Angiographic and clinical outcomes of 100 consecutive severe calcified lesions requiring rotational atherectomy prior to sirolimus-eluting stent implantation in hemodialysis and non-hemodialysis patients

Abstract

Both severe calcified lesions and hemodialysis (HD) are predictors for high rates of restenosis, even in the drug-eluting stent era. We sought to investigate the angiographic and clinical outcome in a population of HD versus non-hemodialysis (non-HD) patients with severe calcified lesions requiring rotational atherectomy. One hundred consecutive lesions (28 lesions in the HD group, 72 in the non-HD group) from 82 patients (19 patients in the HD group, 63 in the non-HD group) requiring rotational atherectomy prior to sirolimus-eluting stent (SES) implantation were analyzed post-procedure and at 8 months. Clinical outcomes were assessed at 12 months. Inclusion criteria were calcified lesions with >270° of superficial calcification on the intravascular ultrasound (IVUS), lesions that the IVUS could not cross, or undilatable lesions. There were no differences in patient characteristics except for age. Although both baseline and post-procedure angiographic findings were similar between the two groups, late loss in stented segment was significantly greater in the HD group than in the non-HD group (HD vs. non-HD: 0.69 ± 0.74 mm vs. 0.34 ± 0.50; P = 0.030). Also, the HD group revealed significantly worse clinical outcomes. In conclusion, mid-term results of highly complex, severely calcified lesions requiring rotational atherectomy in non-HD patients were permissible as compared to on-label lesions. However, in HD patients, both angiographic and clinical outcomes were still suboptimal in this lesion subset, even using SES.

Clinical Characteristics and Long-Term Outcomes of Rotational Atherectomy ― J2T Multicenter Registry ―

“…13 Kyono et al also reported that both angiographic and clinical outcomes were still suboptimal for highly complex, severely calcified lesions requiring RA in patients with hemodialysis, even when using DES. 25 The present study provides one of the largest sets of observational data with the longest follow-up period, and confirms a 21.5% rate of cardiac death, similar to other registry data from smaller samples with shorter follow-up. In contrast, statin use was the only significant predictor associated with more positive outcomes on multivariate analysis.…”

Comparison of clinical outcomes of coronary artery stent implantation in patients with end‐stage chronic kidney disease including hemodialysis for three everolimus eluting (EES) stent designs: Bioresorbable polymer‐EES, platinum chromium‐EES, and cobalt chrome‐EES

“…In addition, several studies have identified dialysis as the strongest predictor of adverse outcomes after PCI . The increased risk of adverse outcomes among patients with CKD, particularly those on HD, might be associated with the severity of calcified lesions, enhanced platelet activation, and differences in the physiological measurement of fractional flow reserve . Coronary in‐stent restenosis among patients with CKD might also result from neointimal hyperplasia, a very complex process that is influenced by several pathophysiological mechanisms, including vascular inflammation, an increase of calcification promoters and the activation of the renin‐angiotensin system, resulting in an enhanced production of reactive oxygen species …”

Cardiovascular Disease in Patients with End-Stage Renal Disease on Hemodialysis

“… 36 , 37 ) Rotablator can theoretically facilitate stent delivery and stent expansion as well as avoidance of polymer damage. Several studies evaluated clinical outcomes after rotational atherectomy and SES implantation between hemodialysis and non-hemodialysis patients with severely calcified lesions; they found that clinical outcomes were significantly worse in hemodialysis patients than in non-hemodialysis patients 38 – 40 ) ( Fig. 2 ).…”