CATHETER-BASED ATHERECTOMY: SHOULD THIS MODALITY BE IN YOUR ENDOVASCULAR ARMAMENTARIUM?

OBJECTIVES:
The role of atherectomy in lower extremity revascularization has yet to be determined. Theoretical advantages include lesion debulking and decreased arterial trauma. This review examines a single center experience to determine if these advantages lead to improved clinical results.
METHODS: From January 2005 to June 2007, 321 limbs underwent endovascular revascularization including 52 limbs (16.2%) treated with catheter-based atherectomy. Patient demographics included; mean age 69 (range 47-94), 33 males, 19 females, diabetes 44.2%, symptomatic coronary artery disease 24%, and renal failure 25%. 12 (23.1%) had previous revascularization. Indications were claudication 30.8% (n=16), rest pain 11.5% (n=6), and tissue loss 57.7% (n=30). Clinical endpoints were symptomatic improvement, ABI, wound healing, and need for further revascularization.
RESULTS:
95 arterial segments were treated (average of 1.83 segments per limb) including; SFA (n=37), profunda femoris (n=1), popliteal (n=29, 22AK, 7BK), and tibial (n=28, 9 AT, 7 PT, 12 peroneal). 29 (55.8%) were sole procedures with adjunctive endovascular therapy in 23 (44.2%); angioplasty (n=10), stent deployment (n=13). Complications included 2 seromas, a dissection, and a distal embolization. ABI increased a mean of 0.35 (pre 0.48 to post 0.83). Clinical results at 3 months demonstrated improvement in 100% of patients with claudication or rest pain (n=22). Wound healing occurred in 43.3% (n=13) of limbs with tissue loss. At 12 months, 83% (n=10) of claudicants remained improved with rest pain alleviated in 100% (n=5). Wound healing was complete in 34.8% (n=8). Additional revascularization was required in 23% (n=9); 5 endovascular, 4 open bypasses.
CONCLUSIONS:
Based on this experience, atherectomy has a role in our approach to endovascular revascularization of the lower extremity. This role appears best for those patients with focal disease and resultant claudication. Adjunctive procedures are often required to obtain optimal results in limb salvage patients. Further prospective studies are required to determine the clinical advantages compared to other endovascular therapy.