Peripheral directional atherectomy: 4-year experience

Early outcomes of novel Temren atherectomy device combined with drug-coated balloon angioplasty for treatment of femoropopliteal lesions

OBJECTIVES

In this study, perioperative properties and early outcomes of patients who underwent combined Temren rotational atherectomy (RA) and drug-coated balloon (DCB) angioplasty treatment for complex femoropopliteal lesions in a single center were reported.

METHODS

Between June 2019 and February 2020, 40 patients who underwent combined Temren RA and DCB treatment due to critical lower limb ischemia or claudication-limiting daily living activities were retrospectively evaluated.

RESULTS

The mean age of patients was 73.2 ± 7.8 years and the majority of the patients were male (65%). Of the patients, 17 had critical limb ischemia and 23 had lifestyle-limiting claudication. Pathologies were total occlusion in 33 limbs and critical stenosis in seven limbs. Nine patients previously underwent endovascular intervention or surgery. The mean total occlusion length was 140.9 ± 100.9 (range, 20-360) mm in patients with chronic total occlusion. There was an additional iliac artery pathology in 5 and below the knee pathology in 8 patients. Rotational atherectomy was possible in all cases. Flow-limiting dissection was seen in six patients (15%). Provisional stent was performed to these patients. Following Temren RA, all patients underwent DCB. Adequate vascular lumen (less than 30% stenosis) was provided in all patients and the symptoms regressed. No distal embolization was encountered. Access site complications (17.5%) were small hematoma in four patients, ecchymosis in two patients, and pseudoaneurysm of the femoral artery in one patient. The mean follow-up was 13.55 ± 4.2 (range, 1-18) months. Re-occlusion was seen in three patients (7.5%) (n = 2 at 2 months and n = 1 at 4 months). Of these patients, two had required open revascularization via femoropopliteal bypass graft with common, superficial femoral, and popliteal artery endarterectomy and one had required femoro-posterior tibial artery bypass. Four minor toe amputations (10%) were performed to reach complete wound healing in the critical limb ischemia patients. A below-knee amputation was performed in a 94-year-old patient with long segment stenosis at the end of a 1-month follow-up period. There was no mortality after follow-ups. The Kaplan-Meier estimator estimated the rate of freedom from target lesion revascularization (TLR) which was 92.3%. The decrease in the Rutherford levels after the procedure was found to be statistically significant in 36 patients (p < 0.001). The increase in the ankle-brachial index after the procedure was found to be statistically significant in 36 patients (p < 0.001).

CONCLUSIONS

Combined use of Temren RA with adjunctive DCB is safe and effective method with high rates of primary patency and freedom from TLR and low rates of complication in the treatment of femoropopliteal lesions.

Safety and effectiveness of the Phoenix Atherectomy System in lower extremity arteries: Early and midterm outcomes from the prospective multicenter EASE study

Objectives

To evaluate the novel Phoenix Atherectomy System as percutaneous treatment of de novo and restenotic infrainguinal arterial lesions.

Methods

This prospective, multicenter, nonrandomized investigational device exemption trial was conducted across 16 US and German centers between August 2010 and April 2013. Intention-to-treat enrollment was 128 patients (mean age: 71.8 years, 59% male) with 149 lesions (mean length: 34 mm, mean diameter stenosis: 89.5%), and the primary analysis per-protocol population consisted of 105 patients with 123 lesions. The primary efficacy endpoint, technical success, was the achievement of acute debulking with a post-atherectomy residual diameter stenosis ≤50% (before adjunctive therapy). The primary safety endpoint was the major adverse event (MAE) rate through 30 days.

Results

For the primary analysis per-protocol population, the rate of lesion technical success was 95.1% (117/123), with the lower limit of the 95% CI 90.6%, meeting the prospectively established target performance goal of ≥86%. After post-atherectomy adjunctive therapy, residual stenosis was ≤30% for 99.2% (122/123) of lesions (mean final diameter stenosis 10.5%). Improvement of ≥1 Rutherford class occurred for 74.5% of patients through 30 days and for 80% through six months. MAEs were experienced by 5.7% (6/105) of patients through 30 days (with the upper limit of the 95% CI 11.0%, meeting the target performance goal of <20%), and 16.8% through six months. Six-month freedom from TLR and TVR was 88.0% and 86.1%, respectively.

Conclusions

Based on the high rate of technical success and the low rates of MAEs through six months, the Phoenix Atherectomy System is safe and effective for the debulking of lower-extremity arterial lesions.

