Advances in percutaneous interventions have profoundly changed the way we manage patients with coronary and peripheral arterial disease. Though the use of stents, particularly drug-eluting stents, is the preferred method for revascularization because of ease of use and lower restenosis rates, there are many short comings. Ostial and bifurcation lesions as well as heavily calcified and tortuous arteries remain problematic. Mechanical debulking with rotational and direct coronary atherectomy may be beneficial in these situations. In this review, we present the general concepts of mechanical debulking and attempt to summarize the available data on its use in the setting of drug-eluting stents. In addition, we will discuss its special role in the management of peripheral arterial disease.
Drug-eluting stents have profoundly impacted the interventional cardiology fi eld. Their effi cacy against the smooth muscle hyperplasia responsible for in-stent restenosis has signifi cantly altered practice patterns and patient selection for percutaneous and surgical revascularization. However, their potent antiproliferative properties and polymer coatings delay the healing process of the arterial wall and appear to prolong the duration of stent thrombogenicity. The actual clinical impact of this effect is controversial. However, the sequelae of stent thrombosis can be catastrophic and have driven much recent discussion on this subject. This article attempts to provide perspective on the benefi ts and limitations of these devices so that their use achieves maximum benefi t and lowest risk.
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