The use of stents during coronary angioplasty has increased over the past few years. In selected patients, stents can improve early and long-term clinical outcomes. However, extending stent use to patients with complex lesions or small vessels produces less favorable results. Directional coronary atherectomy was developed to excise obstructive coronary atheroma and, when combined with intravascular ultrasonography, directional coronary atherectomy has provided good long-term results in patients with coronary artery disease. No recent studies have compared the effectiveness of primary stenting with that of directional coronary atherectomy. Tsuchikane and associates compared angiographic and clinical outcomes of stent placement during coronary angioplasty and atherectomy by aggressive directional coronary atherectomy using intra-vascular ultrasonography.

The STent versus directional coronary Atherectomy Randomized Trial (START) was a randomized clinical trial designed to compare primary stenting with aggressive directional coronary atherectomy. Patients were eligible for the study if angiographic data indicated that they had suitable coronary artery lesions for stenting or directional coronary atherectomy. Those who met the enrollment criteria were randomized to receive stent placement during angioplasty or directional coronary atherectomy. Patients were assessed for various complications and blood chemistry at baseline and again at four, six and 24 hours postoperatively. Clinical follow-up examinations were conducted at three, six and 12 months with coronary angiography and intravascular ultrasonography to assess the occurrence of an adverse cardiac event. The primary angiographic end point of the study was restenosis six months after the procedure.

A total of 122 patients enrolled in the study, with 60 receiving directional coronary atherectomy and the others receiving stents. Angiographic lesion characteristics were similar between groups. Initial procedural success was obtained in all patients enrolled in the study, and there were no major complications during or after either procedure. Minimal lumen diameter and diameter stenosis measurements obtained immediately after the procedure were the same in both groups. However, minimal lumen diameter was significantly smaller and diameter stenosis significantly higher in the stent group at three and six months. Binary angiographic restenosis rates were also significantly higher (23 versus 8.5 percent) in the stent group compared with the directional coronary atherectomy group at this time. At six months, angiographic restenosis rates were significantly lower in the directional coronary atherectomy group (32.8 versus 15.8 percent). After one year, there were no deaths in the directional coronary atherectomy group and only one in the stent group.

The authors conclude that directional coronary atherectomy provides better clinical and angiographic outcomes in patients with coronary artery disease than primary stenting during angioplasty. They also emphasize that relatively large vessels are most suitable for directional coronary atherectomy.