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OBJECTIVES This study was conducted to evaluate: 1) the effect of adjunctive percutaneous transluminal coronary angioplasty (PTCA) after directional coronary atherectomy (DCA) compared with stand-alone DCA, and 2) the outcome of intravascular ultrasound (IVUS)-guided aggressive DCA. BACKGROUND It has been shown that optimal angiographic results after coronary interventions are associated with a lower incidence of restenosis. Adjunctive PTCA after DCA improves the acute angiographic outcome; however, long-term benefits of adjunctive PTCA have not been established. METHODS Out of 225 patients who underwent IVUS-guided DCA, angiographically optimal debulking was achieved in 214 patients, then they were randomized to either no further treatment or to added PTCA. RESULTS Postprocedural quantitative angiographic analysis demonstrated an improved minimum luminal diameter (2.88 ± 0.48 vs. 2.6 ± 0.51 mm; p = 0.006) and a less residual stenosis (10.8% vs.15%; p = 0.009) in the adjunctive PTCA group. Quantitative ultrasound analysis showed a larger minimum luminal diameter (3.26 ± 0.48 vs. 3.04 ± 0.5 mm; p CONCLUSIONS With IVUS guidance, aggressive DCA can safely achieve optimal angiographic results with low residual plaque mass, and this was associated with a low restenosis rate. Although adjunctive PTCA after optimal DCA improved the acute quantitative coronary angiography and quantitative coronary ultrasonography outcomes, its benefit was not maintained at six months.

The Shiga Pravastatin Study (SHIPS) is a 5 center randomized, double blind placebo controlled trial to test whether pravastatin, 10 mg twice daily begun at least 10 days prior to elective PTCA in patients with total cholesterol (T-Chol) hess than 280 mg/dl can decrease restenosis. The endpoint is a between group comparison of frequency of restenosis defined as a more than 50% loss of gain at PTCA site at 3 months follow-up by automated quantitative coronary arteriography. 179 lesions (85 pravastatin. 94 placebo) in 124 patients (62 pravastatin. 62 placebo) were randomized. The two groups were comparable for baseline clinical and angiographic characteristics. T-Chol decreased from 204 to 172 mg/dl in pravastatin group (P l 0.001), but not in placebo (201 vs 202 mg/dl). Although restenosis rate was not different in the two groups (29.4% in pravastatin vs 39.4% in placebo. P = 0.16) as a whole, it was reduced to about 1/5 (8.B%) in pravastatin group compared to 44.B% in placebo (P = 0.0011) when the analysis was restricted to high grade lesions (≥ 75% diameter stenosis by automated analysis. which is equivalent to ≥90% stenosis by visual analysis; 34 lesions in pravastatin, 29 lesions in placebo). The effect of pravastatin in prevention of restenosis in high grade lesions was equally seen both in the groups with baseline T-Chol of above (10.5 vs 45.5%, P = 0.029) and below 200 mg/dl (6.7 vs 44.4%. P = 0.015). Conclusion Pravastatin prevents restenosis after PTCA of high grade lesions irrespective of baseline T-Chol level.