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Aggressive plaque modification with rotational atherectomy and/or cutting balloon before drug-eluting stent implantation for the treatment of calcified coronary lesions.

INTRODUCTION
Calcified coronary lesions may be associated with stent underexpansion, malapposition, and high rates of restenosis. The use of drug-eluting stents (DES) in such lesions has not been fully addressed in the major trials. We sought to examine the outcomes of patients who were treated with plaque modification (PM) to facilitate DES implantation.


METHODS
We analyzed 164 calcified coronary lesions in 145 consecutive patients who underwent aggressive PM with either rotational atherectomy (RA) and/or cutting balloon (CB) before DES implantation. CB was used in moderate calcified lesions and RA alone or followed by CB in severe calcified lesions.


RESULTS
Patients were 68.7 +/- 10.1 years old, 47% were diabetic, 34% had left ventricular ejection fraction (LVEF) < or =50%, and 39% had 3-vessel disease. Ninety-five percent of lesions were classified as B2/C, 100% as moderately/severely calcified. PM was achieved by using CB in 57% and by RA alone or followed by CB in 43%. In 100%, a DES was implanted. There was no failure to deliver a stent. At 15 +/- 11 months follow-up, the overall major adverse cardiac events (MACE) rate was 9.6% (3.4% cardiac death, 2.3% myocardial infarction, and 3.4% target lesion revascularization [TLR]). The only independent predictor of MACE was LVEF < or =50% (odds ratio 3.88; 95% confidence interval: 1.15-13.1; P = 0.03). The incidence of stent thrombosis (ST) was 2.1%. There were no significant differences in MACE and TLR based on the type of PM used.


CONCLUSIONS
In this population at high risk of restenosis, aggressive PM by CB and/or RA before DES implantation provides excellent mid-term outcomes with only 3.4% TLR and 2.1% ST.