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.

Turbo-Power™ Laser Atherectomy Combined with Drug-coated Balloon Angioplasty is Associated with Improved One-Year Outcomes for the Treatment of Tosaka II and III Femoropopliteal In-stent Restenosis

BACKGROUND

Femoropopliteal (FP) artery in-stent restenosis (ISR) is associated with high rates of re-intervention and occlusion. The combined use of laser atherectomy (LA) with balloon angioplasty (BA) is superior to conventional balloon angioplasty (BA). Drug-coated balloons (DCBs) when combined with LA have provided additional efficacy for the treatment of FP-ISR. The aim of this study was to investigate the combination of DCB + LA with the recently approved Turbo-Power™ (Spectranetics Inc., Colorado Springs, CO, USA) LA device.

METHODS

This was a dual-center retrospective study enrolling 78 consecutive patients with Tosaka type II (n = 18) or III (n = 60) FP-ISR. The lesions were treated with either Turbo-Power™ LA followed by DCB (n = 27) or with other LA devices followed by plain BA (LA + BA; n = 51) from 2015 to 2017. A Cox regression analysis was performed to examine the association between the two groups in terms of target lesion revascularization (TLR) and occlusion rates over a follow up period of 12 months. Kaplan-Meier survival curves were estimated and compared with the log-rank test.

RESULTS

The overall procedural success was 90%. Eight periprocedural complications occurred without any difference between the two groups (Turbo-Power™ + DCB: 7.4% vs LA + BA: 11.8%, p = .7). The 12-month KM estimates for freedom from TLR were 90.9% in the Turbo-Power™ + DCB group vs 55.7% in the LA + BA group (p = .005). Among Toasaka III lesions, the 12 m-KM survival estimates for freedom from TLR were 88.9% in the Turbo-Power™ + DCB group vs 54.2% in the LA + BA group (p = .009). The 12 m-KM estimates for freedom from re-occlusion were 89.0% in the Turbo-Power™ + DCB group vs 58.9% in the LA + BA group (p = .070).

CONCLUSIONS

Turbo-Power™ laser atherectomy combined with DCB exerted synergistic mechanism of actions and improved 12-month TLR rates for the treatment of complex FP-ISR lesions.

Jetstream Atherectomy System for Treatment of Femoropopliteal Artery Disease: A Single Center Experience and Mid-term Outcomes

BACKGROUND

The aim of this study is to assess our experience and mid-term outcomes using Jetstream atherectomy system for treatment of femoropopliteal artery disease (FPAD).

METHODS

Data of 30 patients with FPAD treated at our center between 2013 and 2016 were analyzed. Two subgroups of patients were identified: Group A included patients (n = 18) with de novo lesions; Group B (n = 12) included those with in-stent restenosis. The primary study end points assessed were technical success, perioperative mortality, and major adverse event (MAE) rate at 30 days (distal embolization, major amputation, and target lesion revascularization). Other outcomes measured were survival, primary, and secondary patency, and freedom from amputation at 1 and 3 years of follow-up, respectively.

RESULTS

Technical success was 100% for both groups. The MAE rate was 8.7%. No distal filter was adopted during intervention. Angioplasty was associated with 93.3% of cases (93.3% vs. 100%; P = 0.15), drug-eluting balloon (DEB) in 12 cases (22.2% vs. 66.6%; P = 0.008), drug-eluting stent and bare metal implantation in 1 (5.6% vs. 0%; P = 1) and 4 cases (11.1% vs. 16.7%; P = 1), respectively. The cumulative primary and secondary patency rates were 75.1% and 95.5% at 1 year, and 70.4% and 84.8% at 3 years of follow-up, respectively. The survival and freedom from amputation were 96.4% and 85.8% at 1 and 3 years of follow-up, respectively. The freedom from target lesion revascularization was 91.7% and 83.4% at 1 and 3 years from intervention.

CONCLUSIONS

The use of the Jetstream appears to be safe and feasible with no distal embolization and low rate perioperative complications. Moreover, encouraging outcomes were observed when atherectomy was associated to DEB angioplasty.

Atherectomy using a solid-state laser at 355 nm wavelength

Peripheral arterial disease (PAD), caused by atherosclerotic processes, is allied with an increased risk of ischemic events, limb loss, and death. Recently, the use of a solid-state laser at 355 nm within a hybrid catheter was suggested for that purpose. In this work, short nanosecond pulses of a solid-state laser at 355 nm delivered through a hybrid catheter, composed of optical fibers and a blunt mechanical blade, are used to conduct a pre-clinical study and two clinical cases. The pre-clinical study consisted of an atherosclerotic calcified cadaveric leg and a porcine in vivo trial within the iliac artery, respectively. The clinical cases include chronic total occlusions with a calcified lesion. The occluded cadaveric leg is recanalized successfully and no evidence of thermal necrosis is indicated in the histopathology analysis of the porcine study. No arterial wall damage is demonstrated on the animals' treated arteries and no significant impact on blood count and biochemistry analysis is noted in the animal trial. Successful recanalization of the occluded arteries followed by balloon angioplasty is obtained in both clinical cases. Our work constitutes a proof of concept for using a solid-state pulsed laser at 355 nm in atherectomy.

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

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.

Safety and Effectiveness of the Nav-6 Filter in Preventing Distal Embolization During Jetstream Atherectomy of Infrainguinal Peripheral Artery Lesions

BACKGROUND

The risk of distal embolization (DE) during infrainguinal peripheral artery interventions (PAI) is often mitigated by the use of embolic protection devices. There are limited data on the use of filters with the Jetstream (JS) atherectomy device, a rotational cutter with aspiration capacity. The Nav-6 filter is uniquely suited for use with the JS due to its wire compatibility and detachment from the filter; however, data on the off-label use of this combination have not been reported.

