Atherectomy Devices in Peripheral Arterial Disease: Principles, Technologies, and Clinical Applications

Atherectomy represents a specialized endovascular approach for the treatment of peripheral arterial disease, involving the direct removal or modification of atherosclerotic plaque from the arterial wall. Unlike balloon angioplasty and stenting, which compress plaque against the vessel wall, atherectomy devices physically remove or pulverize plaque material, potentially reducing elastic recoil, minimizing barotrauma, and creating a smoother luminal surface. This comprehensive guide explores the principles, device technologies, procedural considerations, clinical applications, and evidence base for atherectomy in peripheral arterial disease management, providing insights for healthcare professionals navigating this specialized area of endovascular intervention.

原理和作用机制

Conceptual Framework

Understanding the fundamental approach:

Basic concept:
Direct plaque removal or modification
Reduction of plaque burden
Alternative to balloon-based luminal gain
Potential for reduced barotrauma
Creation of smoother luminal surface
Theoretical advantages:
Reduced elastic recoil
Minimized vessel trauma
Lower dissection rates
Potential for reduced restenosis
Treatment of complex lesion morphologies
Mechanism variations:
Directional cutting/shaving
Rotational grinding/pulverization
Orbital sanding/abrasion
Laser vaporization/ablation
组合方法

Plaque Modification Effects

Tissue-level changes:

Immediate effects:
Physical debulking
Calcium fragmentation
Plaque modification
Luminal gain
Surface smoothing
Biological responses:
Altered healing patterns
Modified inflammatory response
Potential for reduced neointimal hyperplasia
Changes in flow dynamics
Altered drug uptake for combination therapies
Histopathological findings:
Device-specific tissue effects
Depth of wall injury
Media and adventitia involvement
Healing patterns
Long-term vessel remodeling

Atherectomy Device Technologies

Directional Atherectomy

Selective plaque excision:

作用机制:
Rotating cutting blade
Directional orientation
Collection reservoir for debris
Selective tissue removal
Controlled depth
Available systems:
SilverHawk/TurboHawk (Medtronic)
HawkOne (Medtronic)
Pantheris (Avinger) – with OCT guidance
Technical specifications
Size range and applications
Procedural considerations:
Positioning and orientation
Multiple passes technique
Debris management
辅助治疗
学习曲线

Rotational Atherectomy

High-speed plaque pulverization:

作用机制:
High-speed rotating burr
Diamond-coated crown
Differential cutting
Microparticulate debris
Pulverization effect
Available systems:
Rotablator (Boston Scientific)
Jetstream (Boston Scientific)
Phoenix (Philips)
Technical specifications
Size range and applications
Procedural considerations:
Sizing principles
Rotational speed
Run duration
Heat generation management
Slow advancement technique

Orbital Atherectomy

Eccentric sanding mechanism:

作用机制:
Eccentrically mounted crown
Orbital rotation pattern
Increasing orbit with speed
360° treatment zone
Bidirectional capability
Available systems:
Diamondback 360 (Cardiovascular Systems, Inc.)
Technical specifications
Crown designs
Size range and applications
Control console features
Procedural considerations:
Crown selection
Speed settings
Advancement rate
Treatment algorithm
Adjunctive therapy timing

Laser Atherectomy

Photoablative plaque removal:

作用机制:
Excimer laser energy
Photochemical ablation
Photomechanical ablation
Photothermal ablation
Vapor bubble formation
Available systems:
Turbo-Elite (Philips)
Turbo-Tandem (Philips)
Technical specifications
Catheter sizes
Energy parameters
Procedural considerations:
Energy settings
Saline infusion
Advancement rate
Pulse repetition rate
Treatment algorithm

Clinical Applications and Patient Selection

解剖学考虑因素

Location-specific applications:

Femoropopliteal disease:
Most common application
Device selection principles
Lesion characteristics
Outcomes data
Comparative effectiveness
Infrapopliteal disease:
Limited device options
Technical challenges
Outcomes considerations
Calcium burden impact
Role in critical limb ischemia
Iliac and aortoiliac disease:
Limited role
Specific indications
Device selection
技术考虑因素
Alternative approaches

Lesion Morphology Considerations

Targeting specific challenging lesions:

Calcified lesions:
Classification of calcification
Device-specific capabilities
Preparation for other therapies
技术成功率
Complication risks
Long segment disease:
Run length considerations
Device selection
Embolic protection considerations
辅助治疗
Outcomes data
In-stent restenosis:
Device-specific applications
Safety considerations
Technical approach
Outcomes data
Alternative strategies
Ostial lesions:
Positioning challenges
Device selection
技术考虑因素
Outcomes data
Adjunctive approaches

患者选择因素

Identifying appropriate candidates:

Clinical indications:
Claudication
Critical limb ischemia
Tissue loss
Rutherford classification
Symptom severity
Anatomical factors:
容器直径
病变长度
钙化负担
Tortuosity
Previous interventions
Patient factors:
Comorbidities
Anticoagulation status
Renal function
Life expectancy
Functional status

Procedural Considerations

程序前规划

Setting the stage for success:

Imaging assessment:
Angiography
CTA/MRA
Duplex ultrasound
Calcium scoring
Lesion characterization
Access planning:
Antegrade vs. retrograde
Sheath size requirements
Distance to target lesion
Vessel tortuosity
Alternative access considerations
Device selection principles:
Lesion morphology matching
容器尺寸
Calcification pattern
Location considerations
Operator experience

Periprocedural Management

Optimizing the intervention:

