الفهرس 
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Abstract
Summary
In the field of interventional cardiology, heavily calcified coronary lesions (HCCL) pose great technical challenges and are associated with a high frequency of restenosis and target lesion revascularization (TLR) (Moses, Carlier and Moussa, 2004).
Advanced age, renal disease and diabetes have all been associated with coronary artery calcification (CAC), with severe CAC affecting between 6 and 20% of patients treated with PCI. Occasionally, the degree of calcification and geometry of the plaque prevents the crossing of the lesion with balloon or stent; also heavily calcified lesions are difficult to dilate adequately and are associated with failure to deliver a stent, impaired drug delivery and possible polymer disruption with drug-eluting stents (DES), and stent under expansion. Revascularization of calcified lesions results in significantly increased periprocedural complications, long-term adverse events and high rates of restenosis (Généreux et al., 2014). Adequate lesion preparation before stent implantation remains an essential component of contemporary practice of coronary-stent implantation in patients with complex lesions to improve both immediate and long-term outcomes. CAC is routinely encountered yet often underdiagnosed with angiography. Intravascular ultrasound (IVUS) studies have demonstrated that CAC is missed in nearly half of the cases with angiography alone (Mintz et al., 1995). Recognition of heavily calcified lesions allows appropriate utilization of ablative techniques for initial vessel preparation. It was gradually demonstrated that CT is much more sensitive than fluoroscopy in calcium detection (Stanford, Thompson and Weiss, 1993). Patients with extensive CAC (CT-calcium score >1,000) represent a unique very high-risk phenotype with mortality outcomes commensurate with high-risk secondary prevention patients (Peng et al., 2019). Intravascular imaging has provided insights into the etiology of in-stent restenosis (ISR) and the role that inadequate vessel preparation often plays (Witzenbichler et al., 2014). To address the challenges faced by CAC, lesion preparation has evolved over the past four decades to help optimize the results of PCI. Rotational atherectomy is one of several ways to perform atherectomy in a coronary vessel. It is the most commonly used atherectomy device and removes atheromatous plaque by differential cutting, that is removing the inelastic calcified plaque with microscopic (20 to 50 micrometers) diamond chips embedded on the surface of a rapidly rotating (150,000 to 200,000 rpm) olive-shaped burr. Such abrasion generates 2 to 5-micrometer micro particles that propagate through the coronary microcirculation and are removed by the reticuloendothelial system. The burr travels over a specialized 0.009-inch guide wire and is available in diameters ranging from 1.25 to 2.50 mm. In the setting of severe calcification, smaller burr sizes should be used initially, followed by larger burrs in 0.25 to 0.50-mm increments up to 70% of the reference vessel diameter. David Auth first investigated the possibility of using a rotational device to debulk atherosclerotic plaque in the early 1980s. Fourier et al. performed the first case of RA in human coronary arteries in 1988. (Sharma et al., 2019)(Zhang et al., 2019)(Dhillon et al., 2019).
Our study is a randomized single center controlled clinical trial that was conducted in the Cardiology department of Beni-Suef university hospital which is a high-volume cardiac centerbetween July 2020 & January 2022.
Our study objective was examining success of rotational atherectomy versus balloon-based `strategy (non-compliant or modified balloons) as debulking methods for lesion preparation before drug-eluting stents implantation in patients with very high calcium score >1000 as measured by MDCT. Thirty patients were enrolled (fifteen patient for each group).
Clinical inclusion criteria:
1- Age above 18 years and consentable.
2- Angiographically proven coronary artery disease.
3- Anginal symptoms and/or reproducible ischemia in the target area by ECG, functional stress testing, or fractional flow reserve
4- Calcium score more than 1000 on MS-CT coronary angiography.
5- Provided informed consent.
Angiographic Inclusion criteria:
1- De-novo lesion in a native coronary artery
2- Target reference vessel diameter between 2.25 and 4.0 mm by visual estimation
3- Luminal diameter reduction of 50-100% by visual estimation
4- Severe calcification of the target lesion is defined as radiopacities noted without cardiac motion before contrast injection generally compromising both sides of the arterial lumen.
Clinical exclusion criteria:
1- Myocardial infarction within 1 week
2- Decompensated heart failure
3- Limited long-term prognosis due to other conditions.
Angiographic exclusion criteria:
1- The target lesion is in a coronary artery bypass graft
2- Target lesion is an in-stent restenosis
3- Target vessel thrombus.
Results:
Our study showed that RA appears to be feasible and effective, with a high rate of procedural success and favorable short- and long-term outcomes as the strategy of pre-dilatation with balloon angioplasty failed in almost 46.6% (7 patients) of attempted procedures versus 100% (15 patients) in the RA arm.
There were no statistically significant differences regarding secondary outcomes.
Conclusion:
In conclusion, lesion preparation with upfront RA before DES implantation is feasible in nearly all patients with complex calcified coronary lesions (as high as >1000 ca-score as detected by MS-CT) and is more commonly successful as a primary strategy compared with conventional PCI using non-compliant balloons.