Directional atherectomy

Summary

The concept of atherectomy, defined as excision and removal of atherosclerotic plaque by a transcatheter technique, was introduced by Simpson et al in 1985. Thereafter, the technique underwent several generational improvements. Intuitively, directional coronary atherectomy prior to stenting should be complementary in reducing restenosis since in-stent restenosis is mainly due to neointima formation, which is increased proportionally to the amount of plaque. Furthermore, plaque removal prior to stent implantation may allow greater and more uniform stent expansion, and minimise plaque shift, thereby improving angiographic and clinical results. Several single-centre and multicentre registries supported the concept that directional atherectomy prior to stenting would reduce restenosis. However, 2 randomised trials (AMIGO and DESIRE) failed to substantiate the findings of these registries. The introduction of drug-eluting stents has further decreased the utilisation of atherectomy. Nevertheless, recent device registries have suggested that the combination of drug-eluting stents and directional atherectomy may reduce restenosis in complex lesions such as left main bifurcations. Careful lesion selection and optimal atherectomy are essential in preventing complications and determining the efficacy of directional atherectomy in improving angiographic outcomes. There may still be a role in the drug-eluting stent era for performing lesion debulking with atherectomy prior to stent...