A Comparison of Directional Atherectomy with Balloon Angioplasty for Lesions of the Left Anterior Descending Coronary Artery

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Abstract
Restenosis is a major limitation of coronary angioplasty. Directional coronary atherectomy was developed with the expectation that it would provide better results than angioplasty, including a lower rate of restenosis. We undertook a randomized, multicenter trial to compare the rates of restenosis for atherectomy and angioplasty when used to treat lesions of the proximal left anterior descending coronary artery. Of 274 patients referred for first-time, nonsurgical revascularization of lesions of the proximal left anterior descending coronary artery, 138 were randomly assigned to undergo atherectomy and 136 to undergo angioplasty; 257 of 265 eligible patients (97 percent) underwent follow-up angiography at a median of 5.9 months. Computer-assisted quantitative measurements of luminal dimensions were determined from the angiograms obtained before and immediately after the procedure and at follow-up. The primary end point of restenosis was defined as stenosis of more than 50 percent of the vessel's diameter at follow-up. Quantitative analysis showed that the procedural success rate was higher in patients who underwent atherectomy than in those who had angioplasty (94 percent vs. 88 percent, P = 0.061); there was no significant difference in the frequency of major in-hospital complications (5 percent vs. 6 percent). At follow-up, the rate of restenosis was 46 percent after atherectomy and 43 percent after angioplasty (P = 0.71). Despite a larger initial gain in the minimal luminal diameter with atherectomy (mean [±SD], 1.45 ±0.47 vs. 1.16 ±0.44 mm; P<0.001), there was a larger late loss (0.79 ±0.61 vs. 0.47 ±0.64 mm, P<0.001), resulting in a similar minimal luminal diameter in the two groups at follow-up (1.55 ±0.60 vs. 1.61 ±0.68, P = 0.44). The clinical outcomes at six months were not significantly different between the two groups. the role of atherectomy in percutaneous coronary revascularization remains to be fully defined. However, as compared with angioplasty, atherectomy did not result in better late angiographic or clinical outcomes in patients with lesions of the proximal left anterior descending coronary artery. (n Engl J Med 1993;329:228-33.).