This document discusses various adjunct devices that are used in percutaneous coronary interventions (PCI). It describes plaque modification devices like cutting balloons and lasers that can facilitate procedural success and reduce restenosis. Cutting balloons make controlled incisions in plaque to enlarge vessels at lower pressures. Lasers precisely remove plaque but are infrequently used due to high cost. Thrombectomy devices like manual aspiration catheters can reduce thrombus burden in acute myocardial infarction to improve perfusion. Embolic protection devices trap debris during stenting of saphenous vein grafts to prevent distal embolization.

1. Role of Adjunct devices in PCI
Dr Mahadeva Swamy B
SR Cardiology, JIPMER

2. Adjunct devices in PCI
 Plaque modification
 Cutting Balloon (CBA)
 Laser (ELCA)
 Atherectomy (DCA, PTRA)
 Thrombectomy
 EPD

4. Plaque modification
 Atheroablative devices during PCI → facilitate
procedural success and reduce restenosis
 Plaque modification is valuable tool for treatment of
complex lesions
 Vessel pretreatment → larger MLD and lower TLR rate

5. Lesion pretreatment & plaque modification
 Regular balloon & stent do not adequately address
problems of plaque shift and resistant lesions
 Lesion pretreatment is to facilitate procedural
success and reduces restenosis
 Mechanism:
 Minimizes plaque shifting
 Decreases recoil
 Optimal stent expansion

7. Cutting balloon angioplasty (CBA)
 Cutting balloon – controlled longitudinal incisions
(atherotomy)
 Improve luminal enlargement at lower pressure
inflation
 Improved acute results with less barotrauma → long
term clinical benefit

10. Mechanism of action of CBA
 Controlled microincisions in atheroma at lower
pressure – reduced barotrauma
 Better luminal enlargement at lower pressures
 In calcified lesions, CBA achieves larger lumen gain

11. Cutting Balloons

12. Equipment
 Cutting balloons – 6, 10 & 15 mm
 Atherotomes (3-4)are mounted longitudinally along
the balloon surface
Atherotomes Balloon diameter
3 2 & 3.25 mm
4 3.5 & 4 mm

13. Technique
 Less compliant and trackability
 Tortuous proximal anatomy – CBA may not be feasible
 Risk of blade fracture or retention – minimized by slowly
inflation and deflation
Complications:
 Slightly higher risk of coronary perforation (0.8 % vs 0.0
%)

15. Conclusion: Cutting/scoring balloon
 In RCT, cutting balloon alone has not shown to
improve outcomes compared to balloon angioplasty
 CBA – Plaque modification in complex procedures
 Bifurcation lesions
 Ostial lesions
 Mild to moderately calcified lesions
 Instent restenosis

16. Lesion selection
 Bifurcation lesion – plaque shift and high
restenosis
CBA lower restenosis (40 % vs 67%)
 Instent restenosis (REDUCE 3 trial )
Reduced balloon slippage
Plaque extension through the stent struts
 Ostial lesions

18. CBA recommendations
 Class IIb
Cutting balloon angioplasty might be considered to avoid
slippage-induced coronary artery trauma during PCI for
in-stent restenosis or ostial lesions in side branches.
(LOE: C)
 Class III:
Cutting balloon angioplasty should not be performed
routinely during PCI. (LOE: A)
2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

19. Angiosculpt
 Scoring balloon catheter – semicompliant balloon
with nitinol spiral cage
 Low crossing profile (2.7F)
 More flexible alternative to cutting balloon

21. Laser angioplasty
 ELCA – precise plaque removal
 Infrequently used (high cost, lack of benefit over PCI
alone)
 Adjunctive method for debulking

22. Excimer laser
Excimer laser in UV wavelength is well absorbed by both
atheromatous plaques and thrombi
Laser :
 Thrombolysis
 Inhibit platelet aggregation
 May ablate atherosclerotic plaque
Tissue ablation mechanisms:
 Vaporization of tissue (Photothermal effect)
 Ejection of debris (Photoacoustic effect)
 Direct breakdown of molecules (Photochemical dissociation)

23. Excimer laser (ELCA)
 Photoacoustic effects and collateral damage
 Technique:
Laser catheter 1 cm smaller than reference diameter of
vessel
Saline flush
Slow catheter advancement at 0.2 mm/s → maximal
ablation

25. ECLA: Lesion selection
 Long lesions
 Moderately calcified lesions
 Total occlusions (AMRO trial – successful recanalization
in 60 % of uncrossable total occlusions with conventional
guidewires)
 Undilatable lesions ( ECLA has similar success rate as
PTRA)
 No benefit in ISR