ClinicalTrials.gov identifier NCT01541774

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.

[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.

Endovascular management of the popliteal artery: comparison of atherectomy and angioplasty

PURPOSE

Symptomatic atherosclerotic disease of the popliteal artery presents challenges for endovascular therapy. We evaluated the technical success, complications, and midterm outcomes of atherectomy and angioplasty involving the popliteal segment.

METHODS

We conducted a retrospective review of outcomes of popliteal artery intervention using atherectomy or angioplasty performed between 2003 and 2008.

RESULTS

A total of 56 patients (36% women, age 72.8 +/- 12.2 years, 77% critical limb ischemia) underwent popliteal atherectomy (n = 18) or angioplasty (n = 38). These patients had similar clinical characteristics, TransAtlantic Intersociety Consensus (TASC)/ TASC II classification, mean lesion length, and runoff scores. We observed a trend toward higher rates of technical success defined as <30% residual stenosis after atherectomy compared to angioplasty (94% vs 71%, P = .08). While angioplasty was associated with a higher frequency of arterial dissection (23% vs 0%, P = .003), atherectomy was associated with a higher rate of thromboembolic events (22% vs 0%, P = 0.01). Adjunctive stenting was used more frequently following angioplasty compared to atherectomy (45% vs 6%, P = .005). Thrombolysis was used to treat embolization in 4 patients in the atherectomy group. The improvement in the ankle-brachial index (ABI) was similar between the 2 treatment groups. Primary patency of the popliteal artery at 3, 6, and 12 months was 94%, 88%, and 75% in the atherectomy group and 89%, 82%, and 73% in the angioplasty group (P = not significant [NS]). There were no significant differences in limb salvage and freedom from reintervention at 1 year between the atherectomy and angioplasty groups.

CONCLUSIONS

Our experience with popliteal artery endovascular therapy indicates a distinct pattern of procedural complications with atherectomy compared to angioplasty but similar midterm patency, limb salvage, and freedom from intervention.

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.

Long-term results after directional atherectomy of femoro-popliteal lesions

OBJECTIVES

Our objective in this research was the evaluation of the long-term results after directional atherectomy using the Silverhawk device (FoxHollow Technologies, Redwood City, California) of femoro-popliteal lesions.

BACKGROUND

Considering reports on stent fractures in femoro-popliteal arteries, atherectomy may be a valuable alternative to stenting.

METHODS

Eighty-four patients with 100 legs and 131 lesions with peripheral occlusive disease Rutherford categories 2 to 5 were included in a prospective registry. Forty-five lesions were de novo lesions (group 1; 34%), 43 lesions native vessel restenoses (group 2; 33%), and 43 lesions in-stent restenoses (group 3; 33%). Additional low pressure balloon angioplasty was used in 78 of 131 lesions (59%) and stenting in 8 lesions (6%).

RESULTS

Technical success rate was 86% for atherectomy only and 100% after additional therapy. Mean lesion length was 43 +/- 54 mm, 105 +/- 122 mm, and 131 +/- 111 mm for group 1, group 2, and group 3, respectively (p < 0.001). Primary patency, defined as freedom of a >50% restenosis detected by duplex, was 84%, 54%, and 54% at 12 months (p = 0.002) and 73%, 42%, and 49%, at 18 months (p = 0.008); secondary patency rates were 100%, 93%, and 91% at 12 months (p = NS) and 89%, 67%, and 79% at 18 months (p = 0.001), respectively; and target lesion revascularization rate was 16%, 44%, and 47% at 12 months and 22%, 56%, and 49% at 18 months (p = 0.003 each) for group 1, group 2, and group 3, respectively. The only independent predictor for restenosis was treatment of restenotic lesions. Ankle-brachial index was significantly improved after 12 months and 18 months in all groups.

CONCLUSIONS

Long-term technical and clinical results after directional atherectomy of femoro-popliteal lesions are in favor of de novo lesions compared with restenotic lesions.

Midterm results after atherectomy-assisted angioplasty of below-knee arteries with use of the Silverhawk device

PURPOSE

Prospective evaluation of the 3- and 6-month results after atherectomy of below-knee arterial lesions with a reference diameter of at least 2.0 mm with use of the Silverhawk device.