METHODS

Consecutive patients between October 2008 and April 2015 undergoing endovascular infrainguinal PAI with JS were analyzed as part of the Excellence in Peripheral Artery Disease (XL-PAD) registry (NCT01904851). Patients were divided into two subgroups with Nav-6 filter use vs no filter use. Descriptive and univariate analyses were performed.

RESULTS

Among 141 patients (mean age, 67.8 ± 10.8 years; 169 lesions) included in this study, the Nav-6 filter was used in 82 (59%). Use of a filter was more frequent in longer lesions (146 ± 106 mm vs 91 ± 72 mm; P=.01), in more severe stenoses (95% vs 87%; P=.04), and in chronic total occlusions (33% vs 8.3%; P=.01). Patients receiving filters had longer procedure duration (102 ± 51 min vs 66 ± 41 min; P=.01) and longer fluoroscopy times (31 ± 16 min vs 21 ± 10 min; P<.001). Use of the Nav-6 filter with the JS during PAI was associated with numerically lower rates of DE (1.8% vs 8%; P=.10) and similar rates of death and amputation. At 12 months, the target-lesion revascularization rate was higher in the filter group (22% vs 2.7%; P=.02), likely secondary to use of the filter in more complex lesions.

CONCLUSION

Nav-6 filter during JS atherectomy was predominantly used during complex infrainguinal PAI and was associated with less occurrence of DE.

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.

Atherectomy Devices for the Treatment of Calcified Coronary Lesions

The presence of moderate and severe coronary artery calcification (CAC) is associated with higher rates of angiographic complications during percutaneous coronary intervention (PCI), as well as higher major adverse cardiac events compared with noncalcified lesions. Diabetes mellitus, a risk factor for CAC, is increasing in the United States. Vessel preparation before PCI with atherectomy can facilitate successful stent delivery and expansion that may otherwise not be possible. We review here CAC prevalence, risk factors, and impact on PCI, as well as the currently available coronary atherectomy devices including rotational atherectomy, orbital atherectomy, and laser atherectomy.

Percutaneous Coronary Intervention in Severely Calcified Unprotected Left Main Coronary Artery Disease: Initial Experience With Orbital Atherectomy

OBJECTIVE

We report the clinical outcomes of patients who underwent percutaneous coronary intervention (PCI) with orbital atherectomy for severely calcified unprotected left main coronary artery (ULMCA) disease.

BACKGROUND

Although surgical revascularization is the gold standard for patients with ULMCA disease, not all patients are candidates for this. PCI is increasingly used to treat complex coronary artery disease, including ULMCA disease. The presence of severely calcified lesions increases the complexity of PCI. Orbital atherectomy can be used to facilitate stent delivery and expansion in severely calcified lesions. The clinical outcomes of patients treated with orbital atherectomy for severely calcified ULMCA disease have not been reported.

METHODS

From May 2014 to July 2015, a total of 14 patients who underwent PCI with orbital atherectomy for ULMCA disease were retrospectively evaluated. The primary endpoint was major cardiac and cerebrovascular event (cardiac death, myocardial infarction, stroke, and target-lesion revascularization) at 30 days.

RESULTS

The mean age was 78.2 ± 5.8 years. The mean ejection fraction was 41.8 ± 19.8%. Distal bifurcation disease was present in 9 of 14 patients. Procedural success was achieved in all 14 patients. The 30-day major adverse cardiac and cerebrovascular event rate was 0%. One patient had coronary dissection that was successfully treated with stenting. No patient had perforation, slow flow, or thrombosis.

CONCLUSIONS

Orbital atherectomy in patients with severely calcified ULMCA disease is feasible, even in high-risk patients who were considered poor surgical candidates. Randomized trials are needed to determine the role of orbital atherectomy in ULMCA disease.

Stent and Non-Stent Based Outcomes of Infrainguinal Peripheral Artery Interventions From the Multicenter XLPAD Registry

BACKGROUND

There are limited data regarding contemporary use of stent and non-stent based treatment strategies of infrainguinal peripheral artery disease (PAD).

METHODS

We analyzed data from the ongoing multicenter XLPAD registry between July 2005 and October 2013 to report on the use of non-stent (atherectomy ± balloon angioplasty) and stent-based treatment of superficial femoral artery (SFA), popliteal, and below-the-knee (BTK) vessels in contemporary clinical practice.

RESULTS

A total of 584 interventions (SFA, 82.5%; popliteal, 7.2%; BTK, 9.9%) were performed in 372 patients (mean age, 63.2 years; diabetes mellitus, 57.7%; Rutherford category 1-3, 73.5%; Rutherford category 4-6, 20.1%). Stents were deployed in 389 lesions (66.6%; SFA, 90.5%; popliteal, 5.1%; BTK, 4.1%) and non-stent strategy (atherectomy, 49%) in 195 lesions (33.4%; SFA, 66.7%; popliteal, 11.3%; BTK, 21.5%). In the stent and non-stent groups, mean lesion lengths were 133.9 mm and 86.0 mm (P<.001), chronic total occlusions (CTOs) constituted 63.0% and 49.7% (P<.01), and restenotic lesions were 12.6% and 32.3% (P<.001), respectively. At a mean follow-up of 260 ± 130 days, in the stent and non-stent treated patients, all-cause mortality was 4.3% and 3.5% (P=.65), clinically indicated repeat revascularization was 17.5% and 14.9% (P=.42), and amputation was 4.6% and 9.2% (P<.01), respectively. SFA lesion location, long lesion length, and CTO were associated with the use of stents. Advanced Rutherford class was associated with a non-stent treatment strategy.

CONCLUSION

The majority of endovascular peripheral arterial interventions are performed in the SFA; most include a CTO and in patients with diabetes mellitus. Operators use stents to primarily treat complex SFA lesions with overall similar outcomes, except for fewer amputations compared to a non-stent strategy.