26. ECLA recommendations
 Class IIb .
Laser angioplasty might be considered for fibrotic or
moderately calcified lesions that cannot be crossed
or dilated with conventional balloon
angioplasty.(LOE: C)
 Class III.
Laser angioplasty should not be used routinely
during PCI. (LOE: A)
2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

27. Directional coronary atherectomy (DCA)
 First FDA approved non balloon PCI device (1990)
 SilverHawk – novel plaque excision system
 DCA failed to acheive better clinical outcome compared
to PTCA in randomized trials
 Periprocedural MI
 Difficulty in achieving optimal debulking

28. Rotational atherectomy (PTRA)

29. Mechanism of PTRA
 Differential cutting
Cuts more rigid, inelastic material
 Orthogonal friction displacement
Reduces friction between vessel wall and entering
device

30. Rota hardwares

31. Rota burr

32.  Burr /artery ratio: 0.7
 Rotational speed up to 2,00,000 rpm
 Lower rpm 1,40,000 a/w less heat generation and platelet
activation
 Runs should be limited to 20 seconds
 Decelerations of >5000 should be avoided

33. Contraindications to Rotablation
 Dissection
 Angulated lesions (> 60-90⁰)
 Thrombus containing lesion
 Saphenous venous grafts
 Acute MI

34. Indications for PTRA
 Calcified lesions
 Undilatable lesions
 Bifurcation lesion
 Ostial lesion

35. Complications
 Slow flow, no reflow
 Non QWMI
 Coronary perforation
 Dissection
 Bradycardia & AV block
 Vasospasm
Rotablator system failure
 Burr entrapment (Kokesi
effect)
 Burr detachment
 Burr stalling
 Rota guide wire fracture

37. PTRA recommendations
 Class IIa
Rotational atherectomy is reasonable for fibrotic or
heavily calcified lesions that might not be crossed by a
balloon catheter or adequately dilated before stent
implantation. (LOE: C)
 Class III:
Rotational atherectomy should not be performed routinely
for de novo lesions or in-stent restenosis. (LOE: A)

40. Mechanical thrombectomy
 PCI in acute MI @ distal emboli, no reflow & abrupt
closure
 Thrombectomy in primary PCI was a/w improved
myocardial perfusion (TIMI III flow, MBG 3, & ST
resolution)
 No difference in overall 30 day mortality
 Increased risk of stroke
 Survival benefit with manual aspiration catheters and
worse outcome with mechanical devices

41. Simple vs ‘Complex’
X-Sizer AngioJet ThromCat
Pronto Export Diver

42. Manual thrombus aspiration
 Reduction of thrombotic burden
 Prevents of thrombus embolization
 Preservation of microvascular integrity
 Reduction of infarct size
 Improved myocardial tissue perfusion
 Improved LV function recovery and modelling

45. Limitations:
 Difficult delivery along tortuous vessels
 Reduced ability to aspirate at distal segment
 Dissection/perforation
 Distal embolization
 Insufficient thrombus removal

46. Power sourced thrombectomy devices
 Angiojet rheolytic thrombectomy
 Excimer laser
 X-Sizer
 Higher extraction yield in large thrombus burden

47. Angiojet rheolytic thrombectomy
 Venturi effect:
Saline jets inside the catheter that travel at high speed to create a
negative pressure zone
 More effective in removing thrombus <48 hrs duration
 Native coronaries, SVG grafts and peripheral arteries
 Angiojet treat large thrombus burden in STEMI and provide more
effective myocardial perfusion
 Transient bradycardia

51. Recommendations
Aspiration thrombectomy is reasonable for
patients undergoing primary PCI. (Level of Evidence:
B)

52. Coronary ultrasound thrombolysis (Acolysis)
 Acolysis probe deliver low frequency sound – lyse /liquify
the thrombus
 Therapeutic ultrasound frequency - 19 to 50 kHz
 Higher power & low frequencies →higher amplitude of
probe motion (20-110 micro m) → tissue disruption, cavitation
and heating
 Acolysis system in SVG PCI in ACS (RCT)
Lower success and higher 30 day MACE

54. Embolic protection devices
 PCI of SVG grafts and thrombus lesions → distal
microembolization & spasm → no reflow and
periprocedural MI
 EPD’s minimize ischemic injury and no-reflow by
trapping fragmented plaque & thrombus

58. EPD devices Primary PCI
 Disappointing
 No benefit of routine EPD use in primary PCI
(RCT- EMERALD, PROMISE, DEDICATION, PROXIS)
 Lack of benefit of EPD in acute MI
 Delay in reperfusion
 Increased embolization during delivery
 Embolization in to side branches

59.  Class I
Embolic protection devices (EPDs) should be used
during saphenous vein graft (SVG) PCI when
technically feasible. (Level of Evidence: B)

61. THANK YOU