MATERIALS AND METHODS

Fifty-two below-knee lesions in 33 patients (61% men; mean age, 70 years +/- 11) with chronic peripheral occlusive disease of the lower limbs were treated with directional atherectomy. Target lesions were the popliteal artery (segment 3), n = 4 (8%); tibioperoneal trunk, n = 22 (42%); peroneal artery, n = 18 (34%); anterior tibial artery, n = 5 (10%); posterior tibial artery, n = 3 (6%); and in-stent lesions, n = 8 (16%). All interventions were performed via a 6-F sheath. The average degree of diameter stenosis was 89% +/- 10% (range, 70%-100%; n = 12 [23%] occlusions) and the mean lesion length was 48 mm +/- 28.

RESULTS

All but one lesion (2%) could be treated with the atherectomy catheter. After additional balloon angioplasty, all but one lesion was treated, with a residual stenosis no greater than 30% (98%), with 7.2 passes per lesion +/- 2.8 (range, 1-12) performed with the device. Fifteen lesions (29%) were treated after predilation and 37 (71%) were treated with primary atherectomy. In 15 lesions (29%), additional balloon angioplasty was performed, and two lesions required stent implantation as a result of dissection. The mean stenosis diameter after atherectomy was 12% +/- 18% (range, 0-100%). After additional therapy, the mean stenosis diameter was 6% +/- 9% (range, 0%-30%). A residual stenosis no greater than 30% was achieved in 50 lesions (96%). The mean ankle-brachial index significantly increased from 0.46 +/- 0.27 to 0.80 +/- 0.34 before discharge and remained improved during follow-up. One procedural complication (3%) was observed in which an intermittent occlusion of the target vessel occurred after an unsuccessful attempt to cross the lesion with the atherectomy device; this was then treated successfully with local lysis. One patient with one treated lesion died during follow-up. The rates of restenosis of at least 70% (diagnosed by duplex ultrasonography) were 14% (seven of 51 lesions) after 3 months and 22% (11 of 51) after 6 months. The 3-month and 6-month cumulative event-free survival were 91% +/- 4.1% and 76.9% +/- 5.8% and the 3-month and 6-month cumulative patency rates were 98% +/- 1.9% and 94.1% +/- 3.3%, respectively.

CONCLUSION

Below-knee native vessel lesions with a diameter of at least 2.0 mm can be treated with the Silverhawk catheter with a high success rate and a low complication rate. Midterm technical and clinical results are encouraging. Additional balloon angioplasty might be necessary in selected cases.

Percutaneous Peripheral Atherectomy of Femoropopliteal Stenoses Using a New-Generation Device:Six-Month Results From a Single-Center Experience

PURPOSE

To report the early and 6-month results after atherectomy of femoropopliteal lesions using a new atherectomy device compatible with a 7-F sheath.

METHODS

Fifty-two patients (36 men; mean age 67+/-7 years) with stable, chronic lower limb occlusive disease were enrolled prospectively in a study of percutaneous directional atherectomy using the SilverHawk Atherectomy Catheter. The 71 femoropopliteal stenoses were grouped for analysis according to pathology: 30 (42%) primary stenoses, 27 (38%) native vessel restenoses, and 14 (20%) in-stent restenoses. The overall average stenosis length was 48+/-64 mm (range 10-300). There were more diabetics in the primary lesion cohort, whereas the lesion length of the in-stent restenoses was nearly twice as long as the other groups.

RESULTS

After atherectomy alone, residual stenosis was < or =50% in 68 (96%) lesions and < or =30% in 54 (76%). Additional balloon angioplasty was used in 41 (58%) lesions, primarily to smooth the arterial contour; stents were implanted in 4 (6%) arteries. Acute results after atherectomy and additional therapy were identical for the 3 groups (mean residual stenosis 15% in primary lesions, 8% in restenoses, and 14% in in-stent lesions). At the beginning of the study, 5 cases of tissue embolism were successfully treated with aspiration (device modification solved this problem). Restenosis rates after 6 months were not significantly lower in primary lesions (27%) compared with the other groups (41% for restenoses and 36% for in-stent restenoses). Reintervention after 6 months was also lowest for primary lesions (20% versus 37% for restenoses and 29% for in-stent lesions; p=NS). The ankle-brachial index was significantly improved after 6 months in all groups. At the 6-month follow-up, >80% of all patients were symptom free or had no lifestyle-limiting claudication.

CONCLUSIONS

Short and medium-length femoropopliteal lesions can be treated successfully and safely in most cases with this new atherectomy catheter. Technical and 6-month clinical outcomes seem to favor primary lesions compared with restenoses.

