Injury of the superficial femoral artery and posterior tibial artery associated with an atherectomy device

OBJECTIVES

Rotational atherectomy can offer a viable treatment for occlusive peripheral artery disease; maintaining the minimal invasiveness of an endovascular procedure, while allowing for a more complete lesion debridement compared with balloon angioplasty. This case report outlines a complication of guidewire entrapment associated with rotational atherectomy in the superficial femoral artery (SFA).

METHODS

A 57-year-old male underwent an atherectomy with Rotorex for left lower limb foot pain. During the procedure, the guidewire was suctioned into the atherectomy device, preventing any further advancement of the device and damaging the SFA and posterior tibial artery (PTA).

RESULTS

The atherectomy device was withdrawn and a new vascular access site was gained in the left PTA. A covered stent was inserted to treat the original SFA lesion, and balloon angioplasty was used to repair the device-induced damaged to the PTA.

CONCLUSION

While guidewire complications have been previously reported, this case report details the first reported case, to our knowledge, of guidewire entrapment while using a rotational atherectomy device. Knowledge of this possible complication of rotational atherectomy can aid in clinical decision making when choosing between treatments for peripheral vascular disease.

Atherectomy-assisted versus percutaneous angioplasty interventions for treatment of symptomatic infra-inguinal peripheral arterial disease

Introduction

The role of atherectomy (ATHERO) for the treatment of symptomatic infra-inguinal arterial lesions remains controversial. We evaluated the effectiveness and safety of atherectomy-assisted endovascular interventions in comparison with percutaneous angioplasty (PTA).

Material and methods

A systematic search utilizing MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials was conducted for studies comparing ATHERO with PTA from February 1995 to May 2018. Only studies comparing ATHERO to PTA for symptomatic infra-inguinal disease were included. Random-effects meta-analysis was used to pool the data and endpoints across studies. Study endpoints included vessel dissection, distal embolization, residual stenosis (> 30%), vessel patency at 6 months, target lesion revascularization (TLR) at 12 months and major amputation rates at 1, 6, and 12 months.

Results

A total of 2923 patients were included from 8 studies. PTA was associated with higher vessel dissection (OR = 4.00, 95% CI: 1.15–13.86) and lower 12-month major amputation rates (OR = 0.73, 95% CI: 0.59–0.90). There was no significant difference between ATHERO and PTA groups in terms of distal embolization (OR = 0.45, 95% CI: 0.04–4.63), residual stenosis (OR = 1.28, 95% CI: 0.58–2.80), vessel patency at 6 months (OR = 1.27, 95% CI: 0.50–3.22), TLR at 12 months (OR = 1.07, 95% CI: 0.46–2.51), or limb amputation at 1 month (OR = 0.69, 95% CI: 0.44–1.07) or 6 months (OR = 1.54, 95% CI: 0.38–6.15).

Conclusions

In patients undergoing infra-inguinal endovascular interventions, PTA was associated with higher peri-procedural vessel dissection and lower 12-month major amputation rates. Both modalities were associated with similar distal embolization, residual stenosis, and 6-month vessel patency and amputation rates.

Peripheral Arterial Endovascular Procedures Performed in a Non-Hospital-Based Facility by First-Year Vascular Surgery Fellows

Objective:

Traditionally, vascular surgery fellows (VSFs) have learned to perform peripheral arterial endovascular procedures in a hospital setting. Many vascular surgeons currently perform these procedures in an “outpatient” non-hospital-based setting. Loss of these cases from the hospital setting may impact vascular surgery fellowship endovascular volume. We assessed the safety of first-year VSFs performing peripheral endovascular procedures under the supervision of vascular surgery attending surgeons in a non-hospital-based facility.

Methods:

Between January 1, 2012, and December 31, 2016, 166 patients underwent 193 endovascular procedures in a non-hospital-based ambulatory facility: 136 interventions (65 femoral, 40 iliac, 13 popliteal, and 9 infrapopliteal arteries) and 31 diagnostic arteriograms for claudication (57.8%; 85), rest pain (11.6%; 17), tissue loss (12.9%; 19), and failing grafts (17.7%; 26). Interventions included balloon angioplasty alone in 8.8% (12/136) of cases, stents in 16.9% (23/136), covered stents in 14% (19/136), atherectomy in 60.3% (82/136), and mechanical thrombolysis in 0.7% (1/136).

Results:

First-year VSFs performed an increasing percentage of these procedures during this interval: academic year 2012 to 2013 = 0% (0/49), 2013 to 2014 = 31% (17/54), 2014 to 2015 = 93% (56/60), and 2015 to 2016 = 82% (57/70). All but 5 (3%) patients having 167 procedures were discharged home after 2 to 6 hours of bed rest without any 30-day adverse outcomes. Four patients were immediately transferred to our hospital after the intervention: 2 for respiratory issues (hypoxia), 1 for groin hematoma (observation only), and 1 for arterial occlusion (required tibial stent not available at outpatient center). One patient returned to our hospital with rest pain due to treatment site occlusion the following day.

Conclusion:

Our results demonstrate that complex peripheral arterial endovascular procedures can be performed safely by first-year VSFs under vascular attending supervision in an outpatient, non-hospital-based setting.

Three-year results after directional atherectomy of calcified stenotic lesions of the superficial femoral artery

OBJECTIVE

To investigate the 3-year outcome of patients with peripheral arterial disease (PAD) and heavily calcified stenotic lesions of the superficial femoral artery after directional atherectomy.

MATERIALS AND METHODS

Fifty-three patients (mean age 67 ± 10 years; 18 females, 35 males, TASC B and C, mean lesion length 7.9 ± 3.5 cm) with PAD (Rutherford 2-6) were enrolled into this prospective monocentric study. In total, 59 calcified lesions of the superficial femoral artery were treated with the Silverhawk atherectomy device (Covidien, Plymouth, MN, USA). Patients were followed-up for 36 months with a 6-month interval to perform clinical re-evaluation, including measurement of maximum walking distance and ankle-brachial index (ABI) as well as duplex-sonography.

RESULTS

The primary success rate of the procedure was 92 %. In five cases (8 %), additional balloon-PTA and/or stent-PTA was necessary. Procedure-related embolization occurred in seven cases (12 %), which were all successfully treated by aspiration. The primary patency rate after 3 years was 55 %. Median Rutherford score decreased significantly from 5 to 0 after 36 months (p < 0.001). At the same time, the ABI increased from 0.65 to 1.12 (not significant). The limb-salvage rate after 3 years was 87 %.

CONCLUSION

In this subgroup of patients with POD and calcified stenotic lesions, atherectomy was successfully applied to decrease the plaque burden. Results after 3 years showed a significant decrease of Rutherford score with persistent improvement of ABI and reasonable patency rate.

Jetstream® atherectomy for subacutely or chronically occluded femoro-popliteal prosthetic bypass grafts: a report of three cases

A failed infrainguinal bypass is associated with poor prognosis for the limb in question, particularly if the graft was initially placed for limb salvage. Revascularization of occluded grafts is an important but challenging issue. We present three patients with occluded femoro-popliteal graft in whom the Jetstream(®) system was used successfully to perform thromboatherectomy. The Jetstream(®) system is minimally invasive and avoids use of thrombolytic therapy and its associated costs and complications. The device seems to be highly effective in removing thrombus beyond the acute setting.