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Atherectomy
Brandt C. Wible, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Procedure

      • Outcomes

        TERMINOLOGY

        • Definitions

          • Atherectomy: Physical removal of atherosclerotic plaque, typically by cutting, shaving, or abrading with catheter-based mechanical device
            • Directional atherectomy
              • Advantage of avoiding barotrauma
                • Reducing risk of dissection & intimal hyperplasia
              • Plaque excised by rotating cutting blade
              • Blade housed in cutting window on device
                • Bend in catheter apposes window against plaque
                • Window rotated/positioned against plaque
                • Blade excises only area that window exposes
              • Excised plaque collected in chamber at device tip
                • Device must be removed to empty chamber
              • SilverHawk/TurboHawk/HawkOne (Medtronic; Plymouth, MN)
                • 0.014" monorail guidewire compatible
                • Plaque excised is collected in tip variable capacity
                • HawkOne: 2- to 7-mm diameter vessel (consider below-knee)
                • TurboHawk: Variant for highly calcified lesions
            • Rotational atherectomy
              • High-speed 360° rotating device tip or burr
              • Preferentially abrades inelastic plaque
                • Microscopic nonobstructing particles enter arterial circulation
              • Phoenix (Volcano; San Diego, CA): 5-Fr, over-the-wire rotating blades pull debris into catheter, reducing risk of distal emboli
              • Jetstream (Boston Scientific; Marlborough, MA): Rotating cutting tip expands; continuous infusion & aspiration removes excised debris without removal of device; consider use with mixed calcified & thrombotic lesions
              • Peripheral Rotablator (Boston Scientific; Marlborough, MA): Rotating diamond-coated burr advanced via 4-Fr guide sheath
            • Orbital atherectomy
              • Eccentrically mounted rotating crown sands down plaque
              • Diamondback 360° (Cardiovascular Systems; St. Paul, MN): Rotating diamond-coated crown, 4-Fr device, used in arteries as small as 2 mm in diameter
            • Laser atheroablation
              • Excimer Laser System (Spectranetics; Colorado Springs, CO)
              • Can debulk in-stent restenosis & fibrous cap

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Equipment Preparation

                    • Procedure Steps

                      • Alternative Procedures/Therapies

                        OUTCOMES

                        • Complications

                          • Expected Outcomes

                            Selected References

                            1. Diamantopoulos A et al: Atherectomy of the femoropopliteal artery: a systematic review and meta-analysis of randomized controlled trials. J Cardiovasc Surg (Torino). 55(5):655-65, 2014
                            2. Feldman DN: Atherectomy for calcified femoropopliteal disease: are we making progress? J Invasive Cardiol. 26(8):304-6, 2014
                            3. Kim JH et al: Identifying the target lesions for 245 laser angioplasty cases and a review of the literature. Vasc Endovascular Surg. 46(8):640-7, 2012
                            4. Mezilis N et al: Rotablation in the drug eluting era: immediate and long-term results from a single center experience. J Interv Cardiol. 23(3):249-53, 2010
                            5. Garcia LA et al: Atherectomy for infrainguinal peripheral artery disease. J Endovasc Ther. 16:II105-15, 2009
                            6. Kaid KA et al: Analysis of particulate debris after superficial femoral atherectomy. J Invasive Cardiol. 21(1):7-10, 2009
                            7. Shavelle DM: Plaque excision with distal protection: a logical next step for superficial femoral artery SilverHawk atherectomy. J Invasive Cardiol. 21(1):11-2, 2009
                            8. Zeller T et al: One-year outcome of percutaneous rotational atherectomy with aspiration in infrainguinal peripheral arterial occlusive disease: the multicenter pathway PVD trial. J Endovasc Ther. 16(6):653-62, 2009
                            9. Biskup NI et al: Infrainguinal atherectomy: a retrospective review of a single-center experience. Ann Vasc Surg. 22(6):776-82, 2008
                            10. McKinsey JF et al: Novel treatment of patients with lower extremity ischemia: use of percutaneous atherectomy in 579 lesions. Ann Surg. 248(4):519-28, 2008
                            11. Ramaiah V: Endovascular infrainguinal revascularization: technical tips for atherectomy device selection and procedural success. Semin Vasc Surg. 21(1):41-9, 2008
                            12. Sarac TP et al: Midterm outcome predictors for lower extremity atherectomy procedures. J Vasc Surg. 48(4):885-90; discussion 890, 2008
                            13. Shammas NW et al: Preventing lower extremity distal embolization using embolic filter protection: results of the PROTECT registry. J Endovasc Ther. 15(3):270-6, 2008
                            14. Bunting TA et al: Peripheral atherectomy: a critical review. J Interv Cardiol. 20(6):417-24, 2007
                            15. Zeller T et al: Two-year results after directional atherectomy of infrapopliteal arteries with the SilverHawk device. J Endovasc Ther. 14(2):232-40, 2007
                            Related Anatomy
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                            Related Differential Diagnoses
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                            References
                            Tables