Optimal therapeutic approaches to femoropopliteal artery intervention

Superficial femoral artery disease presents a complex challenge for therapy. The extent of vascular involvement may vary from focal disease with symptoms of intermittent claudication to long total occlusions manifest as critical limb ischemia. Optimal therapy requires understanding the available options including exercise programs, pharmacologic medical therapy, surgery and interventional endovascular therapy. Rapidly advancing endovascular technology for enabling safe intervention in complex, long occlusive segments of the superficial femoral artery continues to emerge. New devices like the SafeCross wire, Excimer laser, Silverhawk Atherectomy catheter, Cryoplasty catheter and new generations of bare metal and drug-eluting nitinol stents are shifting the paradigm for therapy from surgical to more endovascular treatment even for the most complex disease presentation.

Adjunctive techniques in percutaneous mechanical thrombectomy

Percutaneous mechanical thrombectomy is an established method in interventional radiology and refers to the removal of acute embolic or thrombotic occlusive material in arteries, veins, or vascular grafts using percutaneous transluminal methods. However, initial complete removal of occlusive material can be achieved only in a minority of patients. The amount of removed material varies with the age and composition of the occlusive material. To achieve sufficient revascularization, adjunctive use of a variety of percutaneous endovascular recanalization techniques is necessitated. Additional treatment with local intra-arterial fibrinolysis, balloon angioplasty, stent implantation, endoluminal atherectomy, and other measures results in primary technical success rates of 70% to 100% for revascularization of acutely occluded vessels. The above-mentioned different techniques should not be viewed as competitive treatment modalities, rather a synergistic approach should be offered. The aim of this report is to review different adjunctive techniques in percutaneous mechanical thrombectomy with emphasis on techniques, mechanisms of action, experimental and clinical results, potential complications, and their potential role in view of clinical pathways to treat acute limb ischemia.

A novel approach in treating recurrent bilateral hepaticojejunostomy biliary strictures post-liver transplantation: Successful use of Simpson's atherectomy device

Biliary complications occur in 6% to 34% of patients who undergo orthotopic liver transplantation. Strictures at the anastomosis site or elsewhere in the biliary tract are common. These strictures are amenable to interventional radiological and surgical procedures; however, retransplantation is sometimes an inevitable outcome. An 8-year-old boy received combined liver and kidney transplants May 31, 1998. Hepatic artery thrombosis was diagnosed postoperative day 1 and treated with revascularization. The choledochojejunostomy was revised twice and resulted in a high hepaticojejunostomy. Significant strictures on both the right and left hepatic ducts at the anastomosis site were unsuccessfully treated by multiple interventional radiological procedures. The option of retransplantation was seriously explored. Simpson's atherectomy device was used in a novel approach February 24, 1999, and strictures on both ducts were successfully treated. At 1-year postprocedure, the patient has normal liver function with no evidence of recurrence of the strictures. Further experience with this novel technique is required to assess its role in treating biliary strictures post liver transplantation.

Peripheral directional atherectomy evaluated with a rotational digital angiography system

BACKGROUND

One of the factors that affect the recurrence rate after peripheral directional atherectomy (DA) is the degree of residual stenosis. A new method of peripheral DA to reduce residual stenoses was evaluated with a rotational digital angiography (RDA) system that provides both angiography and fluoroscopy at multiple projections within 360 degrees.

PATIENTS AND METHODS

Between March 1995 and July 1999, severe short segmental stenoses of six iliac arteries and two superficial femoral arteries (SFA) in eight patients were treated with the Simpson DA catheter under RDA system guidance. After pre-procedural RDA evaluation, the first series of DA were performed under ordinary PA fluoroscopic guidance. The residual stenoses were evaluated with RDA. If the residual stenoses exceeded 30%, a second series of DA were performed covering the residual plaque with the cutter window of the DA catheter. To this purpose the fluoroscopy of the RDA system was fixed in the direction in which the residual stenoses were largest and most eccentric. The end point was defined to be a residual stenosis of less than 30% evaluated with the RDA system, and the procedures were repeated until the end point was achieved.

RESULTS

Five of six iliac artery lesions were curved at the pre-procedural RDA evaluation. After the first series of DA, only two of six iliac lesions but all SFA lesions achieved the end point. Among the four other iliac lesions, three achieved the end point with one or two additional series of DA using the RDA system guidance to control the selective cuts of the residual plaques. One patient had a residual stenosis of 50% because the procedure could not be completed by balloon rupture of the DA catheter. In the patients with iliac stenoses, there was no final residual stenosis in one, and the range was from 20% to 25% in the four patients. The residual stenoses were located on the greater curvature side of the curved artery in three of these four patients.

