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The first successful coronary angioplasty was performed by Andrea Gruentzig in 1977. This procedure has become widely accepted around the world. However, there were 2 major limitations of this initial procedure ; 1. Abrupt closure immediately after the procedure (approximately 5%). 2. Restenosis at the chronic stage (approximately 40% to 50%). Directional coronary atherectomy (DCA) was developed by Dr. John Simpson and first became available in 1990 in the USA. DCA was expected to reduce the abrupt closure rate and the late restenosis of balloon angioplasty. However, the first large randomized clinical trial (CAVEAT study) failed to demonstrate the superiority of DCA compared to balloon angioplasty. Even though the restenosis rate was similar in both groups, the incidence of early-phase composite endpoint was higher in the atherectomy group than the angioplasty group. Thereafter, intravascular ultrasound (IVUS)-guided DCA was recommended to debulk the coronary artery plaque effectively and safely as the previous studies reported that 70% of coronary artery plaque was eccentric -. In the late 1990’s, several studies demonstrated the superiority of DCA compared to balloon angioplasty using the IVUS-guided technique -. However, coronary stenting became available in 1994 ; and accordingly, the dual anti-platelet therapy was established in 1995. Many studies demonstrated that coronary stenting was effective to control abrupt closure and reduce restenosis compared to balloon angioplasty . Consequently, many user-friendly stents were developed and became widely accepted due to the fact that stenting was simple, easy to perform, and effective. In addition, the drug-eluting stent (DES) first became available in 2001 and the restenosis rate was reduced to less than 10%. Under this environment, DCA device users declined, with the DCA catheter removed from the device market in 2008. On the other hand, there were some Japanese cardiologists who strongly desired to revive the DCA device. They reported in 2007 that DCA was useful for limited patients, especially for bifurcated lesions including left main trunk, the ostial left ascending coronary artery and the ostial left circumflex coronary artery ; 2% of target vessel revascularization and no stent thrombosis (PERFECT study). A new DCA catheter has been developed by NIPRO corporation (Osaka, Japan) and was approved by the Japan Ministry of Health, Labor and Welfare in December 2014. Nobuyuki Soeda (a medical engineer of our hospital) and I were actively involved in the device development process. This article introduces the newly developed DCA catheter and considers the role of this device in the DES era.

The Role of the Revived Directional Coronary Atherectomy (DCA)