Atherectomy in the Treatment of Peripheral Arterial Disease-A Case Series to Demonstrate Preferable Indications with Good Outcomes and a Literature Review

Abstract

Background: Endovascular therapy for lower-limb arterial disease is widely performed today. A vast array of sheaths, catheters, wires, balloon types, stents, and tools such as atherectomy, thrombectomy, and lithotripsy devices are now available to achieve the best outcomes in terms of vessel patency and ultimately limb salvage. The use of atherectomy devices, however, has raised some controversies in terms of outcome efficacy, cost effectiveness, and safety profile in various series and studies. Objectively, the types and disease pattern in these studies are also greatly heterogeneous. Methods: Here, we reported three cases which exemplify how these atherectomy devices have served as a valuable tool, especially for patients with complex and heavily calcified lesions. Results: The three cases highlighted scenarios where atherectomy displayed good outcomes, each involving the use of atherectomy devices to treat highly calcified vessels. Conclusions: Despite the concerns with atherectomy devices, we believe that with proper selection, patients will benefit most from their ability to achieve the best outcomes of both vessel patency and limb salvage.

Keywords: angioplasty; atherectomy; endovascular; peripheral arterial disease.

Figure 1

(A) Left first-toe wet gangrene at initial presentation. (B) First-toe ray amputation with good bleeding from raw edges of wound. Healing first-toe ray amputation wound at (C) 8 weeks and (D) 3 months post-angioplasty.

Figure 2

Intraoperative diagnostic angiography demonstrating (A) patent above-the-knee and tibioperoneal (TP) trunk arteries and (B) occlusion of anterior tibial artery (ATA) and posterior tibial artery (PTA). (C) Failed attempt to trace lesion with JADE 1.5. (D) Attempt at balloon deployment using forcible manner (BADFORM) for lesion; however, we were unable to track balloon. (E) Phoenix atherectomy of ATA occlusion. (F) Attempt at phoenix atherectomy of PTA occlusion but perforation was seen. (G,H) Post-procedure angiogram revealed good arterial flow to ATA and DPA.

Figure 3

(A) Duplex ultrasound scan (DUS) showed long-segment chronic superficial femoral artery (SFA) in-stent occlusion. (B–D) Intraoperative diagnostic angiography showing chronic total occlusion from superficial femoral artery (SFA) to end of previous stent with some narrowing, of approximately 50%, noted at P1 area with possible dissection. (E) Embolic protection device was deployed at P1 to prevent distal embolization. (F) JETSTREAM atherectomy was performed. (G,H) Angioplasty performed. (I) Coverage of dissection flap by extending stent distally. (J–M) Post-procedure angiogram showed good result with no significant dissection, residual stenosis, or recoil.

Figure 4

(A) Superficial wound with developing eschar seen on her left lateral lower shin during initial presentation. (B) Left lower-limb wound debridement with good bleeding after. (C,D) Healing of wound during inpatient stay.

Figure 5

(A) DUS showed moderate to severe calcification throughout arterial system of left lower limb. (B,C) Intraoperative diagnostic angiography demonstrated patent common femoral artery with occlusion of femoro-popliteal vessels from P1 to P3 area. (D) Difficulty to track JADE 2 due to tight occlusion. (E) Phoenix atherectomy was performed. (F) Shockwave intravascular lithotripsy was performed with 4.5 × 60 mm Shockwave M⁵⁺ balloon. (G–I) Post-procedure angiogram showed good result with no significant dissection, residual stenosis, or recoil.