Endovascular arterial atherectomy procedures

Endovascular arterial atherectomy is a minimally invasive procedure used to remove atherosclerotic plaque from the walls of arteries, improving blood flow in patients with peripheral artery disease (PAD). This procedure can be performed using different types of devices, each designed to address specific characteristics of arterial plaque.

Types of Atherectomy Devices

1. Directional Atherectomy
   • Mechanism: Uses a cutting blade to excise plaque from the arterial wall, capturing the debris in a collection chamber.
   • Devices: Examples include the SilverHawk® and TurboHawk® systems.
   • Indications: Effective for eccentric or large plaque burdens, particularly in the femoropopliteal and infrainguinal arteries.
   • Procedure: The device is positioned against the plaque, and the blade is activated to shave off the plaque, which is then collected in the device.
2. Rotational Atherectomy
   • Mechanism: Uses a rotating burr or other rotary cutting device to grind away plaque.
   • Devices: Examples include the Rotarexr® and Phoenix® Atherectomy Systems.
   • Indications: Suitable for calcified or fibrotic lesions that are resistant to other forms of intervention.
   • Procedure: The device is advanced over a guidewire to the lesion site, where the rotating burr pulverizes the plaque into micro-particles that are washed away in the bloodstream.
3. Orbital Atherectomy
   • Mechanism: Utilizes an eccentrically mounted, diamond-coated crown that orbits within the artery, sanding down plaque while preserving the healthy arterial wall.
   • Devices: Diamondback 360® is a commonly used system.
   • Indications: Particularly useful for treating heavily calcified lesions.
   • Procedure: The device is positioned at the lesion site, and the crown’s orbital motion abrades the plaque into fine particles that are naturally expelled from the body.
4. Laser Atherectomy
   • Mechanism: Employs ultraviolet (excimer) laser energy to vaporize plaque.
   • Devices: The Turbo-Elite® and other excimer laser systems.
   • Indications: Effective for complex lesions, including in-stent restenosis and chronic total occlusions.
   • Procedure: The laser catheter is positioned at the plaque site, and laser pulses are delivered to break down the plaque.

Procedure Steps

1. Patient Preparation:
   • Pre-procedure Assessment: Includes medical history, physical examination, imaging studies (like angiography or ultrasound) to map out the arterial disease.
   • Anesthesia: Local anesthesia with or without sedation, depending on the complexity of the procedure and patient condition.
2. Access Site Preparation:
   • Vascular Access: Usually via the femoral artery, though radial or brachial access can be used in certain cases.
   • Sheath Insertion: A vascular sheath is placed to facilitate device introduction and catheter manipulation.
3. Navigation and Lesion Crossing:
   • Guidewire Placement: A guidewire is advanced past the lesion under fluoroscopic guidance.
   • Device Advancement: The atherectomy device is advanced over the guidewire to the target lesion.
4. Plaque Removal:
   • Atherectomy Execution: Depending on the device type, plaque is either shaved, ground, abraded, or vaporized.
   • Debris Management: Special devices may capture debris, while smaller particles are typically washed away by blood flow.
5. Adjunctive Treatments:
   • Angioplasty and Stenting: Balloon angioplasty or stent placement may be performed to ensure optimal vessel patency post-atherectomy.
   • Imaging: Follow-up angiography to confirm adequate plaque removal and vessel patency.
6. Post-procedure Care:
   • Hemostasis: Achieved by manual compression or using closure devices at the access site.
   • Monitoring: Patients are monitored for complications such as bleeding, vessel injury, or restenosis.
   • Medications: Antiplatelet therapy is usually continued to prevent thrombotic events.

Indications and Contraindications

Indications

• Symptomatic peripheral artery disease (PAD) not amenable to medical management alone (Click here to read more on Peripheral Arterial Disease)
• Severe claudication or critical limb ischemia (Click here to read more on Critical Limb Threatening Ischaemia)
• Restenosis after previous endovascular interventions.
• Heavily calcified or fibrotic lesions resistant to balloon angioplasty.

Contraindications

• Severe vessel tortuosity or inability to access the lesion site.
• Active infection or untreated sepsis.
• Severe coagulopathy or bleeding disorders.
• Significant renal impairment (relative contraindication, particularly with laser atherectomy due to contrast use).

Benefits and Risks

Benefits

• Minimally invasive with shorter recovery times compared to open surgery.
• Effective for various types of plaque, including calcified and fibrotic lesions.
• Potential to improve symptoms and quality of life in PAD patients.

Risks

• Vessel perforation or dissection.
• Embolization of debris causing distal ischemia.
• Restenosis or recurrent stenosis.
• Bleeding or hematoma at the access site.

Conclusion

Endovascular arterial atherectomy offers a versatile and effective approach to managing peripheral artery disease, particularly in complex or calcified lesions. Selection of the appropriate device and technique is crucial for optimizing outcomes, and a multidisciplinary approach ensures comprehensive care and monitoring for potential complications.