[Remote results of endovascular atherectomy with the SilverHawk device]

The authors studied the remote results of 27 endovascular catheter atherectomies performed in 25 patients. All patients had lesions of arteries of the femoropopliteal segment according to the TASC II classification. The duration of follow up varied from 6 to 34 months. Endovascular catheter atherectomy was carried out by means of the SilverHawk EV3 system with protection of the distal bed from embolism using Spider EV3. Our findings prove that catheter atherectomy with the SilverHawk system is most efficient it treatment of short stenotic lesions, lesions localizing in the zone of increased dynamic activity, multi-level lesions of arteries of the femoropopliteal segment, as well as short lesions in patients suffering from diabetes mellitus.

Atherectomy of the femoropopliteal artery: a systematic review and meta-analysis of randomized controlled trials

A systematic review was performed to provide a qualitative analysis and quantitative data synthesis of randomized controlled trials (RCTs) assessing debulking atherectomy versus balloon angioplasty for treatment of femoropopliteal artery occlusive disease. PubMed (MEDLINE), EMBASE, AMED, Scopus, online content and meeting abstracts were searched in May 2014 for eligible RCTs following the PRISMA selection process. Risk of bias was assessed using the Cochrane Collaboration's tool. Pooled risks were calculated with a random effects model to account for clinical and conceptual heterogeneity. Sensitivity analysis was employed to test the robustness of the results. Six RCTs comprising 287 patients (328 lesions) treated with either debulking atherectomy or balloon angioplasty for femoropopliteal artery disease were analyzed and synthesized. Technical success was similar between the atherectomy and the angioplasty group (93.6% vs. 96.2%, RR: 0.99. 95%CI: 0.95-1.03, P=0.57, I(2)=0%). Need for bail-out stenting and distal arterial embolization were largely similar between atherectomy and balloon angioplasty alone. After a median follow-up of 9 months the 2 groups showed similar primary patency (RR: 0.90, 95%CI: 0.56-1.46, P=0.68, I(2)=69%). Only 2 low-quality studies reported amputation and mortality rates, both of which were found significantly less in the atherectomy arms. Analysis of a limited body of low quality evidence with high risk of bias showed that debulking atherectomy of the femoropopliteal artery does not seem to confer any procedural advantage or improvement of clinical outcomes over balloon angioplasty alone.

Which is currently the best strategy for treatment of SFA in-stent restenosis?

Stents have been created to prevent vessel recoil after percutaneous transluminal angioplasty (PTA). Despite the evolution in stent design, intimal hyperplasia and stent fractures and the resulting in-stent restenosis (ISR) still occur. Different strategies to treat ISR have been described with variable results in patency rates in the short and the long-term. PTA only in the treatment of ISR showed high procedural success, but the mid and long-term patency rates were very disappointing. Atherectomy devices have showed same insufficient results. If stent fracture is the cause of the ISR, the fracture has to be overstent. The best two options are covered stents and drug eluting stents (DES). Drug eluting devices like DES and drug eluting balloons (DEBs) showed promising results, with patency rates up to over 90% after one year. DEBs have the advantage of leaving nothing behind. Combined treatment of ISR with atherectomy and DEB has a similar good result. Endovascular brachytherapy showed high patency rates after one year but this technique is limited due to the time-consuming nature of the procedure, complex radiation safety measurements, and staffing requirements. Overall drug-eluting devices are emerging as the best treatment of SFA ISR with patency rates over 90% after 2 years.

Crossing of infrainguinal peripheral arterial chronic total occlusion with a blunt microdissection catheter

PURPOSE

Crossing of lower-extremity arterial chronic total occlusion (CTO) can be challenging. Use of the Viance peripheral CTO crossing device (Covidien) in the superficial femoral (SFA), popliteal, and below-the knee (BTK) arterial locations has received limited study.

METHODS

Fifty-eight patients from the Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851) were treated between April 2010 and November 2013 with the Viance device. The procedural and 30-day clinical outcomes were collected.

RESULTS

Mean age was 65.5 ± 8.7 years and 55.1% had diabetes mellitus. Most lesions (n = 58) were TASC classification type C (n = 16; 27.6%) and D (n = 16; 27.6%), with mean lesion length 140.0 ± 71.0 mm; 93.1% of lesions were de novo and 81.0% were severely calcified. Technical success (crossing without the use of a reentry device) was achieved in 87.9% of cases and procedural success was obtained in 86.2%; 51.7% of lesions received stents, with the remaining treated with balloon angioplasty and/or atherectomy. Average fluoroscopy time was 39.1 ± 21.2 min, with 187.8 ± 72.0 mL of contrast and 210.0 ± 212.0 Gy cm² radiation dose-area product. There was 1 periprocedural complication (access-site hematoma treated conservatively without blood transfusion). At 30 days post procedure, there was significant improvement in ankle-brachial index (0.72 ± 0.30 to 0.84 ± 0.16; P=.01) and Rutherford class (3.33 ± 0.81 to 1.54 ± 1.47; P<.001). Clinically-indicated target vessel revascularization, surgical intervention or amputation at 30 days was 5.2%.

CONCLUSION

Use of Viance to cross infrainguinal arterial CTO was associated with high success, low complication rates, and significant symptom improvement.

Role of laser atherectomy for the management of in-stent restenosis in the peripheral arteries

The prevalence of PAD is expected to increase as the population ages and the treatment for chronic disease becomes more sophisticated. The safety, efficacy, and lower cost of endovascular treatment for peripheral vascular disease of the lower extremities when compared with surgical revascularization are well known. Despite the clinical improvements and advances in endovascular techniques over the past decade, in-stent restenosis of peripheral arteries remains a challenge for the endovascular specialist. The use of excimer laser atherectomy has been shown to be safe and effective for the revascularization of complex, critical de novo peripheral lesions and offers promise in the treatment and prevention of in-stent restenosis.

