Akram Y. Elgendy

There are several techniques for performing coronary atherosclerotic plaque modification, known as atherectomy. Historically, clinical trials show mostly equivalence between various coronary atherectomy techniques, balloon angioplasty, and percutaneous coronary stenting. In the last several years the use of a given atherectomy technique has been mostly as a means of facilitating stent delivery in vessels that are heavily calcified. No clinical trials have shown superiority of any atherectomy method over more standard techniques of percutaneous coronary intervention. This review begins with a discussion of directional atherectomy, which is no longer available. The rotational atherectomy technique and its clinical trial data are presented. Orbital atherectomy is then discussed in detail, including the relevant clinical trials. Finally, laser atherectomy techniques are reviewed, and the pertinent trial data are presented. Lastly, future directions are detailed.

The efficacy of second‐generation drug‐eluting stents (DES; eg, everolimus and zotarolimus) compared with bare‐metal stents (BMS) in patients undergoing percutaneous coronary intervention was challenged recently by new evidence from large clinical trials. Thus, we aimed to conduct an updated systematic review and meta‐analysis of randomized clinical trials (RCTs) evaluating the efficacy and safety of second‐generation DES compared with BMS. Electronic databases were systematically searched for all RCTs comparing second‐generation DES with BMS and reporting clinical outcomes. The primary efficacy outcome was major adverse cardiac events (MACE); the primary safety outcome was definite stent thrombosis. The DerSimonian and Laird method was used for estimation of summary risk ratios (RR). A total of 9 trials involving 17 682 patients were included in the final analysis. Compared with BMS, second‐generation DES were associated with decreased incidence of MACE (RR: 0.78, 95% confidence interval [CI]: 0.69‐0.88), driven by the decreased incidence of myocardial infarction (MI) (RR: 0.67, 95% CI: 0.48‐0.95), target‐lesion revascularization (RR: 0.47, 95% CI: 0.42‐0.53), definite stent thrombosis (RR: 0.57, 95% CI: 0.41‐0.78), and definite/probable stent thrombosis (RR: 0.54, 95% CI: 0.38‐0.80). The incidence of all‐cause mortality was similar between groups (RR: 0.94, 95% CI: 0.79‐1.10). Meta‐regression showed lower incidences of MI with DES implantation in elderly and diabetic patients (P = 0.026 and P < 0.0001, respectively). Compared with BMS, second‐generation DES appear to be associated with a lower incidence of MACE, mainly driven by lower rates of target‐lesion revascularization, MI, and stent thrombosis. However, all‐cause mortality appears similar between groups.

Randomized clinical trials that examined long‐term clinical outcomes of routine aspiration thrombectomy prior to primary percutaneous coronary intervention (PCI) in patients with acute ST‐segment elevation myocardial infarction have yielded different results. We hypothesized that the routine use of manual thrombus aspiration prior to primary PCI lacks long‐term clinical benefits. Electronic databases were searched for randomized trials comparing routine aspiration thrombectomy and conventional PCI. We included only trials that reported clinical outcomes beyond 6 months. The primary outcome was all‐cause mortality, and the secondary outcomes included major adverse cardiovascular events, re‐infarction, cardiovascular mortality, and stent thrombosis (ST). A DerSimonian‐Laird model was used to construct the summary estimates risk ratio (RR). We retrieved 18 trials with 20 641 ST‐segment elevation myocardial infarction patients, of whom 10 331 patients underwent routine aspiration thrombectomy prior to primary PCI. At a mean follow‐up of 12 months, there was no significant decrease in the risk of all‐cause mortality (RR: 0.93, 95% confidence interval [CI]: 0.82‐1.05, P = 0.22), major adverse cardiac events (RR: 0.95, 95% CI: 0.87‐1.03, P = 0.18), re‐infarction (RR: 0.95, 95% CI: 0.80‐1.13, P = 0.59), cardiovascular mortality (RR: 0.80, 95% CI: 0.47‐1.36, P = 0.40), or ST (RR: 0.80, 95% CI: 0.63‐1.01, P = 0.06) with routine aspiration thrombectomy. Routine aspiration thrombectomy prior to primary PCI was not associated with a reduction in long‐term mortality or clinical outcomes. Future randomized trials are warranted to further evaluate the role of aspiration thrombectomy in select patients and coronary lesions.