Debulking Atherectomy in the Peripheral Arteries: Is There a Role and What is the Evidence?

Abstract

Traditional percutaneous balloon angioplasty and stent placement is based on mechanical plaque disruption and displacement within the arterial wall. On the contrary, transcatheter atherectomy achieves atherosclerotic plaque clearance by means of directional plaque excision or rotational plaque removal or laser plaque ablation. Debulking atherectomy may allow for a more uniform angioplasty result at lower pressures with consequently less vessel barotrauma and improved luminal gain, thereby decreasing the risk of plaque recoil and dissection that may require permanent metal stenting. It has been also argued that atherectomy may disrupt the calcium barrier and optimize drug transfer and delivery in case of drug-coated balloon applications. The authors discuss the various types of atherectomy devices available in clinical practice to date and critically appraise their mode of action as well as relevant published data in each case. Overall, amassed randomized and observational evidence indicates that percutaneous atherectomy of the femoropopliteal and infrapopliteal arteries may achieve high technical success rates and seems to lessen the frequency of bailout stenting, however, at the expense of increased risk of peri-procedural distal embolization. Long-term clinical outcomes reported to date do not support the superiority of percutaneous atherectomy over traditional balloon angioplasty and stent placement in terms of vessel patency or limb salvage. The combination of debulking atherectomy and drug-coated balloons has shown promise in early studies, especially in the treatment of more complex lesions. Unanswered questions and future perspectives of this continuously evolving endovascular technology as part of a broader treatment algorithm are discussed.

Keywords: Amputation; Atherectomy; Atherosclerosis; Directional; Embolization; Laser; Patency; Plaque excision; Rotational.

Fig. 1

Example of plaque debulking. A Baseline image of long-segment total occlusion of the right superficial femoral artery in a female patient with critical limb ischemia. B Rotational–aspiration atherectomy with the JETSTREAM 2.4/3.4 device. C Immediate post-atherectomy result after two passes—one with the blades down and the second with the blades up. Note that no balloon has been used yet

Fig. 2

Percutaneous popliteal atherectomy. A Baseline antegrade angiogram of a 5-cm chronic total occlusion of the proximal left popliteal artery (P1 segment) in a young male claudicant patient. B Rotational–aspiration atherectomy with the JETSTREAM 2.4/3.4 device. C Immediate post-atherectomy result after two passes (blades down and blades up) shows a very good atherectomy result with minimal residual stenosis. D Completion angiogram after adjunctive paclitaxel-coated balloon angioplasty to inhibit late restenosis. The vessel was found to be widely patent at DUS at 1-year follow-up

Fig. 3

Infrapopliteal debulking atherectomy. A Elderly male patient with an ischemic previously debrided left hallux wound. Baseline subtraction angiography demonstrates long-segment occlusion of the posterior tibial artery and segmental occlusion of the distal third of the anterior tibial artery with reconstitution of the dorsalis pedis through collateral networks. B Antegrade rotational atherectomy with the PHOENIX device following a complex subintimal–intraluminal recanalization that required a combined pedal puncture. C Immediate post-atherectomy result after several passes shows a good atherectomy result with some early venous filling. D Completion angiogram after adjunctive 3-mm-long balloon angioplasty demonstrates a very good anatomical result with brisk antegrade filling of the pedal circulation. The wound healed successfully 3 months later