Evaluating embolic reduction techniques concurrent to infrainguinal interventions: a single-center experience

OBJECTIVE

To report a single-center retrospective evaluation of embolic reduction strategies concurrent to infrainguinal atherectomy intervention.

METHODS

Fifty-five consecutive atherectomy patients from 2011 to 2012 treated with embolic reduction devices were analyzed. Embolic load was stratified by lesion type, atherectomy technique, debris capture effectiveness, and risk factor characteristics. Over 80% of lesions were complex. Baseline stenosis and average lesion length were 94.2 ± 6.4% and 172.8 ± 85.5 mm, respectively. Our embolic reduction strategy included a systematic approach using the Proteus device in all cases and then in combination with the SpiderFX for long or complex lesions. Debris was analyzed for count and aggregate surface area.

RESULTS

Procedural success was 98.2%, with no in-hospital serious adverse events. The mean aggregated surface area of captured debris was 22 ± 20 mm². Thrombolysis with laser produced the highest amount of embolic load followed by laser, directional, and orbital atherectomy procedures (P<.05). Patients with restenotic/in-stent restenotic lesions produced larger amounts of debris (P<.05). No embolizations were recorded up to discharge. Proteus accounted for two-thirds of the debris captured in our study; its capture efficiency increased as device and lesion length met. An inverse relation was also found between lesion length and embolic protection device capture efficacy (TASC-II B vs D; P<.02).

CONCLUSION

An embolic reduction strategy using the Proteus catheter alone, particularly when Proteus and lesion lengths meet, or with the SpiderFX in complex infrainguinal atherectomy procedures, can be an effective tool. Current findings suggest potential optimization of future "at risk" interventions.

Orbital atherectomy: device evolution and clinical data

A number of atherectomy devices were developed in the last few years. Among them, the DiamondBack 360° Peripheral Orbital Atherectomy System (Cardiovascular Systems, Inc) was specifically designed to work in severely calcified plaque. This article reviews the history, mechanism of action, evolution, clinical data, and future applications of this particular atherectomy device.

Plaque excision in the management of lower-limb ischemia of atherosclerosis and in-stent restenosis with the SilverHawk atherectomy catheter

AIM

Aim of the present study was to compare the effectiveness of plaque excision in management of lower limb ischemia of atherosclerosis and in-stent restenosis with the SilverHawk atherectomy catheter.

METHODS

From November 2010, to August 2011, 43 patients were involved and completed follow-up. They were divided into two groups: group A is the atherosclerotic plaque group (16 cases, 37.2%) and group B is the in-stent restenosis/occlusion lesion group (27 cases, 62.8%). The average age of group A was 68.3 years and group B was 72 years, the mean duration was 27.4 months and 26 months, respectively. Intermittent claudication was 8 cases and 16 cases respectively, and rest pain both was 4 cases, foot ulcer was 1 case and 4 cases, toe gangrene both was 3 cases. Ankle Brachial Index (ABI)≤0.4 was 2 in group A and 8 in group B, ABI>0.4 was 12 and 16, ABI=0 was 2 and 3, respectively. Excision with protective devices in 6 cases. Nine cases and 17 cases received treatment for proximal and distal lesions over the same period, respectively, included the proximal iliac artery stenting 1 case in group A and 5 cases in group B, distal calf arteries stenting 6 cases in group A and 11 cases in group B, balloon angioplasty 2 in group A and 1 in group B. Endpoints included postoperative mortality or amputation of target limb.

RESULTS

Forty-one operations were successful, the technical success rate was 95.3%, one case in group B suffered above-knee amputation. The target vessels of 41 patients maintain patency after discharge. Postoperative claudication distance increased to 500 meters except for one case in each group, all 4 rest pain patients got alleviated, reduced toe ulcer area happened in 1 and 2 cases respectively, all 3 cases of gangrene dried up/infection controlled in each group. Postoperative ABI result 0.7-0.8: 4 in group A and 5 in group B; 0.81-0.9 was 5 and 8; >0.91 was 6 and 13, respectively. Symptom improvement result had no significant difference between the two groups (P>0.05). Follow-up covered 41 patients, average 17.5±3.3 months. Group A patients stayed in good condition, 7 claudication patients's walking distance above 500 meters remains; rest pain no recurrence, one ulcer healing, 2 of 3 toe gangrene self-shedding and stump healing, 1 toe gangrene removed by surgery and wound healing. Group B, 4 of 15 claudication cases recurrence, and received plaque excision again. Rest pain no recurrence. 3 of 4 ulcer healing, 1 ulcer area reduced significantly. One out of 3 gangrene received below knee amputation (toe osteomyelitis), wound healing. One recurrence, angiography showed in-stent severe restenosis, received plaque excision again. One toe gangrene removed by surgery and wound healing.

CONCLUSION

Plaque excision with "SilverHawk" treatment for lower limb ischemia of atherosclerosis or in-stent restenosis is safe and effective. No significant difference for these two lesions in efficacy. Long term follow-up and larger randomized study is needed for further information on treatment.

Plaque debulking for femoro-popliteal occlusions: techniques and results

Although currently there is a trend of using percutaneous transluminal angioplasty (PTA) and stenting for the treatment of long occlusions of superficial femoral artery, many studies reported comparable results in terms of mid- and long-term patency between PTA and stenting and plaque debulking techniques such as remote endarterectomy, directional atherectomy catheter atherectomy and laser guided atherectomy. A successful debulking procedure is strongly associated with patients comorbidities, length of lesions and clinical presentation. In the last decade many new devices have been proposed to improve debulking results. Despite encouraging data about technical feasibility and limb salvage rate, debulking is still associated with a low rate of long-term primary and secondary patency. However, randomized clinical trials are expected and can hopefully provide conclusions on the effective durability of these procedures.

