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In the treatment of branch-ostial lesions (BOL) balloon angioplasty (PTCA) is associated with suboptimal results and a higher complication rate. Rotational atherectomy (RA) before PTCA might improve results. This approach was used in 37 patients (mean age 62 +/- 10 years; 27 men, 10 women) with 42 BOL. Mean burr size was 1.7 +/- 0.3 mm; burr-artery ratio was 0.75 +/- 0.10. Procedural success was achieved in 39 (93%) BOL; the only major complication was a periprocedural myocardial infarction (CPKMB=58IU/ml). In 2 cases the stenosis was not crossed by the guidewire. Diameter stenosis (DS) decreased from 72 +/- 14% before RA to 30 +/- 12% after RA (p < 0.001) and 15 +/- 10% after PTCA (p < 0.001). All patients with a successful procedure underwent repeat angiography 24 hours DS was 18 +/- 15 (NS versus after PTCA); no lesion had DS > or = 50%. RA with adjunctive PTCA is a safe and effective treatment of BOL, with short-term stable results.

Over the past 16 years coronary angioplasty has become an established therapy for coronary artery disease. Advances in technology and growing operator experience have improved initial success rates, lowered the complications associated with coronary angioplasty and expanded the indications of percutaneous revascularization to include large numbers of patients with complex lesions. The mechanisms of coronary angioplasty include plaque fracture, intimal atherosclerotic flaps, localized medial dissection and stretching of plaque-free segments. The problems and limitations of coronary angioplasty are: unfavourable lesion morphology which may preclude complete revascularization or increase the risk of major complications, "high-risk" patients requiring pharmacological or mechanical support, acute coronary occlusion, and restenosis, the 2 latter problems being related to the very mechanisms of coronary angioplasty. Recently, new interventional devices have been introduced: intracoronary stents, directional coronary atherectomy, rotational atherectomy, transluminal extraction atherectomy, excimer laser coronary angioplasty. A multidevice lesion-specific approach integrated with balloon angioplasty may optimize procedural results in a growing number of patients with complex coronary lesions. However, restenosis occurring within 6 months after successful angioplasty remains the "Achilles' heel" of coronary interventional procedures and erodes the potential advantages angioplasty holds over coronary bypass surgery. These 2 forms of myocardial revascularization are currently compared for the treatment of multivessel disease in randomized trials.

Ambulatory coronary arteriography was carried out in 604 patients, 143 women and 461 men, mean age 53 +/- 14 years. An absolutely stable clinical condition was the main criterion of selection for this investigation and the protocol consisted in day-hospital admission, absence of routine anticoagulation, small calibre (5 French = 1.7 mm diameter) catheters, mobilization 4 hours and discharge 6 hours after the end of the procedure. The percutaneous femoral approach was used in 95% of cases; 56% of patients presented significant single-or multi-vessel coronary artery disease: there were 7 cases of left main coronary artery narrowing; 31 patients required full hospital admission, mainly because of the severity of coronary lesions. Minor complications occurred in 2% of cases.