Current Status of Atherectomy for Peripheral Arterial Occlusive Disease

Abstract

Atherectomy physically removes plaque by cutting, pulverizing, or shaving it in atherosclerotic arteries using a mechanical, catheter-deliverable endarterectomy device. Theoretically, atherectomy offers the following advantages over percutaneous transluminal angioplasty (PTA): It shows a greater immediate success rate with less dissection and acute occlusion, treats complex lesions, and reduces the restenosis rate. This article presents the unique features of four atherectomy devices designed to meet the above challenges: Simpson AtheroCath, Transluminal Extraction Catheter (TEC), Trac-Wright Catheter, and Auth Rotablator. The results, complications, and limitations reported by clinical investigators are discussed critically and realistically. A new device, the OmniCath, under investigative trial, is presented briefly. Clinical studies evaluating the Simpson AtheroCath have reported impressively high initial success rates (ranging from 82% to 100%) but disparate intermediate patency results (ranging from 35% to 84%). Complications associated with the device include hematoma, pseudoaneurysm, and distal embolization. Clinical studies show that the device is relatively ineffective for treating diffusely diseased and long-occluded lesions. Restenosis has also been a primary constraint of the Simpson device, with reported restenosis rates ranging from 11% to 55% at 6 months. The initial technical and clinical success rates reported with the TEC atherectomy device have been promising at 79% to 92%; however, short- and mid-term follow-up results have been either lacking or disappointing, with a reported patency of 67% at 6 months and 51% at 12 months. Furthermore, the problems of restenosis and reocclusion have limited its short-term benefits. The Trac-Wright catheter has demonstrated widely disparate technical success rates (from 58% to 100%) and clinical success rates (from 33% to 80%). Patency rates reported have been suboptimal, ranging from 25% to 68% at 6 months and 25% to 45% at 12 months. Furthermore, severe complications associated with the device include perforation, dissection, and embolization. Reocclusion also limits the applicability of the device. The reported immediate success rates of 72% to 94% using the Auth Rotablator are similar to those reported for other atherectomy devices. Patencies reported at 1 and 2 years are dismal, ranging from 31% to 61% and from 12% to 18%, respectively. Significant complications are associated with the device, including thrombosis, arterial spasm, hemoglobinuria, hematoma, and embolization. Contrary to previous studies and expectations, perforations and dissections have been encountered by some investigators. Late restenosis and reocclusion are also significant limiting factors of the Auth Rotablator. Atherectomy currently has limited applications for treatment of peripheral arterial occlusive disease. The intermediate- and long-term results obtained with the atherectomy devices are worse than those reported for PTA. Furthermore, all of the atherectomy devices have faile...

Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication

“…EVT options for FPOD include PTA alone, especially for short focal lesions <4 cm, 193 angioplasty with selfexpanding stents, 194 angioplasty with balloon-expandable stents, 195 angioplasty with covered stent grafts, 196,197 atherectomy, [198][199][200] antimyoproliferative drug-coated balloons, [201][202][203] and drug-eluting stents (DESs). 204 Combination EVT involving atherectomy and DESs has been reported in European trials.…”

Long-Term Results After Directional Atherectomy of Femoro-Popliteal Lesions

“…Thus, the initial use of the system tested here is more successful than that of the old Simpson Atherocath, reporting primary success rates of 82% to 100% (12,20). Additional stent implantation was indicated only in a minority of lesions.…”

The role of atherectomy in the treatment of lower extremity peripheral artery disease

“…Recently, technological advances favoured a significant evolution of percutaneous revascularization therapies that now can be offered as treatment options less invasive than traditional surgery. The optimal endovascular therapy is not well established: there are several options including percutaneous transluminal angioplasty (PTA), stents, drug-coated balloons, crioplasty, percutaneous thrombectomy (rheolytic [9] and aspiration thrombectomy) and atherectomy [10,11]. In particular, the promise of atherectomy is to overcome the limitations and complications of traditional angioplasty such as dissection, elastic recoil, and disruption of the internal elastic lamina, resulting in overwhelming neo-intima and smooth muscle cell proliferation [12].…”