Progress in catheter technology led to the introduction of long balloons of 30, 40, and even 60 mm in length, which improved the acute results in the setting of long lesions by distributing the inflation pressure more evenly across the diseased vessel segment and decreasing the shear forces at the endpoints of the lesion (9,10). Treatment with a 30 mm-long balloon required fewer inflations and resulted in fewer moderate or severe dissections compared to a standard 20 mm balloon (11); however, the use of a long balloon did not appear to influence the risk of restenosis (12). A very long (60 mm) balloon was used in a small study of 14 high-risk patients: Only three patients (21%) required a reintervention and one patient (7%) had undergone surgical revascularization (13).

Another problem with long lesions, especially in the left anterior descending (LAD) artery, is tapering of the vessel. In a study by Banka et al., the incidence of significant tapering (>0.5 mm along 20 mm in length) was found in 42% of the cases (14). The use of a balloon catheter with a decremental diameter, to minimize oversizing of the distal segment, was proposed, resulting in an overall angiographic success rate of more than 95% (14,15).

Conventional balloon angioplasty (BA) provides a possible way of treating long diffused coronary lesions. However, longer lesions clearly carry a heightened risk of restenosis relative to discrete stenoses following BA. In patients with diffuse disease, particularly in heavily calcified vessels, the balloon may either rupture or create dissection at its two shoulders. In addition, proper balloon sizing may be difficult in the presence of diffuse disease, which often renders the angiographic determination of normal vessel reference impossible.

In conclusion, conventional BA of long lesions can be performed with a success and complication rate comparable to that of short, concentric lesions. A long balloon, or in some cases a tapered balloon, is preferable to a standard balloon. Although the data on restenosis are controversial, the risk of restenosis in this patient population seems to be significantly higher.

Although high-speed rotational atherectomy (HSRA) has been proposed as an alternative treatment in patients with complex, long, calcified lesions, who are poor candidates for BA, initial studies with this device in this patient population were discouraging (16). To optimize the immediate results of HRSA, adjunctive PTCA was proposed (17). In the Rotablator multicenter registry, procedural success of HSRA, when combined with BA, the incidence of non-Q-wave MI and Q-wave MI was slightly higher in the group with longer lesions (18). In the Excimer Laser, Rotational Atherectomy, and Balloon Angioplasty Comparison (ERBAC) randomized study, comparing the different strategies to treat patients with complex lesions with rotational atherectomy, excimer laser, or BA alone, those patients who underwent rotational atherectomy had a higher rate of procedural success than those who underwent excimer laser angioplasty or conventional BA (89% versus 77% and 80%, p = 0.0019) (19).

Other recent published multicenter, prospective, randomized studies (Comparison of Balloon Angioplasty versus Rotational Atherectomy [COBRA] and Study to Determine Rotablator and Transluminal Angioplasty Strategy [STRATAS]) to compare the short- and long-term effects of rotablation and percutaneous transluminal coronary angioplasty (PTCA) in patients with angiographically predefined complex coronary artery lesions showed no advantage of rotational atherectomy over routine angioplasty (20,21).

Directional coronary atherectomy (DCA) was developed to treat short (10 mm), noncalcified, eccentric lesions in proximal segments of the coronary artery tree or at bifurcations with large side-branches. Although DCA has been used successfully in lesions >10 mm in length, results from several large randomized DCA trials (Coronary Angioplasty versus Excisional Atherectomy Trial [CAVEAT-I], Balloon versus Optimal Atherectomy Trial [BOAT], and Optimal Atherectomy Restenosis Study [OARS]) indicate an adverse outcome (22, 23, 24, 25, 26, 27).

Analysis from the Excimer Laser Coronary Angioplasty (ELCA) registry, which included 3,000 patients, showed a high procedural success rate of 90% with an acceptable complication rate. Procedural success or complication rates were not influenced by lesion length or complexity (28). However, in subsequent randomized trials (Amsterdam Rotterdam [AMRO] and Excimer Laser, Rotational Atherectomy, and Balloon Angioplasty Comparison [ERBAC]), a trend toward a higher incidence of binary restenosis was observed in the ELCA group compared to the BA group (29,19). This could be explained by a more intense vessel wall injury during laser intervention. More recently published data showed that ELCA did not yield a favorable clinical outcome in patients with long (more than 20 mm) coronary lesions, calcified lesions, small diseased vessels (≤2.5 mm reference diameter), or total coronary occlusions. A worse clinical outcome was observed in patients with tandem lesions treated with ELCA compared with BA (30).

In conclusion, the procedural success of rotational atherectomy in patients with long lesions, whether or not combined with adjunctive BA, seems to be better compared to conventional BA. However, the restenosis rate still is not satisfactory. This device should be preferred in patients with diffuse, calcified lesions. DCA usually is not performed in patients with long lesions, due to a mismatch between the window length of the cutter and the lesion length. The procedural success of ELCA in long, complex lesions is comparable to standard BA. However, the long-term outcome with this technique is disappointing.