CONCLUSION

The RDA system is a valuable tool in aiding reduction of the residual stenoses during peripheral DA. Minimal stenoses often remain on the greater curvature side of the wall because the rigid and straight metallic capsule (cylindrical housing) of the Simpson DA catheter does not completely fit the curved wall. This phenomenon was thought to be a mechanical limitation of this device.

Comparison of balloon angioplasty and Simpson atherectomy for lesions in the femoropopliteal artery: angiographic and clinical results of a prospective randomized trial

PURPOSE

This study involves a prospective randomized trial comparing clinical and angiographic results of balloon angioplasty (BA) and Simpson directional atherectomy (DA) in patients with short lesions in the femoropopliteal artery causing symptoms of intermittent claudication.

MATERIALS AND METHODS

Thirty-five patients were treated with BA and 38 with DA. Procedural complications were seen in eight patients. Residual stenoses immediately after the procedure with between 30% and 50% diameter reduction (DR) were observed in three patients after BA and in five patients after DA. In all other patients, residual stenosis was less than 30% DR. Two study end-points during a 2-year follow-up were used: the angiographic occurrence of restenosis with a DR of 50% or greater or the recurrence of symptoms.

RESULTS

Clinical success after 2 years, according to the criteria of the Society for Vascular Surgery/International Society for Cardiovascular Surgery, was seen in 79% of the BA patients and 56% of the DA patients (P = .07). The 2-year primary angiographic patency rates were 67% in patients treated with BA and 44% in patients treated with DA (P = .06). The secondary angiographically determined patency rates were 80% and 65%, respectively (P = .15).

CONCLUSION

Simpson atherectomy is an interventional technique to treat arterial lesions in the femoropopliteal artery with an acceptably low complication rate. The clinical and angiographic results of DA and BA are comparable. DA should not be used to replace BA for routine treatment of short femoropopliteal lesions.

Mid-term and long-term results with directional atherectomy of vein graft stenoses

PURPOSE

The purpose of this study was to evaluate the outcomes of our 6-year experience with directional atherectomy used for treatment of stenoses in infrainguinal vein grafts.

METHODS

From March 1988 to April 1994, 52 directional atherectomy procedures were undertaken in 42 patients to treat 67 stenoses in 44 vein grafts. Follow-up consisted of periodic physical examinations and graft surveillance; ankle/brachial indexes, pulse volume recordings, and color-flow duplex ultrasonography. Follow-up angiography (n = 18) was performed for recurrent symptoms, reproducible drop in ankle/brachial index of greater than 0.15, a twofold to threefold focal increase in peak systolic velocity, or incidentally during evaluation of the opposite leg.

RESULTS

Forty-nine of 52 (94%) procedures were technically successful. In two the residual diameter stenosis was greater than 30%, and in one atherectomy could not be performed. Complications were minor in six (11%) and major in three (6%): two acute graft occlusions and one delayed pseudoaneurysm at the atherectomy site. There were no deaths at 30 days. With a mean follow-up of 21 +/- 18 months, 36 of 44 grafts (82%) remained patent without restenosis; 6 others were patent but considered "failed"--5 (11%) with restenosis, 1 with a pseudoaneurysm; and 2 grafts (5%) occluded. Clinically 33 of 44 extremities (75%) were asymptomatic during follow-up. Claudication improved in five, recurred in three, and was unchanged in one. There was one below-knee amputation. Life-table analysis including all 52 procedures reveals cumulative primary atherectomy patency rates for the 44 grafts of 82%, 78%, and 78%, respectively, at 1, 2, and 3 years after atherectomy, and 86%, 83%, and 83% for the 67 individual stenoses treated.

CONCLUSIONS

Directional atherectomy of vein graft stenoses has high technical and clinical success rates, acceptably low morbidity rates, and offers better sustained patency rates than balloon angioplasty. Its long-term patency rate seems to approach that of surgical vein patch angioplasty.

Prevention of intimal hyperplasia by irradiation. An experimental study in rabbits

PURPOSE

This experimental study was designed to investigate the effect of irradiation in prevention of intimal hyperplasia.

MATERIAL AND METHODS

Twenty rabbits were divided into 4 groups, which were irradiated with 2, 5, 10 and 20 Gy, respectively. The intima of both femoral arteries was injured by air-drying, and irradiation was performed on the unilateral side. The contralateral+ femoral artery served as a control. Angiograms as well as histologic specimens were obtained 1 month later.

