Preliminary experience with the Xtrak debulking device in the treatment of peripheral occlusions

Critical Appraisal of the Contemporary Use of Atherectomy to Treat Femoral-Popliteal Atherosclerotic Disease

OBJECTIVE

Atherectomy has become increasingly used as an endovascular treatment of lower extremity atherosclerotic disease in the United States. Concerns and controversies about its indication and outcomes exist. The goal of this systematic review and meta-analysis was to investigate the outcomes and complications related to atherectomy to treat femoropopliteal atherosclerotic disease.

METHODS

A systematic review following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was performed. Four major scientific repositories, MEDLINE, EMBASE, The Cochrane Library, and Thompson Web of Sciences were queried from their inception to April 5, 2020. Data was reviewed and entered in a dedicated dataset by the investigators. Outcomes included patency rates, clinical and hemodynamic improvement, and morbidity and mortality associated with atherectomy interventions.

RESULTS

Twenty-four studies encompassing 1900 patients met inclusion criteria for this study. 74.3% of patients presented with Rutherford class (RC) 1-3 and 25.7% presented with RC class 4-6. 1445 patients underwent atherectomy, and 455 patients were treated without atherectomy. Atherectomy patients underwent directional atherectomy (DA, n = 851), rotational atherectomy (RA, n = 851), laser atherectomy (LA, n = 201), and orbital atherectomy (OA, n = 78). The majority of patients additionally received adjunct treatments which were variable across studies and included a combination of stenting, balloon angioplasty (BA), or drug coated balloon (DCB) angioplasty. Technical success was achieved in 92.3% of cases. Distal embolization, vessel perforation, and dissection occurred in 3.4%, 1.9%, and 4% of cases respectively. Initial patency was 95.4% and at 12-month median follow up primary patency was 72.6%. ABI improved from pre-operative mean of 0.6 to post-operative mean of 0.84. Incidence of major amputation and mortality over the follow up period was 2.2% and 3.4% respectively.

CONCLUSIONS

This review of the published data suggests that femoropopliteal atherectomy can be completed safely while modestly improving ABIs and maintaining one-year patency in nearly three out of four patients; however, this is based on heterogeneous studies that skew generalizable conclusions about atherectomy's efficacy. Atherectomy places a high cost burden on the healthcare system and is utilized in the United States at a higher rate than in other countries. Our review of the literature does not demonstrate clear atherectomy superiority to alternatives that would warrant pervasive and increasing use of this costly technology. Future work should focus on developing high quality randomized controlled trials to determine specific patient and lesion characteristics in which atherectomy can add value.

Initial Clinical Experience with Percutaneous Atherectomy in the Infragenicular Arteries

Purpose:

To evaluate the efficacy and safety of a new atherectomy device for the treatment of infragenicular lesions in arteries with a reference diameter of at least 2.5 mm.

Methods:

Twenty-seven below-the-knee lesions in 17 patients (12 men; mean age 69±12 years) with chronic peripheral arterial occlusive disease were treated with directional atherectomy. The target lesion was in the popliteal artery (segment 3) in 2 (7%) cases, the tibioperoneal trunk in 12 (44%), the peroneal artery in 8 (30%), the anterior tibial artery in 2 (7%), and the posterior tibial artery in 3 (11%). Six (22%) of the lesions were in-stent stenoses. The mean diameter stenosis was 87%±9%, and the mean lesion length was 34±24 mm.

Results:

All but 2 (7%) of the lesions could be treated successfully (residual stenosis <30%) with the atherectomy catheter (93% technical success) using an average of 5±2 (range 1–10) passes of the device. Six lesions (22%) were treated after predilation and 21 (78%) with primary atherectomy. In 8 (30%) lesions, additional balloon angioplasty was performed. The 2 failures were in heavily calcified lesions through which the device could not pass despite predilation. The mean diameter stenosis after atherectomy was 14%±22% (range 0%–90%); after additional balloon angioplasty, the mean residual stenoses reduced to 12%±21% (range 0%–100%). One (6%) of the 2 patients who failed atherectomy sustained a thrombotic occlusion of the target vessel. This complication was treated successfully with local lysis, but the vessel reoccluded 3 days later; a stent was implanted. The mean ankle-brachial index increased from 0.50±0.27 to 0.86±0.40 before discharge.

Conclusions:

Below-the-knee native vessel lesions and in-stent restenoses with a diameter of at least 2.5 mm can be treated successfully and safely with this new atherectomy catheter. Additional balloon angioplasty was necessary in only a few cases.

Two-Year Results after Directional Atherectomy of Infrapopliteal Arteries with the SilverHawk Device

Purpose:

To report the 12- and 24-month results after directional atherectomy (DA) of below-the-knee (BTK) arterial lesions with the SilverHawk device.

Methods:

Forty-nine BTK lesions in 36 patients (58% men; mean age 70611 years) with peripheral occlusive disease of the lower limbs were treated with DA; 19 (53%) of the limbs were classified with Rutherford-Becker 4 or 5 ischemia. Target lesions were in the popliteal artery (n=6, 12%), tibioperoneal trunk (n=25, 51%), peroneal artery (n=10, 20%), anterior tibial artery (n=5, 10%), and posterior tibial artery (n=3, 6%). Nine (18%) lesions were located in a stent. Twelve lesions extended to 2 artery segments. The average degree of diameter stenosis was 89%±10% (range 70%–100%); there were 11 (22%) occlusions. The mean lesion length was 48±28 mm.

Results:

Sixteen (33%) lesions were treated after predilation; 33 (67%) lesions were treated with primary DA. All but 1 (2%) lesion could be treated with DA. In 19 (39%) lesions, additional balloon angioplasty was performed, and 2 (4%) lesions required stent implantation as a result of dissection. The mean stenosis diameter after DA was 12%±18% (range 0%–100%). After additional therapy, the mean stenosis diameter was 8%±9% (range 0%–100%). A residual stenosis ≤30% was achieved in 48 (98%) lesions. The mean ankle-brachial index significantly increased from 0.48±0.26 to 0.81±0.32 (p<0.05) before discharge and remained improved during follow-up. Primary and secondary patency rates were 67% and 91% after 1 year and 60% and 80% after 24 months. The 12-and 24-month cumulative event-free survival rates (primary patency) by Kaplan-Meier analysis were 58%±8% and 46%±9%; at the same time intervals, the cumulative survival rates (secondary patency) were 88%±6% and 73%±9%, respectively.

Conclusion:

BTK lesions can be treated successfully and safely with DA. Midterm clinical results are encouraging.

Infrainguinal Arterial Intervention: Is There a Role for an Atherectomy Device?

Excision of atheromatous plaque is an attractive option for the minimally invasive treatment of peripheral arterial disease. Approved for use in 2003, the SilverHawk Plaque Exicison System (FoxHollow Technologies, Redwood City, CA) is a catheter-based plaque excision device allowing percutaneous removal of atheromatous material. This device represents the most recent generation of atherectomy tools. Overall experience with plaque debulking in the peripheral arteries spans almost two decades, and understanding of the technique continues to evolve. This article reviews the technology, current practices, and data on plaque excision.