Recognition of the limitations of coronary artery balloon angioplasty fostered the development of nonballoon approaches to percutaneous coronary revascularization. Directional coronary atherectomy (DCA), which received US Food and Drug Administration (FDA) approval in 1990, was the first such technique to be widely applied. The basis for this technique was directionally controlled resection and removal of atheromatous plaque (Fig. 7–1). DCA, which was limited to proximal and midcoronary arterial sites and saphenous vein grafts, produced a larger and smoother lumen than that achieved with conventional balloon angioplasty, and it was hoped that this improved result would translate into fewer complications and even potentially less restenosis. However, initial randomized trials [1–5] comparing DCA with balloon angioplasty for the treatment of de novo native coronary artery lesions (CAVEAT [Coronary Angioplasty Versus Excisional Atherectomy Trial] and CCAT [Canadian Coronary Atherectomy Trial]) did not show significantly better long-term results with DCA; indeed, initial hospital stay was complicated by more non-Q-wave infarctions in the DCA group [1,2].
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