RESULTS

Marked intimal hyperplasia was observed in all control sites. There were no significant differences in thickness of intimal hyperplasia between irradiated and control sites in groups irradiated with 2 and 5 Gy. However, in the 10-Gy- and 20-Gy-irradiated groups, intimal hyperplasia of the irradiated site was significantly suppressed. Medial thinning and dilation of the lumen were observed in the 20-Gy-irradiated group.

CONCLUSION

Radiation may prevent intimal hyperplasia. Further investigation of the optimal dose, timing of irradiation, and long-term patency of irradiated vessels may be needed.

A randomized trial of transcutaneous extraction atherectomy in femoral arteries: intravascular ultrasound observations

OBJECTIVES

The purpose of this study was to test the hypothesis that in occlusions of the superficial femoral artery, removal of atherosclerotic plaque would result in a higher long-term patency rate compared to balloon dilatation alone. A secondary hypothesis was that long term patency would be proportional to the amount of plaque removed.

METHODS

A randomized controlled study of patients with occluded superficial femoral arteries was performed comparing balloon dilatation alone versus a 2.7 mm or a larger (4.0 mm or 4.7 mm) transcutaneous extraction catheter (TEC) atherectomy device followed by balloon dilatation. The effect of these devices on plaque area was assessed directly by intravascular ultrasound imaging.

RESULTS

The mean occlusion length was 19.4 cm +/- 11.7 cm. The mean lumen area increased from 4.7 mm2 to 15.1 mm2, primarily due to balloon dilatation, but the mean atheroma area of 19.8 mm2 did not change with either size of TEC device. Although the initial procedure success rate was high (79%), the 6 month patency was only 45%. There was no difference in 6 month patency between the 3 groups.

CONCLUSIONS

The data indicate that the TEC atherectomy devices do not remove a significant amount of atherosclerotic plaque in occluded superficial femoral arteries. The 6 month patency is no different with these atherectomy devices than with balloon dilatation alone. The larger (4.0 mm or 4.7 mm) TEC device does not remove any more tissue than the smaller (2.7 mm) device. The use of intravascular ultrasound to quantitate the effects of this atherectomy device provides important insights into the mechanism of action and lack of efficacy of the TEC atherectomy catheter.

Intravascular ultrasound imaging of peripheral arteries as an adjunct to atherectomy: preliminary experience

12 atherosclerotic lesions in nine patients, including four restenoses after balloon angioplasty, were treated by atherectomy under the guidance of intravascular ultrasound (US). Echogenicities of the plaques and morphological alterations in the arterial walls produced by atherectomy were evaluated. The two-layered appearance of post-angioplasty restenoses was found to be inner fibrous intimal thickening with proliferation of smooth muscle cells and outer residual collagen-rich plaque. The deep cut surfaces were shown as concave U-shaped defects. Medial tissues were present in all cases where intravascular US demonstrated the disruption of a thin hyperechoic layer of the internal elastic lamina. Intravascular US imaging may provide valuable information on the degree, eccentricity and histological type of stenosis, the presence of calcification before atherectomy, and on the extent of excision and the morphological changes in the arterial wall after atherectomy.

Directional atherectomy versus balloon angioplasty in segmental femoropopliteal artery disease: two-year follow-up with color-flow duplex scanning

PURPOSE

Directional atherectomy is an endovascular interventional technique for excision and removal of obstructive arterial lesions. To evaluate whether atherectomy would provide better results than conventional balloon angioplasty (BA) in symptomatic femoropopliteal disease, a prospective randomized study comparing the early and late outcomes of these techniques was conducted. The rate of restenosis or occlusion was assessed by use of color-flow duplex scanning during the follow-up period.

METHODS

Seventy-three patients were randomized between atherectomy (38 patients) and BA (35 patients). All patients had segmental lesions of the femoropopliteal arteries amenable to either technique. The median follow-up duration was 13 months (range 1 to 39). Follow-up comprised regular clinical and hemodynamic assessment and color-flow duplex examinations. Restenosis was defined on the basis of a peak systolic velocity ratio of 2.5 or greater, and occlusion of the treated segment was diagnosed if flow signals were absent, that is, loss of patency.

