Is atherectomy typically done before angioplasty?

Is Atherectomy Done Before Angioplasty Typically?

No, atherectomy is not routinely performed before angioplasty—it should only be used selectively for fibrotic or heavily calcified lesions that cannot be crossed by a balloon catheter or adequately dilated before stent implantation. 1

Guideline-Based Approach

When Atherectomy Is Reasonable (Class IIa)

Rotational atherectomy is reasonable specifically for:

• Fibrotic or heavily calcified lesions that might not be crossed by a balloon catheter 1
• Lesions that cannot be adequately dilated before stent implantation 1
• Severely calcified lesions where incomplete and asymmetrical stent expansion would occur with balloon angioplasty alone 1

The ACC/AHA/SCAI guidelines emphasize that rotational atherectomy increases chances of angiographic success in severely calcified lesions, and retrospective studies show its use before drug-eluting stent implantation is safe in this specific population. 1

When Atherectomy Should NOT Be Used (Class III: No Benefit)

Rotational atherectomy should not be performed routinely for:

• De novo lesions 1
• In-stent restenosis 1
• Any lesion that can be successfully crossed and dilated with conventional balloon angioplasty 2

The evidence is clear: rotational atherectomy in randomized controlled trials was associated with higher rates of major adverse cardiac events at 30 days and no reduction in restenosis. 1

The Standard Approach: Balloon-First Strategy

The most recent high-quality evidence strongly supports a balloon-first approach. The 2025 ECLIPSE trial—a large multicenter randomized controlled trial of 2,005 patients with severely calcified coronary lesions—demonstrated that routine orbital atherectomy before drug-eluting stent implantation did not increase minimal stent area (7.67 mm² vs 7.42 mm², p=0.078) or reduce target vessel failure at 1 year (11.5% vs 10.0%, p=0.28) compared with balloon angioplasty. 2

These data definitively support a balloon-first approach for most calcified coronary artery lesions that can be crossed and dilated before stent implantation, guided by intravascular imaging. 2

Clinical Algorithm for Decision-Making

Step 1: Attempt Conventional Balloon Angioplasty First

• Try to cross the lesion with a balloon catheter 1
• Attempt adequate dilation with conventional balloon angioplasty 1
• Use intravascular imaging guidance when available (62% of patients in ECLIPSE trial) 2

Step 2: Consider Atherectomy Only If Balloon Strategy Fails

Reserve atherectomy for:

• Lesions that cannot be crossed by a balloon catheter 1
• Lesions with inadequate dilation despite high-pressure balloon inflation 1
• Risk of coronary artery rupture with aggressive high-pressure balloon dilation in severely calcified lesions 1

Step 3: Alternative Strategies for Specific Scenarios

For moderately calcified lesions that cannot be crossed or dilated:

• Laser angioplasty might be considered (Class IIb) 1
• However, laser angioplasty should not be used routinely (Class III: No Benefit) 1

Critical Pitfalls to Avoid

The "Routine Use" Trap

The most common error is performing atherectomy routinely rather than selectively. The guidelines explicitly state Class III: No Benefit for routine use in de novo lesions. 1 The ECLIPSE trial confirms this applies even to severely calcified lesions that can be crossed and dilated. 2

The Restenosis Misconception

Atherectomy as a stand-alone device has not led to reduction in restenosis rates. 1 All published prospective randomized controlled trials excluded patients with severely calcified lesions, so the evidence base comes from nonrandomized single-arm studies showing only that atherectomy is safe before stent implantation—not that it improves outcomes. 1

The Complication Risk

Attempts to remedy underexpanded stents with aggressive high-pressure balloon dilation may result in coronary artery rupture, which is the specific scenario where atherectomy becomes reasonable. 1 However, atherectomy itself carries risks including higher 30-day major adverse cardiac events. 1

Peripheral Arterial Disease Context

In peripheral vascular interventions, the approach differs slightly. The 2021 VIVA REALITY study showed that directional atherectomy before drug-coated balloon angioplasty in severely calcified femoropopliteal disease achieved 76.7% primary patency at 12 months with only 8.8% provisional stent rate. 3 However, this peripheral data should not be extrapolated to coronary interventions, where the ECLIPSE trial provides definitive coronary-specific evidence. 2

Summary of Temporal Sequence

The correct sequence is:

1. Attempt balloon angioplasty first 2
2. Use intravascular imaging to guide adequacy of preparation 2
3. Reserve atherectomy only for balloon-refractory cases 1
4. Proceed to drug-eluting stent implantation after adequate lesion preparation 1, 2