What is Atherectomy?
Atherectomy is a catheter-based endovascular procedure that removes atherosclerotic plaque from blood vessels by physically debulking the obstructive material, typically using cutting blades, rotating burrs, lasers, or grinding mechanisms. 1
Mechanism and Device Types
Atherectomy works by excising or ablating atheromatous plaque from within blood vessels through minimally invasive percutaneous access, rather than simply displacing plaque as balloon angioplasty does. 1, 2 The procedure can be performed using several distinct technologies:
Device Categories
Directional atherectomy: Uses a cup-shaped cutter within a housing unit with a small balloon to selectively remove plaque from specific vessel wall segments 3
Rotational atherectomy: Employs a diamond-tipped burr rotating at high speeds to excavate inelastic atherosclerotic tissue, particularly useful for heavily calcified coronary lesions 1
Orbital atherectomy: Utilizes an eccentrically mounted diamond-coated crown that orbits to modify calcified plaque 1
Laser atherectomy: Uses excimer laser energy to ablate obstructive tissue 2
Clinical Applications
Coronary Arteries
In coronary interventions, rotational atherectomy can be useful to improve procedural success in patients with fibrotic or heavily calcified lesions that hinder stent expansion. 1 The technique enhances stent delivery and expansion in heavily calcified vessels compared to conventional balloons, despite not improving long-term clinical outcomes. 1
Orbital atherectomy, balloon atherotomy, laser angioplasty, or intracoronary lithotripsy may be considered as alternative plaque modification strategies for calcified coronary lesions. 1
Peripheral Arteries
For peripheral arterial disease, atherectomy has been rated "Rarely Appropriate" in most anatomic locations due to lack of comparative evidence supporting its use over balloon angioplasty and stenting. 1
Specific Anatomic Considerations:
Iliac arteries: Atherectomy is rarely appropriate in all clinical scenarios due to absence of data supporting its use compared with balloon angioplasty and stenting 1
Superficial femoral and popliteal arteries: Lower appropriateness ratings due to lack of comparative data relative to other technologies with prospectively collected evidence 1
Below-the-knee vessels: Generally lacks comparative evidence to support routine use 1
Limited Appropriate Indications:
Exceptions where atherectomy may be favored include severe calcification and undilatable lesions, though other technologies have a better evidence base for routine revascularization. 1
Important Clinical Outcomes Data
Long-term outcomes after atherectomy for peripheral arterial disease are concerning. A Medicare-linked registry study of 16,838 patients found that at 5 years, patients treated with atherectomy had a 38% rate of major adverse limb events compared to 33% for plain balloon angioplasty and 32% for stenting. 4
When controlling for confounding factors, atherectomy patients experienced:
- Higher risk of any amputation compared to balloon angioplasty alone (hazard ratio: 1.51) 4
- Significantly higher risk of major amputation compared to stenting (hazard ratio: 3.66) 4
- Higher risk of any amputation compared to stenting (hazard ratio: 2.73) 4
- Higher risk of major adverse limb events compared to stenting (hazard ratio: 1.61) 4
Key Advantages and Disadvantages
Potential Advantages:
- Removes obstructing plaque without leaving a foreign body (stent) in the artery 2
- Reintervention at the same site can be accomplished with low risk if needed 2
- Does not preclude subsequent bypass surgery or change anastomotic sites 2
Critical Limitations:
- Expense without proven benefit: Given the high cost and paucity of comparative data, further investigation is recommended into risks and benefits, particularly in femoropopliteal lesions 1
- Routine use does not improve clinical or angiographic outcomes compared to standard techniques 1
- Associated with increased rates of restenosis and late lumen loss in some studies 1
- Risk of distal embolization, particularly with certain device types 1
Clinical Practice Implications
The current evidence strongly suggests that atherectomy should be reserved for specific challenging scenarios rather than routine use. 1 The most defensible applications are heavily calcified lesions that cannot be adequately dilated with conventional balloons, particularly in coronary interventions where lesion preparation is critical for stent deployment. 1
For peripheral arterial disease, the lack of comparative effectiveness data combined with worse long-term outcomes and higher costs make atherectomy inappropriate as a first-line therapy in most clinical scenarios. 1, 4