RESULTS

Residual stenoses (> or = 30% diameter reduction) resulted in five patients (13%) undergoing atherectomy and three patients (9%) undergoing BA. At 1 month clinical and hemodynamic improvement by Society for Vascular Surgery/International Society for Cardiovascular Surgery criteria for lower limb ischemia was observed in 34 patients (89%) treated with atherectomy and in 34 (97%) treated with BA. By life-table analysis the cumulative rate of clinical and hemodynamic success at 2 years was 52% in patients treated with atherectomy and 87% in patients treated with BA (p = 0.06). The patency rate at 2 years of treated segments was 34% in the atherectomy group and 56% in patients treated with BA (p = 0.07). In patients with lesions greater than 2 cm, the 1-year patency rate of AT was significantly lower than BA (p = 0.03).

CONCLUSIONS

Atherectomy does not result in an improved clinical and hemodynamic outcome. Furthermore atherectomy of segmental atherosclerotic femoropopliteal disease does not result in a better patency rate than BA, and, in lesions with greater length than 2 cm, the atherectomy results are significantly worse.

Treatment of anastomotic bypass graft stenosis with directional atherectomy: short-term and intermediate-term results

PURPOSE

Areas of anastomotic stenosis in lower-extremity bypass grafts (BPGs) were treated by means of directional atherectomy (DA) in hopes of achieving better patency rates than have been reported with percutaneous transluminal angioplasty (PTA).

MATERIALS AND METHODS

During a 4-year period, 17 patients (11 men and six women) with 23 areas of anastomotic stenosis in 18 lower-extremity BPGs were selected for treatment with DA. Urokinase thrombolysis was initially performed in eight BPGs that were thrombosed at the time of presentation. Adjunctive preatherectomy PTA was performed in six lesions, and postatherectomy PTA was performed in three lesions.

RESULTS

The technical success rate for DA was 92% (23 of 25 sites). There was less than 50% restenosis at 74% of the areas of stenosis (14 of 19 sites), with a mean follow-up time for the sites of 13 months. The graft patency rate was 88% (14 of 16 grafts), with a mean follow-up time for the grafts of 14 months. Areas of stenosis treated with DA alone had the same patency rates as those treated with DA and PTA.

CONCLUSIONS

DA is an effective treatment method for anastomotic peripheral arterial BPG stenosis. The intermediate-term patency rates following DA are superior to those reported for PTA and similar to those reported for surgical revision.

A new use of the Simpson percutaneous atherectomy catheter: resection of retained valve cusps of an in-situ vein graft

An in-situ saphenous vein graft occluded because of retained valve cusps. After aspiration thrombectomy, percutaneous transluminal balloon angioplasty was performed, but reocclusion occurred 11 months later. Following a second aspiration thrombectomy, the restenosed retained cusps were resected using the Simpson percutaneous atherectomy catheter. The graft remained patent until the patient's death from unrelated causes 6 months later.

Directional atherectomy in the treatment of anastomotic neointimal hyperplasia associated with prosthetic arterial grafts: technique and preliminary results

The development of anastomotic neointimal hyperplasia is a common cause of late prosthetic arterial bypass graft failure. The cost and morbidity of graft failure are high, hence the widespread use of graft surveillance programmes in order to detect graft-related stenoses before they progress to occlusion. However, the optimal treatment of stenoses secondary to neointimal hyperplasia is not clear, with a number of authors reporting poor results with both balloon angioplasty and surgical revision. We report our early experience with the Simpson atherectomy catheter in the treatment of anastomotic neointimal hyperplasia associated with prosthetic arterial grafts at eight sites in seven patients. A high technical success rate may be expected and further long-term studies of this mode of treatment are indicated.

Infrainguinal directional atherectomy: long-term follow-up and comparison with percutaneous transluminal angioplasty

PURPOSE

To assess the long-term results of directional atherectomy (DA) for femoropopliteal artery atherosclerotic lesions and to compare the results to those previously reported for percutaneous transluminal balloon angioplasty (PTA).

MATERIALS AND METHODS

Eight-four percutaneous DA procedures performed on 75 patients between July 1988 and August 1992 were retrospectively reviewed and evaluated for technical and initial clinical success. Long-term patency was assessed with a combination of ankle-brachial index measurements and angiography.

RESULTS

Initial technical success was achieved in 77 of 84 procedures (92%). Follow-up of 72 patients was obtained, including 74 of the 84 (88%) DA procedures with a mean follow-up of 17.4 months (range 1-48 months). Primary patency was 78% at 1 year and 57% at 2 years. Patients with diabetes, complete luminal occlusion, or limb salvage situations had significantly lower patency.