Treatment of femoropopliteal stenoses and occlusions with mechanical rotational catheters: comparison of results with the Rotarex and Pathway devices

AIM

For the treatment of chronic lesions, various ablative procedures have been developed with the aim of improving the outcome of percutaneous transluminal angioplasty (PTA)/stent and/or reducing the length and number of implanted stents by removing stenotic or occlusive material. The objective of this study was to compare two mechanical rotational catheters (Rotarex and Pathway) with regard to their safety and effectiveness in the treatment of stenoses and occlusions of the femoropopliteal arteries.

METHODS

A total of 156 patients with chronic stenoses or occlusions of the femoropopliteal vasculature were treated, 114 of them with the Rotarex catheter and 42 with the Pathway catheter. The pre-interventional Rutherford classification was on average 3.32 (2-5) in the Rotarex group and 2.93 (2-5) in the Pathway group. The mean lesion length was 13.9 cm (2-30 cm) and 5.1 cm (1-10 cm), respectively (P<0.05). The Ankle-Brachial Index (ABI) was determined pre- and postinterventionally and after 12 months. Colour-coded duplex ultrasound was additionally performed as a follow-up.

RESULTS

The technical success rate was 98.2 % in the Rotarex group and 97.6% in the Pathway group. In the Rotarex group, additional balloon dilatation was performed in 75 patients (65.8%) and stent implantation was necessary in 12 patients (10.5%). In the Pathway group, 27 patients (64.3%) underwent additional balloon dilatation and 5 (11.9%) stent implantation. Clinically, there was an increase in the ankle-brachial index from 0.59 to 0.84 ± 0.15 postinterventionally and 0.80 ± 0.16 12 months after Rotarex treatment, compared with an increase from 0.62 ± 0.14 to 0.84 ± 0.15 postinterventionally and 0.81 ± 0.12 12 months after Pathway treatment. In addition, there was a reduction in the Rutherford stage to 1.73 (1-3) and 1.43 (1-3), respectively. During the follow-up period, 21 (21.4%) restenoses occurred in the Rotarex group and 8 (19.0%) in the Pathway group. Peri-interventional complications included 7 dissections (4 after Rotarex, 3 after Pathway). Two distal embolisations were observed (both after Pathway). Throughout the entire duration of the study there were no amputations or fatalities.

CONCLUSION

The atherectomy of lesions of the femoropopliteal arteries using the Rotarex and Pathway systems is safe. The low stent rate peri-interventionally and the low restenosis rate after 12 months, with a significantly longer lesion length, indicate a better effectiveness of the Rotarex system as a whole.

Technological devices in peripheral percutaneous interventions

New innovations and novel approaches to peripheral arterial occlusive disease have brought enormous benefits to the vascular patient. Diseases that were once manageable only by surgical intervention are now easily and successfully treated by minimally invasive procedures. While the early days of percutaneous intervention were filled with inventions of new devices, today the focus centers on using modern technology and manufacturing to further improve upon these devices. Advances in guidewires and catheters have allowed us to visualize and treat lesions in nearly any vessel, and technology is guiding us towards specialized applications for specific lesions in specific vessels. However, one of the big hurdles remaining in treating arterial occlusive diseases is the rate of restenosis and the need for reinterventions. The location and architecture of these vessels make them uniquely difficult to treat, and call for new technology to address these challenges. Current developments of drug-eluting and bioabsorbable stents are at the forefront of new advancements specifically directed at improving current patency and restenosis rates; perhaps the next step in percutaneous intervention will rely on nanotechnology and the molecular surface engineering that may achieve a new era of devices that are able to target specific cell ligands or proteins to prevent the inflammatory and proliferative response from vessels. The present review will focus on the current literature regarding technological devices in peripheral percutaneous interventions and clinical applications. Future advancements in materials engineering and biotechnology will continue to improve the current standard of percutaneous intervention for peripheral arterial occlusive diseases.

Evolution of atherectomy devices

Percutaneous atherectomy provides an alternative approach to the endovascular treatment of peripheral atherosclerotic occlusive disease beyond angioplasty and stenting, and has the theoretical advantage of lesion debulking and minimizing barotrauma to the vessel wall. Atherectomy has evolved greatly during the last decade, with currently four FDA approved devices for the treatment of peripheral arterial disease. Several reports have focused on the initial technical success rates, and demonstrated the safety and short as well as mid-term efficacy of atherectomy devices. This article will review the evolution of current atherectomy devices and the associated literature.

Safety and efficacy of directional atherectomy for the treatment of in-stent restenosis of the femoropopliteal artery

AIM

The aim of this study was to evaluate safety and efficacy of directional atherectomy with the Silver HawkTM device as first line treatment for in-stent restenosis of the femoropopliteal artery.

METHODS

Over a period of 1.5 years in-stent restenosis of the femoropopliteal artery in 35 lesions (34 legs, 33 patients) was primarily treated with directional atherectomy. Primary endpoint was treatment success (<50% residual stenosis) and the absence of complications. Secondary endpoint was target lesion patency after 3, 6 and 12 month assessed by duplexsonography.

RESULTS

Mean patient age was 70 years (SD+/-10). 74 % were claudicants (Rutherford 2-3), 26% had CLI (Ruther-ford (4-5). 45% were diabetics, 82% had a history of arterial hypertension and nicotine abuse. Mean lesion length was 108 mm (SD+/-102 mm). Treatment success with atherectomy alone was achieved in 86% with additional PTA (43%) success increased to 97%. Adjunctive stent implantation was necessary in 11% of the cases. Post interventional ABI increased from 0.54 (+/-0.26) to 0.77 (+/-0.26). The rate of minor complication was 3% (1/34) and the rate of major complication was 18% (6/34), mainly due to distal embolization. Target lesion patency at 3 month was 86.2%, at 6 month 68% and at 12 month 25%.

