Is Atherectomy Performed Before Angioplasty?
Yes, when atherectomy is used, it is performed before angioplasty as a vessel preparation or "plaque modification" strategy to facilitate subsequent balloon dilation and stent delivery in heavily calcified or fibrotic lesions. 1, 2
Clinical Algorithm for Sequencing
The ACC/AHA recommends a stepwise approach to lesion treatment:
- First-line strategy: Attempt conventional balloon angioplasty initially 2
- Reserve atherectomy for: Lesions that cannot be crossed by a balloon catheter OR cannot be adequately dilated despite high-pressure balloon inflation 2
- Sequence when atherectomy is needed: Perform atherectomy first to modify the plaque, then proceed with balloon angioplasty and/or stent placement 1, 2
Specific Indications for Pre-Angioplasty Atherectomy
Rotational atherectomy (Class IIa recommendation) is reasonable before angioplasty for: 1
- Fibrotic or heavily calcified lesions that cannot be crossed by a balloon catheter
- Lesions that cannot be adequately dilated before stent implantation
- Calcium deposits >500 μm thick or involving >270° arc of the vessel on intravascular imaging 1
Other atherectomy modalities (Class IIb recommendation) may be considered before angioplasty: 1
- Orbital atherectomy
- Balloon atherotomy
- Laser angioplasty
- Intracoronary lithotripsy
Evidence Supporting the Pre-Angioplasty Sequence
The rationale for performing atherectomy before angioplasty is based on mechanical principles: 1
- Atherectomy excavates or modifies inelastic atherosclerotic tissue to "prepare" the lesion 1
- This facilitates subsequent stent delivery and expansion in heavily calcified vessels 1
- Randomized trials demonstrate enhanced stent delivery and expansion with rotational atherectomy compared to conventional balloons alone 1
Combined Procedure Data
Clinical experience with 19 patients undergoing combined procedures showed: 3
- In 58% of cases, atherectomy preceded angioplasty 3
- Angioplasty was used after atherectomy when the atherectomy catheter could not be positioned across the lesion, or to treat unsatisfactory atherectomy results 3
- Overall success rate was 79% for combined interventions 3
Critical Limitations and Contraindications
Do not perform atherectomy routinely (Class III: No Benefit): 2
- Not indicated for routine de novo lesions
- Not indicated for in-stent restenosis
- Should only be used when balloon strategy fails 2
Atherectomy carries significant risks: 1, 2
- Higher rates of major adverse cardiac events at 30 days 2
- No reduction in restenosis rates 2
- Risk of coronary artery rupture 2
- Increased procedural complications including distal embolization 4
Adjunctive Angioplasty After Atherectomy
In 42% of atherectomy cases, adjunct balloon angioplasty is performed to treat either complications or residual stenosis >30% 5. Intravascular ultrasound demonstrates significant residual plaque mass remains after atherectomy, particularly in lesions with calcium arc ≥90° 5.