CONCLUSIONS

Femoropopliteal artery DA can be performed safely with a high technical and initial clinical success. Long-term patency is improved when compared with published series for PTA. With this improvement in mind, DA may have a place in the treatment of focal infrainguinal stenoses.

Percutaneous transluminal atherectomy of the superficial femoral and popliteal arteries: long-term results in 48 patients

PURPOSE

Evaluate retrospectively the long-term primary patency of directional atherectomy (DA) in the femoropopliteal arteries.

MATERIALS AND METHODS

DA was used alone in 59 patients (47%) or in combination with predilatation to allow passage of the device (43%) or after thrombolysis (10%) to treat 127 (93%) excentric atherosclerotic stenoses and nine (7%) occlusions of the femoropopliteal arteries. Forty-eight patients were followed by telephone interview, scheduled outpatient visits, color-flow Doppler evaluation, and angiography for 1-36 months (mean 16.9 months).

RESULTS

Technical success (reduction of the stenosis or occlusion to less than 30% luminal diameter) was achieved in 110 lesions (80.3%) during 48 procedures in 37 patients. Mean luminal diameter was increased 54% with a concomitant increase in mean ankle/brachial indices of 0.33. According to Kaplan-Meier survival curves, patency at 12 and 24 months was 88% and 75%, respectively. When patients who retained patency but developed restenosis were excluded, the probability of patency at 12, 24, and 36 months was 76%, 58%, and 32%, respectively. Major and minor complications occurred in 15 (21.4%) procedures each for a total complication rate of 42.8%.

CONCLUSION

Based on our results, DA is an effective method for percutaneous treatment of atherosclerotic disease involving the femoropopliteal arteries. It has similar patency but a relatively high complication rate compared with PTA.

Classical and endovascular surgery: indications and outcomes

For more than 40 years, endarterectomy and bypass grafting have been the primary means of surgically revascularizing peripheral vessels threatened by atherosclerotic disease. However, with today's endovascular technology, stenoses and occlusions in nearly every circulatory system can be approached intraluminally with a wide variety of techniques: thrombolysis, laser angioplasty, atherectomy, balloon dilation, and intravascular stents. Just as exciting is the newer technique of endoluminal grafting, which has extended percutaneous therapy to aneurysmal disease in the thoracic and abdominal aorta and distal arteries, as well as to long-segment occlusive disease. Today's vascular surgeon is in a unique position to combine his or her classical surgical training with these catheter-based interventions. Certainly, the potential advantages of percutaneous therapy as compared to surgical reconstruction are significant: no general anesthesia or lengthy incisions, shorter hospitalization, lower morbidity and mortality, earlier intervention in the course of the disease, and less complicated reapplication in the event of disease recurrence. Undoubtedly, endovascular techniques will become a major component of the vascular surgeon's armamentarium, and as we approach the year 2000, they will be the treatment of choice in nearly every vascular pathology and circulatory system.

Atherectomy of the subclavian artery for patients with symptomatic coronary-subclavian steal syndrome

OBJECTIVES

This study addresses the efficacy of directional atherectomy in the subclavian artery for the relief of angina in patients with the coronary-subclavian steal syndrome. In addition, we review the histologic findings from the atherectomy specimens.

BACKGROUND

The coronary-subclavian steal syndrome may occur after internal mammary-coronary artery bypass grafting. It is due to a stenosis in the subclavian artery proximal to the origin of the internal mammary artery and causes frank ischemia to the area supplied by the graft. Currently, surgery is the corrective procedure of choice.

METHODS

In three patients with severe subclavian artery stenoses and unstable angina, directional atherectomy was performed using a peripheral atherectomy catheter through a percutaneous femoral approach. The patients ranged from 43 to 71 years of age and had undergone internal mammary-coronary artery bypass grafting 3 to 10 years previously. Each patient had severe peripheral vascular and cerebrovascular disease.

RESULTS

All three patients had immediate symptomatic relief after the atherectomy, and postprocedure exercise testing demonstrated improved cardiac function. Two patients remain asymptomatic at 7 and 8 months, respectively; the third patient developed unstable angina 9 months later because of severe restenosis that was again successfully treated with atherectomy. Histologic examination of the specimens revealed atherosclerotic plaque, occasionally with adventitia. The specimen from the repeat atherectomy showed severe intimal hyperplasia.

CONCLUSIONS

Directional atherectomy appears to be a safe and effective treatment for coronary-subclavian steal syndrome. This procedure may be the treatment of choice for patients in whom a vascular bypass operation is not feasible.