified CTO lesions present a challenge in CTO PCI and are not uncommon. In fact, moderate to severe calcification characterizes over half of the CTO lesions [29]. The use of RA for the preparation of calcified CTO lesions is increasing [30]. The feasibility and in-hospital outcome of RA in CTOs were reported in some studies [32, 33]. We investigated the in-hospital and long-term outcomes after RA for CTO compared to non-CTO calcified lesions [48]. The angiographic success was less in CTO RA procedures, and the procedural success rate was 80% versus 90.5% in CTO RA versus non-CTO RA procedures. In-hospital MACE was comparable in both groups. However, the incidence of slow flow, coronary perforation and cardiac tamponade were higher in the CTO RA group. We observed a higher 2-year TLF in the CTO group, that was driven by higher cardiac deaths. However, target vessel MI and clinically driven TLR rate were comparable between the study groups. On multivariate regression analysis, the presence of CTO lesion, chronic kidney disease (CKD), periprocedural MI and reduced LV-EF (EF < 50%) were independently associated with the two-year TLF. In the CTO group, 38.7% of patients were treated with elective RA. Compared to elective RA, bail-out procedures took longer time, had higher number of dissections and more frequently required two or more burrs. However, the estimated rate of 2-year TLF was not significantly different between those received elective RA and bailout RA. In conclusion, the use of RA is expanding and reaching high-risk populations. In-hospital adverse outcomes during RA are common in patients with more complex target vessel anatomy as indicated by a higher target vessel SYNTAX score (tvSS ≥ 15). Additionally, bailout RA and left ventricular systolic function emerged as predictors of in-hospital adverse outcomes. In-hospital adverse outcomes were not associated with long-term MACE. In the context of high-risk lesions, comparing a strategy of MB versus RA in severely calcified coronary bifurcation lesions, we observed a significantly higher rate of side branch compromise with an MB-based strategy, which did not translate into worse short-term clinical outcome. Side branch compromise was associated with more extensive periprocedural myocardial injury. Therefore, in calcified bifurcation lesions, an upfront debulking with an RA-based strategy might optimize the result of PCI in the side branch. Furthermore, RA in CTO is feasible with a high success rate. However, the long-term outcome is worse than non-CTO RA. Elective RA in CTO can shorten the procedure time and decrease the incidence of dissection in comparison with bail-out RA. Finally, RA is an indispensable modality in every catheterization laboratory and may be the only solution for lesion preparation in heavily calcified cases, especially in situations where PTCA balloons are unable to cross or dilate the lesion.