The Role of Atherectomy in Peripheral Artery Disease: Current Evidence and Future Perspectives

Abstract

The prevalence of peripheral artery disease (PAD) has been rising consistently over the past few decades, along with increasing rates of type 2 diabetes. More than 200 million people are estimated to be affected by PAD worldwide. 1 Despite aggressive modifications of lifestyle and risk factors, and advances in the pharmacological management of patients with PAD using antiplatelet agents, statins, cilostazol, angiotensin-converting enzyme inhibitors, angiotensinreceptor blockers and low-dose anticoagulation with rivaroxaban, patients with PAD frequently require invasive procedures to improve the symptoms of claudication and prevent tissue damage or loss in those with critical limb ischaemia (CLI). 2 Due to recent technological advances in materials and devices for the endovascular treatment of PAD, a minimally invasive percutaneous approach is considered a first-choice strategy for the treatment of symptomatic patients and is given preference over older surgical options. According to current guidelines, endovascular therapy is the most favoured option for infrainguinal stenotic or occlusive lesions <25 cm, whereas open surgery may be associated with better longterm patency, especially when using saphenous vein grafts in patients with long occlusive lesions (>25 cm) that cross the knee. 3 Commonly used techniques include plain balloon angioplasty, drug-coated balloon (DCB) angioplasty, bare metal stents, drug-eluting stents and stent grafts for vessel perforation. Such endovascular approaches have been successfully used to alleviate symptoms in patients with claudication and have been associated with limb salvage in patients with CLI. [4][5][6] In many cases, such 'basic' approaches may be compromised by severe calcification. Calcification may be the reason for a poor primary outcome due to early recoil or extensive flow-limiting dissections after high-pressure angioplasty, culminating in the need for bailout stent placement. 7 Despite the most recent self-expandable nitinol stent technology, rates of re-stenosis may be high, resulting in primary patency rates of <50% for bare metal stents and <70% for drug-eluting stents at 5-year follow-up. 8 Even with dedicated stent devices, stent fractures may occur at sites of extensive movement and flexion as in the popliteal artery, resulting in stent thrombosis and subsequent occlusion. 9 With conventional open surgery, 5-year patency rates of more than 80% have been reported with saphenous vein grafts compared with 67% when using prosthetic conduits. 10 Although no randomised trials are currently available for a head-to-head comparison of endovascular versus surgical treatment for long and calcified femoropopliteal lesions, AbstractAn ageing population and the increasing prevalence of cardiovascular risk factors have aggravated the burden of peripheral artery disease (PAD). Despite advances in the pharmacological treatment of atherosclerosis, many patients with symptomatic PAD require invasive procedures to reduce the symptoms of claudication, salvage tissue and prevent a...

Use of Rotational Atherectomy-Assisted Balloon Angioplasty in the Treatment of Isolated Below-the-Knee Atherosclerotic Lesions in Patients with Chronic Limb-Threatening Ischemia

“…Since POBA or DCB angioplasty work by pressing the atheromatic material to the arterial wall, it is quite logical to expect that these endovascular techniques would benefit from prior compression of the plaques. In this regard, since becoming commercially available, rotational atherectomy for the treatment of PAD has demonstrated both safety and efficacy [ 8 , 11 , 19 ] in the femoropopliteal segment [ 19 , 20 , 21 , 22 ]. However, considering the BTK vessels, the evidence and published data are still scarce and industry-sponsored.…”

Periprocedural Outcomes of Rotational Atherectomy-Assisted Balloon Angioplasty in Isolated Atherosclerotic Popliteal Artery Lesions: The ISO-POP Trial

“…Minimally invasive atherectomy aims to enhance the effectiveness of endovascular therapy by providing luminal gain without barotrauma, since the latter can cause dissection, recoil and disruption of the elastic lamina, leading to restenosis [2]. Thus, atherectomy enables more homogeneous balloon expansion during low pressure angioplasty, facilitating higher deliverability of drugs into the vessel wall during subsequent drug-coated-balloon (DCB) angioplasty [3][4][5]. Due to the plethora of types of atherectomy and the mixed published populations, including lesions from the common femoral artery up to below-the-knee (BTK) vessels, however, definitive conclusions cannot be safely drawn about the incremental values of this vessel preparation tool in atherosclerotic lesions for specific vessel segments.…”

Three‐year outcome of directional atherectomy and drug coated balloon for the treatment of common femoral artery steno‐occlusive lesions

“…Several prospective multicenter studies have investigated the safety and efficacy of atherectomy devices in infrainguinal disease, but few data exist about the CFA district. 9 Patients were eligible if they had CFA calcified disease, diameter of stenosis > 70% and vessel diameter of 5-7 mm.…”

“…Several prospective multicenter studies have investigated the safety and efficacy of atherectomy devices in infrainguinal disease, but few data exist about the CFA district 9 …”