Infrainguinal atherectomy using the Auth Rotablator: patency rates and clinical success for 36 procedures

Effects of high-speed rotational atherectomy in peripheral artery disease patients with calcified lesions: a retrospective multicenter registry

Calcified lesions still remain a technical challenge even in the treatment of infrainguinal artery disease. The aim of this retrospective, multicenter observational study was to investigate interventional outcomes of a high-speed rotational atherectomy device (Rotablator™) and to compare clinical outcomes in patients who underwent Rotablator and those who did not even after failed balloon angioplasty because of underlying calcified lesions. This study enrolled patients who underwent Rotablator (Rota group) and those who did not (Non-rota group) between January 2010 and 2014 December at 12 hospitals. A total of 67 limbs and 68 lesions in 65 patients were included (Rota group; 54 limbs and 55 lesions in 52 patients, Non-rota group; 13 limbs and 13 lesions in 13 patients). In the Rota group, a technical success rate was 94.5% with a complication rate of 1.8%, and all lesions underwent subsequent postdilatation following the adjunctive use of Rotablator, and approximately half of above-the-knee lesions underwent stent implantation. The Rota group had a significantly lower clinically driven reintervention rate at 12 months than the Non-rota group (26.5% vs. 58.3%, respectively, p = 0.046). In addition, Rota group showed a trend toward a higher amputation-free survival compared to the Non-rota group at 1 month (Rota; 98.0% vs. Non-rota; 84.6%, respectively, p = 0.10). Rotablator was used as an adjunctive device with a high technical success and a low complication rates, and Patients who underwent Rotablator yielded a significantly lower clinically driven reintervention rate at 12 months compared to those who did not even after failed balloon angioplasty.

Optimal use of atherectomy in critical limb ischemia

Critical limb ischemia (CLI) is the most severe and debilitating form of peripheral arterial disease and is associated with high rates of limb loss and cardiovascular mortality. The unique physical environment of tibial occlusive disease underlying most CLI cases limits treatment options and long-term durability, with resulting frequent rates of persistent obstruction, restenosis, and reintervention. Atherectomy represents a potential strategy to improve acute and late results when treating patients with CLI. Available atherectomy devices each have specific performance characteristics, evidentiary rationale, and limitations that mandate a clear understanding of the optimal albeit evolving use of this category of interventional tools.

Plaque Excision in Management of Lower Extremity Peripheral Arterial Disease with the SilverHawk Atherectomy Catheter

Atherectomy, the removal of plaque from diseased vessels, is theoretically appealing with respect to various procedures used for revascularization of lower extremity vessels. Instead of damaging the native vessel by pushing aside plaque with a balloon or stent, the plaque is removed. Many atherectomy devices have been designed in attempts to achieve this goal. The SilverHawk device is the latest percutaneous device employing this treatment strategy. We discuss patient selection, technical considerations, and strategies for both above and below the knee revascularization, as well as pitfalls in each location based on our experience with over 200 patients.

[Percutaneous mechanical atherectomy for treatment of peripheral arterial occlusive disease]

Peripheral arterial occlusive disease (PAOD) is still an extremely important politico-economic disease. Diverse treatment procedures exist but the pillars of therapy are changes in lifestyle, such as nicotine abstinence and walking exercise as well as drug therapy. Further therapy options are considered after conventional procedures have been exhausted. These further options consist of improvement of the blood supply by surgical or minimally invasive procedures. The latter therapy options include balloon dilatation and stenting as the most widely used techniques. More recent techniques also used are cryoplasty, laser angioplasty, drug-coated stents or balloons as well as brachytherapy or atherectomy, whereby this list makes no claims to completeness. The multitude of different treatment methods emphatically underlines the fact that no resounding success can be achieved with one single method. The long-term results of both balloon dilatation and stenting techniques show a need for improvement, which elicited the search for additional methods for the treatment of PAOD. Atherectomy represents such an alternative method for treatment of PAOD. Basically, the term atherectomy means the removal of atheroma tissue. For percutaneous atherectomy, in contrast to surgical procedures, it is not necessary to create surgically access to the vessel but accomplishes the atherectomy by means of dedicated systems via a minimally invasive access. There are two basic forms of mechanical atherectomy: directional and rotational systems.