                            Tables

                            KEY FACTS

                            • Terminology

                              • Procedure

                                • Outcomes

                                  TERMINOLOGY

                                  • Definitions

                                    • Atherectomy: Physical removal of atherosclerotic plaque, typically by cutting, shaving, or abrading with catheter-based mechanical device
                                      • Directional atherectomy
                                        • Advantage of avoiding barotrauma
                                          • Reducing risk of dissection & intimal hyperplasia
                                        • Plaque excised by rotating cutting blade
                                        • Blade housed in cutting window on device
                                          • Bend in catheter apposes window against plaque
                                          • Window rotated/positioned against plaque
                                          • Blade excises only area that window exposes
                                        • Excised plaque collected in chamber at device tip
                                          • Device must be removed to empty chamber
                                        • SilverHawk/TurboHawk/HawkOne (Medtronic; Plymouth, MN)
                                          • 0.014" monorail guidewire compatible
                                          • Plaque excised is collected in tip variable capacity
                                          • HawkOne: 2- to 7-mm diameter vessel (consider below-knee)
                                          • TurboHawk: Variant for highly calcified lesions
                                      • Rotational atherectomy
                                        • High-speed 360° rotating device tip or burr
                                        • Preferentially abrades inelastic plaque
                                          • Microscopic nonobstructing particles enter arterial circulation
                                        • Phoenix (Volcano; San Diego, CA): 5-Fr, over-the-wire rotating blades pull debris into catheter, reducing risk of distal emboli
                                        • Jetstream (Boston Scientific; Marlborough, MA): Rotating cutting tip expands; continuous infusion & aspiration removes excised debris without removal of device; consider use with mixed calcified & thrombotic lesions
                                        • Peripheral Rotablator (Boston Scientific; Marlborough, MA): Rotating diamond-coated burr advanced via 4-Fr guide sheath
                                      • Orbital atherectomy
                                        • Eccentrically mounted rotating crown sands down plaque
                                        • Diamondback 360° (Cardiovascular Systems; St. Paul, MN): Rotating diamond-coated crown, 4-Fr device, used in arteries as small as 2 mm in diameter
                                      • Laser atheroablation
                                        • Excimer Laser System (Spectranetics; Colorado Springs, CO)
                                        • Can debulk in-stent restenosis & fibrous cap

                                  PREPROCEDURE

                                  • Indications

                                    • Contraindications

                                      • Preprocedure Imaging

                                        • Getting Started

                                          PROCEDURE

                                          • Patient Position/Location

                                            • Equipment Preparation

                                              • Procedure Steps

                                                • Alternative Procedures/Therapies

                                                  OUTCOMES

                                                  • Complications

                                                    • Expected Outcomes

                                                      Selected References

                                                      1. Diamantopoulos A et al: Atherectomy of the femoropopliteal artery: a systematic review and meta-analysis of randomized controlled trials. J Cardiovasc Surg (Torino). 55(5):655-65, 2014
                                                      2. Feldman DN: Atherectomy for calcified femoropopliteal disease: are we making progress? J Invasive Cardiol. 26(8):304-6, 2014
                                                      3. Kim JH et al: Identifying the target lesions for 245 laser angioplasty cases and a review of the literature. Vasc Endovascular Surg. 46(8):640-7, 2012
                                                      4. Mezilis N et al: Rotablation in the drug eluting era: immediate and long-term results from a single center experience. J Interv Cardiol. 23(3):249-53, 2010
                                                      5. Garcia LA et al: Atherectomy for infrainguinal peripheral artery disease. J Endovasc Ther. 16:II105-15, 2009
                                                      6. Kaid KA et al: Analysis of particulate debris after superficial femoral atherectomy. J Invasive Cardiol. 21(1):7-10, 2009
                                                      7. Shavelle DM: Plaque excision with distal protection: a logical next step for superficial femoral artery SilverHawk atherectomy. J Invasive Cardiol. 21(1):11-2, 2009
                                                      8. Zeller T et al: One-year outcome of percutaneous rotational atherectomy with aspiration in infrainguinal peripheral arterial occlusive disease: the multicenter pathway PVD trial. J Endovasc Ther. 16(6):653-62, 2009
                                                      9. Biskup NI et al: Infrainguinal atherectomy: a retrospective review of a single-center experience. Ann Vasc Surg. 22(6):776-82, 2008
                                                      10. McKinsey JF et al: Novel treatment of patients with lower extremity ischemia: use of percutaneous atherectomy in 579 lesions. Ann Surg. 248(4):519-28, 2008
                                                      11. Ramaiah V: Endovascular infrainguinal revascularization: technical tips for atherectomy device selection and procedural success. Semin Vasc Surg. 21(1):41-9, 2008
                                                      12. Sarac TP et al: Midterm outcome predictors for lower extremity atherectomy procedures. J Vasc Surg. 48(4):885-90; discussion 890, 2008
                                                      13. Shammas NW et al: Preventing lower extremity distal embolization using embolic filter protection: results of the PROTECT registry. J Endovasc Ther. 15(3):270-6, 2008
                                                      14. Bunting TA et al: Peripheral atherectomy: a critical review. J Interv Cardiol. 20(6):417-24, 2007
                                                      15. Zeller T et al: Two-year results after directional atherectomy of infrapopliteal arteries with the SilverHawk device. J Endovasc Ther. 14(2):232-40, 2007