CONCLUSIONS

Although atherectomy of in-stent restenosis as a first line treatment yields a high initial success rate with a low requirement for adjunctive PTA and stent implantation, long term patency rates are low. In our study the theoretical advantage of avoiding barotauma did not result in prevention of recurrent intimal hyperplasia.

[Clinical application of directional catheter-mediated atherectomy in patients with ischaemic-form diabetic foot syndrome]

The authors share their experience gained with the device designed for directional catheter-mediated atherectomy SilverHawk (eV3, U.S.A.) used as an alternative to the conventional procedure of balloon angioplasty and stenting in patients presenting with an ischaemic form of the diabetic foot syndrome. A conclusion was drawn on feasibility of directional catheter-mediated atherectomy in management of diabetic patients presenting with occlusive and stenotic lesions of lower-limb arteries.

Orbital atherectomy for infrapopliteal disease: device concept and outcome data for the OASIS trial

OBJECTIVE

The purpose of this study was to assess the safety and short-term efficacy of orbital atherectomy for chronic infrapopliteal arterial occlusive disease.

BACKGROUND

Infrapopliteal occlusive disease is a common cause of critical limb ischemia and claudication. There are no American College of Cardiology/American Heart Association guidelines for infrapopliteal revascularization for chronic limb ischemia.

METHODS

One hundred twenty four patients (201 stenoses) were enrolled in a prospective non-randomized multicenter registry of orbital atherectomy for severe infrapopliteal disease. Data were collected as part of an investigational device exemption from the Food and Drug Administration.

RESULTS

The primary safety endpoint of major adverse events (MAE) at 30-days (death, myocardial infarction, amputation, or repeat revascularization) was observed in four patients (3.2%). The primary efficacy endpoint (final diameter stenosis) was 17.8 +/- 13.5%. The secondary endpoints of procedural success (final diameter stenosis < or =30%) and 6 month MAE (death, amputation, or target vessel revascularization) were observed in 90.1 and 10.4% of patients, respectively. Stand-alone atherectomy was performed in 116 lesions (57.4%). At 6-months, no patients required surgical bypass or unplanned amputation, and improvement in Rutherford ordinal scale was observed in 78.2% of patients.

CONCLUSIONS

Orbital atherectomy is a unique approach to infrapopliteal disease, and provides predictable and safe lumen enlargement. Short-term data demonstrate substantial symptomatic improvement and infrequent need for further revascularization or amputation.

Analysis of particulate debris after superficial femoral artery atherectomy

PURPOSE

To evaluate the occurrence, size and composition of embolized debris captured during routine directional atherectomy using the SilverHawk device.

METHODS

15 consecutive eligible patients with a nonocclusive superficial femoral artery (SFA) were enrolled. Patients were included if they were > 18 years of age and had > or = 70% stenosis in the SFA. All lesions underwent plaque excision with the SilverHawk atherectomy device. A FilterWire EZ was used for distal protection and retrieval of embolized material. Specimens were collected separately from the filter basket and the SilverHawk atherectomy device's nosecone and were studied by a pathologist for number, size and composition.

RESULTS

Visible debris captured in the filter was found in the majority of patients 14/15 (93%). Clinically-significant debris was found in 7/15 (47%) patients. The proportion of captured debris ranged from 0.1-0.4 cm. Microscopy revealed that the shaved particles consisted predominantly of collagen, fibrin, lipid-laden macrophages, cholesterol and calcium. Analysis of the embolized material revealed a different composition, mostly consisting of collagen with fibrosis, cholesterol and macrophages.

CONCLUSION

In this single-center comparative study we have shown that during SilverHawk atherectomy of SFA lesions, distal embolization is universal. The debris captured in the filter is different in overall composition from the captured material in the nosecone of the SilverHawk device. Debris large enough to cause clinically-significant embolization, no-reflow and ischemia following SFA interventions occurred in nearly 50% of cases.

Popliteal artery pseudoaneurysm following FoxHollow atherectomy: a rare complication

Atherectomy using the FoxHollow device is an exciting treatment as an alternative to lower extremity arterial bypass for treatment of peripheral vascular disease in symptomatic patients with critical limb ischemia and disabling claudication. We present an interesting case of popliteal artery pseudoaneurysm following FoxHollow atherectomy, which is a rare complication. Mechanical factors have been implicated in causation of trauma to the vessel wall during atherectomy. Endovascular treatment of peripheral vascular disease has become increasingly common, thus it is important to know the rare complications associated with it. Pseudoaneurysm is one of the rare complications associated with the use of the FoxHollow atherectomy device.

Recent advances in atherectomy and devices for treatment of infra-inguinal arterial occlusive disease

The prevalence of peripheral arterial disease (PAD) continues to rise in an ever ageing society and consumes a significant part of health resources. Percutaneous revascularization has revolutionized the treatment of lower extremity peripheral vascular disease over the past 10 years. Additionally, novel devices have allowed improved endovascular treatment of femoropopliteal as well as infrapopliteal disease. Although percutaneous transluminal angioplasty (PTA) can be an effective modality for focal lesions in the iliac arteries, the results for complex infra-inguinal arterial disease have been disappointing. One class of new technology has concentrated on debulking the plaque, while others focus to improve safety (distal embolic protection devices) or are directed to specific clinical challenges such as chronic total occlusions. However, the lack of uniform performance criteria and reporting standards for these and other devices has resulted in heterogeneous study end points, making comparative efficacy difficult. Here we review the current data for atherectomy and atheroablative technologies as well as other adjunctive devices in the treatment of lower extremity peripheral arterial disease.