Anticoagulation protocols:
Heparin dosing
ACT monitoring
Direct thrombin inhibitors
Reversal considerations
Post-procedure management
栓塞保护:
设备选项
Indications for use
Placement techniques
Retrieval considerations
Evidence for benefit
Adjunctive therapies:
Pre-dilation
Post-dilation
Stenting indications
Drug-coated balloon application
Sequencing considerations

Technical Tips and Tricks

Enhancing procedural success:

Device-specific techniques:
Directional: orientation and engagement
Rotational: pecking motion advancement
Orbital: crown selection and speed
Laser: saline infusion and energy settings
Advancement rate considerations
Challenging scenarios:
Vessel tortuosity navigation
Crossing total occlusions
Managing calcified nodules
Treating bifurcations
Addressing complications
Combination strategies:
Atherectomy plus angioplasty
Atherectomy plus drug-coated balloon
Atherectomy plus stenting
Multiple device approaches
分阶段程序

临床结果和证据基础

疗效终点

Measuring success:

Technical success metrics:
Procedural success rates
Residual stenosis
Acute luminal gain
Procedural complications
Device-specific considerations
Intermediate outcomes:
Primary patency rates
Target lesion revascularization
Binary restenosis
Duplex-derived metrics
Device-specific data
Clinical endpoints:
Symptom improvement
伤口愈合
肢体抢救
Quality of life measures
Functional status

Key Clinical Trials

Evidence landscape:

Directional atherectomy studies:
DEFINITIVE LE
DEFINITIVE AR
DEFINITIVE Ca++
观察研究
Registry data
Rotational atherectomy studies:
PATHWAY PVD
JET Registry
COMPLIANCE 360
Comparative studies
Real-world data
Orbital atherectomy studies:
CONFIRM series
CALCIUM 360
LIBERTY 360
OPTIMIZE
Long-term outcomes
Laser atherectomy studies:
CELLO
EXCITE ISR
PHOTOPAC
Observational data
In-stent restenosis applications

比较效益

Atherectomy vs. other approaches:

Versus plain balloon angioplasty:
Acute success rates
Bailout stenting rates
Patency outcomes
成本因素
患者选择因素
Versus primary stenting:
Acute results
Long-term patency
Target lesion revascularization
Stent fracture considerations
Future options preservation
Versus drug-coated technologies:
Standalone comparison
Combination therapy
Lesion-specific outcomes
成本效益
患者选择因素

并发症和处理

Device-Specific Complications

认可和管理：

定向粥样硬化切除术:
Perforation
Dissection
Distal embolization
Device entrapment
管理方法
旋转动脉粥样硬化切除术:
Vessel perforation
Distal embolization
No/slow flow phenomenon
Vasospasm
Management strategies
眼眶动脉瘤切除术:
Crown entrapment
Dissection
Perforation
Hemolysis
管理方法
激光粥样斑块切除术:
Perforation
Dissection
Thermal injury
Contrast media bubble formation
Management strategies

一般并发症

Common issues across platforms:

栓塞:
Recognition
Risk factors
预防战略
管理方法
Outcomes impact
Vessel injury:
Dissection grading
Perforation classification
Management algorithm
预防战略
Long-term implications
访问网站的复杂性:
血肿
假性动脉瘤
动静脉瘘
感染
管理方法

未来方向和新兴技术

技术创新

Next-generation approaches:

Device refinements:
Lower profile systems
Enhanced deliverability
Improved cutting efficiency
Better debris management
Specialized applications
Imaging integration:
OCT-guided atherectomy
IVUS integration
Real-time feedback
Automated control systems
Enhanced visualization
Combination devices:
Atherectomy plus drug delivery
Multi-mechanism platforms
Specialized crossing plus atherectomy
Integrated systems
Simplified workflows

Expanding Applications

New frontiers:

Below-the-knee interventions:
Device miniaturization
Specialized calcium modification
Critical limb ischemia applications
技术考虑因素
Early evidence
Complex lesion subsets:
Chronic total occlusions
Heavily calcified disease
Ostial lesions
Bifurcations
Novel approaches
Specialized populations:
糖尿病患者
End-stage renal disease
Elderly and frail
Prior failed interventions
Limited surgical options

医疗免责声明

重要通知: This information is provided for educational purposes only and does not constitute medical advice. Atherectomy represents a specialized endovascular intervention that should only be performed by qualified healthcare professionals with appropriate training and expertise. The techniques and technologies discussed should only be implemented under appropriate medical supervision. Individual treatment decisions should be based on patient-specific factors, current clinical guidelines, and physician judgment. If you have been diagnosed with peripheral arterial disease or are experiencing symptoms such as leg pain with walking, non-healing wounds, or color changes in your feet, please consult with a healthcare professional for proper evaluation and treatment recommendations. This article is not a substitute for professional medical advice, diagnosis, or treatment.

结论

Atherectomy devices represent an important component of the endovascular armamentarium for peripheral arterial disease, offering unique capabilities for plaque modification and removal that complement traditional balloon and stent-based approaches. The diverse mechanisms of action across directional, rotational, orbital, and laser platforms allow for tailored treatment strategies based on lesion morphology, location, and patient characteristics. While the evidence base continues to evolve, atherectomy has demonstrated particular utility in complex lesion subsets such as heavily calcified disease and in-stent restenosis, where conventional approaches may have limitations. As technology advances and clinical experience grows, the role of atherectomy in peripheral interventions will likely continue to expand, particularly when integrated into comprehensive treatment strategies that may include adjunctive drug delivery technologies. The optimal application of these specialized devices requires careful patient selection, thorough preprocedural planning, and meticulous technique to maximize benefits while minimizing potential complications.