Atherectomy Basics

We begin by overviewing the definition of atherectomy and the types of devices. Atherectomy is a procedure that involves the removal of plaque or thrombus and is categorized as a vessel preparation procedure. It is often done before angioplasty and stenting. The goal of the procedure is to obtain luminal gain, meaning that the diameter of the lumen of an artery becomes closer to its original size. There are a variety of devices that allow for different techniques in atherectomy, including rotational, orbital, laser, and directional. They all offer a degree of plaque modification or debulking of the lesion to improve outcomes for angioplasty with or without stenting.

Next, we discuss indications for atherectomy. Both Dr. Saleh and Dr. Tummala begin a peripheral arterial case by doing a full lower extremity angiogram to guide their next steps. They also rely heavily on intravascular ultrasound (IVUS), as this helps determine if the lesion is made of thrombus, calcified, or soft plaque. The type of plaque they find via IVUS as well as the primary location of the plaque will determine which device they will proceed with. There is some controversy regarding atherectomy in regard to its indications and efficacy, mostly due to the lack of randomized control trials and overall data scarcity. Despite this, both Dr. Saleh and Dr. Tummala use atherectomy as vessel prep when they plan on treating a lesion with percutaneous transluminal angioplasty (PTA), either alone or followed by a stent.

Finally, we discuss each operator’s advice for those new to atherectomy or treating peripheral arterial disease (PAD), their most used devices, and their thoughts on performing atherectomy in the subintimal plane (outside of the true vessel lumen). Both operators frequently use rotational excisional atherectomy devices and orbital devices. The specific device varies depending on their setting (OBL vs. hospital), but they recommend choosing a couple of devices and learning how to use them well. When it comes to atherectomy in the subintimal space, both Dr. Tummala and Dr. Saleh recommend against doing this, as it is not an indication for any of the devices, and it risks complications such as the device getting stuck. To avoid doing atherectomy in the subintimal plane, they IVUS as far down the vessel as they can to determine if there are any segments that are subintimal. In legs with only a single runoff vessel or no runoff, they are more conservative with atherectomy due to the risk of embolizing smaller vessels and causing even worse flow to the extremity.