In-hospital and mid-term outcomes of octogeneric and nonageneric patients with heavily calcified coronary lesions treated with rotational atherectomy

Background: Severely calcified coronary lesions are a growing problem in contemporary percutaneous coronary intervention (PCI), especially with the aging of the general population.

Aim: To investigate in-hospital and mid-term outcomes of octogenarian and nonagenarian patients with heavily calcified coronary lesions treated with rotational atherectomy (RA).

Methods: Patients who underwent RA at our center between 2003 and 2023 in a single center were divided into two groups: octogenarians/nonagenarians (age ≥80 years) (n=192) and a control group (age < 80 years) (n=583). Patients presented with acute coronary syndrome (ACS) and those treated with bare metal stents were excluded. In-hospital adverse outcomes were defined as a composite endpoint of residual in stenosis ≥ 30%, persistent slow flow at the end of the procedure,  dissection beyond the primary lesion that necessitates stenting, perforation, burr entrapment, death, periprocedural myocardial infarction, target vessel revascularisation or stroke. After one year a patient oriented composite endpoint (POCE) was
assessed as a composite of cardiac death, spontaneous MI and target lesion revascularisation (TLR).

Results: The octogenarian/nonagenarian group was more frequently female (p=0.021) with chronic renal insufficiency (p<0.001). Other comorbidities such as diabetes mellitus and arterial hypertension were comparable between study groups. The octogenarian/nonagenarian patients had more left main trunk (p=0.001) and bifurcation (p=0.028) target lesions, as well as longer stented lengths (p=0.067) and more frequent use of new-generation DES (p=0.001).
The in-hospital adverse outcome rates were 9.4% in the octogenarian/nonagenarian group versus 13.9% in the control group (p=0.107). After adjusting for potential confounders, octogenarians/nonagenarians experienced more POCE (21% vs 13%) (adj. HR 1.64; 95% CI 1.05-2.54, p=0.028) at one year, which was solely driven by higher cardiac death rates (14% vs 4%) (adj. HR 3.93; 95% CI 2.13-7.27, p<0.001).

Conclusion: RA is both feasible and safe for octogenarian and nonagenarian patients, with in-hospital adverse outcomes comparable to those seen in the general population. Consequently, this approach to lesion preparation should not be denied to extreme elderly patients. However, advanced age continues to be a significant predictor of patient-oriented composite endpoints (POCE), largely due to the inherently higher rates of cardiac mortality in this age group.