Directional coronary atherectomy: Still in evolution

In both the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) and the Canadian Coronary Atherectomy Trial (CCAT), directional coronary atherectomy (DCA) achieved better initial angiographic results than did percutaneous transluminal coronary angioplasty (PTCA). However, DCA was associated with higher rates of periprocedural myocardial infarction and abrupt closure (at least in CAVEAT). Moreover, only in the prespecified subgroup of CAVEAT patients with lesions in the proximal left anterior descending artery were restenosis rates significantly lower in DCA-treated patients than in PTCA-treated patients. Since completion of these trials, there has been increasing emphasis on the need to achieve an ideal angiographic result to substantially decrease restenosis. Whether this strategy of more aggressive tissue removal by DCA and post-atherectomy dilatation to achieve an optimal result will decrease restenosis rates or increase complication rates is the subject of an ongoing randomized trial.