Restenosis after lower extremity interventions: current status and future directions

The incidence of restenosis after percutaneous peripheral interventions (PPI) varies considerably depending upon the vascular bed but appears to be highest in the femoropopliteal and tibioperoneal arteries. The restenosis process in the periphery does not appear to stop at the 6-month mark, as seen with bare metal stents in the coronary arteries, but continues for a longer time, possibly years, after the intervention. This review evaluates the incidence of restenosis following lower extremity arterial interventions and potential drugs or devices that could alter this process, including nonpharmacological (stents, cryoplasty, Cutting Balloon angioplasty, atherectomy, brachytherapy, and photodynamic therapy) and pharmacological (systemic and direct drug delivery) approaches. A global strategy to achieve optimal outcome with PPI is offered: (1) obtain excellent acute angiographic results with less dissection and recoil, (2) protect the distal tibial vascular bed, and (3) reduce smooth muscle cell proliferation with pharmacological intervention.

An evidence-based approach to the use of rotational and directional coronary atherectomy in the era of drug-eluting stents: when does it make sense?

Advances in percutaneous interventions have profoundly changed the way we manage patients with coronary and peripheral arterial disease. Though the use of stents, particularly drug-eluting stents, is the preferred method for revascularization because of ease of use and lower restenosis rates, there are many short comings. Ostial and bifurcation lesions as well as heavily calcified and tortuous arteries remain problematic. Mechanical debulking with rotational and direct coronary atherectomy may be beneficial in these situations. In this review, we present the general concepts of mechanical debulking and attempt to summarize the available data on its use in the setting of drug-eluting stents. In addition, we will discuss its special role in the management of peripheral arterial disease.

Critical limb ischemia: will atherectomy and laser-directed therapy be the answer?

The interventional treatment of peripheral atherosclerotic occlusive disease is increasingly becoming accepted as an appropriate initial form of therapy. Standard methods of treatment include balloon angioplasty and stent assisted angioplasty. Laser catheters and mechanical atherectomy catheters are newer tools, which can be utilized to assist in achieving and maintaining patency in these vessels. In this report, we review the efficacy, safety, and potential advantages of these ablative devices when used for the treatment of peripheral arterial occlusive disease.

Procedural and Clinical Outcomes With Catheter-Based Plaque Excision in Critical Limb Ischemia

PURPOSE

To examine the safety and efficacy of catheter-based plaque excision as an alternative therapy to surgery, conventional angioplasty, and/or stenting in high-risk patients with critical limb ischemia (CLI).

METHODS

Between August 2003 and August 2004, a prospective evaluation was conducted of consecutive patients with CLI (Rutherford category>or=5) who were treated with endovascular plaque excision at 7 institutions. This study enrolled 69 patients (37 women; mean age 70+/-12 years, range 43-93) with CLI involving 76 limbs. Clinical outcomes were prospectively followed for 6 months. The primary endpoint was major adverse events (death, myocardial infarction, unplanned amputation, or repeat target vessel revascularization) at 30 days. Visible healing of ulcerated tissue, avoidance of any amputation, and performance of less extensive amputation than initially planned were also assessed.

RESULTS

Procedural success was achieved in 99% of cases. Major adverse events occurred in 1% of patients at 30 days and 23% at 6 months. The target lesion revascularization rate was 4%, and there were no unplanned limb amputations. Amputation was less extensive than initially planned or avoided altogether in 92% of patients at 30 days and 82% at 6 months.

CONCLUSION

Catheter-based plaque excision is a safe and effective revascularization method for patients with CLI. These findings support further study of this modality as a singular or adjunctive endovascular therapy for limb salvage in CLI.