[Rotational ablation: back to the future]

In the late 1980s, many alternative methods to coronary angioplasty were sought, among which rotational ablation was one of the most popular. With the huge development of coronary stents, this technique, however, was progressively left aside. More recently, though, rotational ablation has reappeared as a unique technique for the most calcified lesions and is used in a small but not negligible percentage of patients with success rates over 95% in recent series.

Hybrid Revascularization Using Silverhawk Atherectomy and Infrapopliteal Bypass for Limb Salvage

Patients with limb-threatening ischemia and a paucity of ipsilateral greater saphenous vein for conduit represent a challenge for lower extremity revascularization. We present four patients with limited autogenous conduit who underwent hybrid revascularization using the Silverhawk atherectomy device and infrapopliteal artery bypass for limb-threatening ischemia. All patients experienced complete wound healing in early follow-up. Hybrid revascularization appears safe, produces excellent short-term outcomes, and may be appropriate for patients with limited autogenous vein who require lower extremity revascularization.

A novel approach using atherectomy for chronic total occlusion of the brachial artery: a case report

Chronic upper limb ischemia is uncommon, and is most often secondary to subclavian artery stenosis. Percutaneous intervention for subclavian stenosis usually includes balloon angioplasty and stent implantation. Brachial artery stenosis is even more scarce and accounts for approximately 12% of symptomatic upper extremity ischemia. Because it is rare, the optimal treatment strategy for brachial artery stenosis remains uncertain. We describe a case of chronic brachial artery ischemia due to atherosclerotic disease treated with the SilverHawk plaque excision system and review the available data regarding its use.

Treatment of severe infrapopliteal vascular disease using a novel atherectomy device: a case report

We report two first in man cases of percutaneous revascularization for severe intrapopliteal arterial disease using the novel PV atherectomy device.

Initial Experience with Directed Laser Atherectomy Using the Clirpath Photoablation Atherectomy System and Bias Sheath in Superficial Femoral Artery Lesions

PURPOSE

To report a safety and efficacy study of directed excimer laser atherectomy with the Bias Sheath guiding catheter to create larger lumens in the superficial femoral artery (SFA).

METHODS

Fourteen patients (9 men; mean age 66+/-9 years, range 46-76) with chronic lower limb ischemia (Rutherford class 2 to 5) referable to SFA stenoses were treated with the 8-F-compatible Bias Sheath and a 1.7- or 2.0-mm laser catheter. Eight (57%) lesions were de novo and 6 (43%) were in-stent restenoses (ISR). Mean diameter stenosis was 96%+/-8% (range 80%-100%; 10 total occlusions), and mean lesion length was 126+/-78 mm (range 30-290). The primary study endpoint was laser success, defined as <50% angiographic residual stenosis post-laser, without major perforations.

RESULTS

The primary endpoint was achieved in 8 (57%) lesions; all patients underwent additional balloon angioplasty, which achieved an angiographic residual stenosis <30% in all. Three lesions could not be completely traversed with the study device. Two dissections were detected after Bias Sheath application; 1 required stenting. There were 2 embolic events (specific to the antegrade device design); both were treated with aspiration therapy. Intravascular ultrasound (IVUS)-based minimal lumen diameters were 0.23+/-0.2 mm (range 0-1.0) at baseline and 3.2+/-0.8 mm after Bias Sheath application. Rutherford category improved at 1 month in 10 (71%) patients. One patient remained unchanged, another worsened (category 2 to 3), 1 died, and the fourth was not examined. The ankle-brachial index improved from 0.41+/-0.18 at baseline to 0.79+/-0.19 at discharge and to 0.80+/-0.19 at 1 month. Primary 1-month patency (<50% restenosis by duplex) was 85% (11/13 lesions).

CONCLUSION

SFA lesions, including ISR, can be treated in the majority of cases with directed laser atherectomy, significantly reducing plaque burden as measured by IVUS. Embolization was attributed to device-specific features of the prototype antegrade sheath design, which was discontinued. Larger studies are mandatory to document the long-term technical and clinical impact of this new device.

Percutaneous Rotational and Aspiration Atherectomy in Infrainguinal Peripheral Arterial Occlusive Disease: A Multicenter Pilot Study

PURPOSE

To report a safety and efficacy study of the first rotational aspiration atherectomy system (Pathway PV) for the treatment of arterial lesions below the femoral bifurcation.

METHODS

From December 2005 to February 2006, 15 patients (9 men; mean age 71+/-9 years) with Rutherford stage 2 to 5 lower limb ischemia were enrolled at 3 study sites. Target lesions were in the superficial femoral (n = 7, 47%), popliteal (n = 7, 47%), and posterior tibial (n = 1, 6%) arteries. Mean diameter stenosis was 97%+/-10%; mean lesion length was 61+/-62 mm (range 5-250). The primary study endpoint was the 30-day serious adverse event (SAE) rate.

RESULTS

Interventional success (residual stenosis <30%) was achieved in all lesions (100%). Stand alone atherectomy was performed in 6 (40%) patients, adjunctive balloon angioplasty in 7 (47%), and stenting/endografting in 2 (13%). The SAE rate at 30 days was 20% (3/15), including 1 perforation due to an unrecognized displacement of the guidewire (sealed with an endograft), 1 false aneurysm at the puncture site (successful duplex-guided compression therapy), and 1 dissection in conjunction with a distal embolism (stent implantation and aspiration thrombectomy). Primary patency rates measured by duplex ultrasound at 1 and 6 months were 100% and 73%, respectively; the TLR rate was 0% after 6 months. The ankle-brachial index increased significantly from 0.54+/-0.3 at baseline to 0.89+/-0.16, 0.88+/-0.19, and 0.81+/-0.20 (p<0.05) at discharge, 1 month, and 6 months, respectively. Mean Rutherford categories were 2.92+/-1.19 (range 1-5), 0.64+/-1.12 (range 0-1), and 0.83+/-1.33 (range 0-3) at the same time points (p<0.05).

