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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\n      \u003Ch2\u003ESummary\u003C\/h2\u003E\n      \u003Cp id=\u0022p-1\u0022\u003EAlthough data indicate that plaque modification does not have a direct influence on target lesion restenosis, it improves stent expansion and makes otherwise impossible cases possible. This article provides an overview of the need for devices to pretreat complex lesions with PM.\u003C\/p\u003E\n   \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecoronary artery disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n      \u003Cp id=\u0022p-2\u0022\u003ECalcified coronary lesions may be associated with stent underexpansion, malapposition, and high rates of restenosis. Aggressive plaque modification (PM) before stenting can reduce the risk of restenosis [Vaquerizon B et al. \u003Cem\u003EJ Interv Cardiol\u003C\/em\u003E 2010]. Although data indicate that PM does not have a direct influence on target lesion restenosis, it improves stent expansion and makes otherwise impossible cases possible. Jos\u00e9 F. D\u00edaz, MD, Juan Ramon Jimenez University Hospital, Huelva, Spain, provided an overview of the need for devices that are currently available to pretreat complex lesions with PM.\u003C\/p\u003E\n      \u003Cp id=\u0022p-3\u0022\u003EThere are several mechanical approaches that are available for PM. Some have been developed to ablate atheromatous plaque during percutaneous coronary interventions (PCIs), including the rotablator, cutting balloon, and a scoring device, which is similar to the cutting balloon.\u003C\/p\u003E\n      \u003Cp id=\u0022p-4\u0022\u003ERotational atherectomy is achieved using the diamond-headed rotablator, which employs differential cutting to remove inelastic tissue. Elastic tissue (healthy) is able to deflect out of the way of the rotablator and remains (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). The rotablator is best employed at medium rotational speeds (150,000 rpm) to polish the inside of the artery. This reduces platelet aggregation. This device should not be used in vessels with left ventricular dysfunction, vessels with extreme tortuosity, or saphenous vein grafts; where there is evidence of thrombus; for dissection; or in vessels with chronic total coronary occlusions. The rotablator has also not been proven to offer any advantages when used as a debulking device, at least regarding target vessel revascularization (TVR) or restenosis. However, it may be useful in situations in which there are heavily calcified lesions or the balloon is unable to cross\/dilate the lesion.\u003C\/p\u003E\n      \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\n         \u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\n            \n               \u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/6\/29\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Rotablator Principle of Operation.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-740745029\u0022 data-figure-caption=\u0022Rotablator Principle of Operation.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/6\/29\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\n            \n            \n         \u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/6\/29\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/6\/29\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12520\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\n         \u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\n            \u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003ERotablator Principle of Operation.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from J. Diaz, MD.\u003C\/q\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\n      \u003Cp id=\u0022p-6\u0022\u003EThe cutting balloon consists of a noncompliant balloon with 3 to 4 cutting microtomes (a sectioning instrument that allows for the cutting of extremely thin slices) that are mounted on its surface, allowing for controlled cutting of the intima. Like the rotablator, the use of the cutting balloon is increasing in Spain (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E). Like the rotablator, balloon cutting offers no clear advantages regarding rates of restenosis and TVR, but its use does result in less dissection, bailout stenting, balloon slippage, and plaque shifting. It may be particularly useful for small vessels, bifurcated vessels, ostial lesions, and in-stent restenosis. The major drawback is deliverability.\u003C\/p\u003E\n      \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\n         \u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\n            \n               \u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/6\/29\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Cutting Balloon.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-740745029\u0022 data-figure-caption=\u0022Cutting Balloon.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/6\/29\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\n            \n            \n         \u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/6\/29\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/6\/29\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12522\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\n         \u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\n            \u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003ECutting Balloon.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from J. Diaz, MD.\u003C\/q\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\n      \u003Cp id=\u0022p-8\u0022\u003EThe third device, the scoring balloon, consists of 3 nitinol spiral \u201cscoring\u201d wires with nitinol-enhanced active deflation. It has a low crossing profile (2.7F) and is compatible with a 6F catheter or 5F sheath. It offers the advantages of being a nonslip device (avoids \u201cgeographic miss\u201d), fewer dissections, fewer \u201csnowplow effects\u201d (pushing atherothrombotic material into a side branch or downstream), good deliverability, and having better stent expansion\/apposition. One study has shown that pretreatment with the scoring balloon enhanced stent expansion and minimized the difference between predicted and achieved stent dimensions [De Ribamer Costa, Jr J et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E 2007]. In another study that was conducted in Israel (Israeli Registry), PM was performed with the scoring balloon prior to stent implantation in 745 patients. Procedural and clinical success rates were greater than 96%, device slippage occurred in only 1.2% of lesions, and there were no scoring balloon-related perforations.\u003C\/p\u003E\n      \u003Cp id=\u0022p-9\u0022\u003EAlthough early studies show the PM has little impact on the rate of restenosis, target lesion restenosis, or death rates and may increase procedural myocardial infarction and major cardiac adverse events [Bittl J et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2004], Prof. Diaz believes PM may be important when dealing with selected acute cases. Specifically, it may help to decrease plaque volume and shifting, alter calcification, increase lesion compliance, facilitate stent delivery, and minimize vessel trauma.\u003C\/p\u003E\n   \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/6\/29.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzn0uq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzn0uq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}