CONCLUSION

The application of this new atherectomy device was feasible in all cases. The serious adverse event rate was moderate; however, all events were solved during the index procedure. The 0% 6-month TLR rate is promising.

Recanalization of infrainguinal vessels: silverhawk, laser, and the remote superficial femoral artery endarterectomy

There are multiple endovascular options to achieve percutaneous revascularization of chronic superficial femoral artery (SFA) stenoses and occlusions. Most rely on forceful displacement of plaque via balloon angioplasty, either as a stand-alone therapy or supplemented by cold thermal injury (cryoplasty), microtome assistance (cutting balloon angioplasty), nitinol stent deployment, or expanded polytetrafluoroethylene-lined nitinol stent deployment. Excellent technical success rates are routinely described in the literature. The essential problem associated with these techniques is the predictable compromise of the initial result by neointimal hyperplasia leading to poor long-term results. An alternative to forceful displacement techniques is use of directional atherectomy or excimer laser to debulk the atheromatous lesion, with the addition of low-pressure angioplasty or stent deployment as needed. Currently, directional atherectomy is performed using the Silverhawk Plaque Excision System (FoxHollow, Redwood City, CA), while laser atherectomy is frequently performed with the CLIRpath Excimer Laser (Spectranetics Corp., Colorado Springs, CO). While both techniques can be utilized for de novo atherosclerotic lesions, even eccentric lesions or ostial lesions, proponents of these devices have also shown good short-term results in the treatment of restenoses. Remote SFA endarterectomy with the Aspire stent (Vascular Architects, San Jose, CA) is a hybrid surgical and endovascular technique that is useful for debulking plaque from the SFA with adjunctive stenting of the distal SFA. We present a review of various alternative techniques to forceful balloon dilation used in the recanalization of the SFA with potential pitfalls and complications, along with a review of literature associated with each of these techniques.

Mechanism of Luminal Gain with Plaque Excision in Atherosclerotic Coronary and Peripheral Arteries: Assessment by Histology and Intravascular Ultrasound

OBJECTIVES

Using intravascular ultrasound (IVUS) and histology, the purpose of this study was to evaluate the occurrence of arterial wall overstretch and Dotter effect following revascularization with a plaque excision (PE) catheter compared with balloon angioplasty.

BACKGROUND

Previous studies have demonstrated the safety and feasibility of plaque excision for the treatment of de novo coronary and peripheral atherosclerotic disease. However, whether mechanical vessel dilatation related to catheter insertion contributes to gains in the final luminal diameter is uncertain.

METHODS

Treatment with PE was assessed in both a porcine model (6 lesions treated with balloon angioplasty or PE) using histology and in humans with IVUS. In the latter part of the study, IVUS study was performed before and immediately following PE in 21 patients with either coronary artery disease (N = 13) or femoral artery disease (N = 8). Ultrasound measures in the femoral artery group were then compared with a control group of atherosclerotic lesions treated with conventional angioplasty that was matched according to lesion location and vessel diameter.

RESULTS

Among individuals with coronary and peripheral arterial lesions treated with PE, the relative increases in luminal area secondary to reductions in plaque volume were 89% and 83%, respectively, with minimal increase in vessel diameter. In contrast, balloon angioplasty was associated with significantly greater vessel expansion and less plaque volume reduction. Vessel dissection also tended to occur less frequently and to a lesser extent with PE.

CONCLUSIONS

Improvement in luminal dimensions using PE is principally due to a reduction in plaque volume rather than mechanical vessel expansion. The potential to increase luminal area while minimizing arterial dissection and barotrauma merits further clinical study with this method of revascularization.

[Treatment for coronary artery calcification]

Coronary calcification frequently coexists with coronary atherosclerosis. Diagnosis methods are traditional coronary angiography, intravascular ultrasound, electron beam CT and muti-slice CT. Treatment for patients with calcified coronary arteries is troublesome. Rotablator or laser atherectomy are candidates for the treatment in coronary intervention. In bypass surgery, calcified area should be avoided for anastomosis. Treatment for coronary calcification itself is not standardized at present.

Ostial RCA intervention: guiding catheter challenges and use of a buddy wire to perform focused-force angioplasty on a severely calcific ostial right coronary lesion

Ostial coronary disease presents a challenge from multiple perspectives with regard to percutaneous intervention. We present a novel case of a technically challenging ostial right coronary artery calcified lesion with a bar of calcium at the aorto-ostial junction which prevented intubation with multiple guiding catheters. We describe the use of a buddy wire as a technique for focused-force angioplasty with slow incremental balloon inflation of increasing diameter for plaque modification prior to stenting in a situation where rotational atherectomy and cutting balloon angioplasty were not an option.

Plaque Excision in the Treatment of Peripheral Arterial Disease

The goals of any percutaneous intervention in the lower extremity are to provide initial technical success and restore durable arterial patency. The first goal can be achieved through a multitude of endovascular techniques, whereas achieving the latter has remained elusive. The large number of choices in treatment options for percutaneous lower-extremity revascularization speak to the fact that no single tool or technique has been proven to be superior. The SilverHawk plaque excision system is designed to debulk stenotic or occlusive arterial lesions. Like many endovascular technologies, reports have focused on rates of initial technical success and short-term outcomes, but long-term results remain unknown. This report reviews selected published or presented results of plaque excision, touches on areas of concern or controversy regarding both the device and some of its proponents, and suggests clinical or anatomic settings in which plaque excision appears most effective. The ultimate utility of this technology will depend on confirmation of its acute and long-term outcomes through unbiased, well-designed clinical trials.