ENDOVASCULAR TECHNIQUES Vascular Disease Management ® January 2017 E6 Atherectomy Prior to Drug-Eluting–Balloon Angioplasty in a Calcified Vessel Marcin K. Kolber, MD 1 ; Robert A. Lookstein, MD 2 From 1 Mount Sinai Beth Israel and the 2 Icahn School of Medicine at Mount Sinai, New York, New York. E ndovascular treatment options for peripheral arterial disease (PAD) of the lower extremity include percutaneous transluminal angioplasty (PTA), stent placement, and atherectomy. However, PTA alone with or without stenting is associated with a significant risk of restenosis. Conventional PTA of femoropopliteal lesions is associated with a restenosis rate of 40% to 60% at 1 year. 1 This is thought to be a result of vessel trauma, as PTA relies of vessel wall stretching and eccentric plaque fracture. 2 Atherectomy may debulk atherosclerotic lesions but still results in late neointimal hyperplasia, possibly related to addi- tional mechanisms of vessel injury during interven- tion. 3 Drug-eluting technologies, such as drug-eluting balloons (DEB) and drug-eluting stents (DES) reduce neointimal hyperplasia via the deposition of antip- roliferative drug into the medial layer of the treated artery. 2 However, dense atherosclerotic calcification limits mural drug deposition and probably reduces the resulting antiproliferative effect. 4 Vessel preparation with atherectomy prior to DEB angioplasty may have a role in debulking calcific plaque and hence improv- ing effective drug deposition. Herein, we describe our preferred method for vessel preparation with rotational atherectomy prior to DEB angioplasty in heavily calci- fied vessels. CASE EXAMPLE A 55-year-old male with coronary artery disease, peripheral vascular disease, and history of left lower ABSTRACT: Endovascular treatment options for peripheral arterial disease of the lower extremity include percutaneous transluminal angioplasty, stent implantation, and atherectomy. Drug-eluting balloons (DEB) show promise in reducing long-term restenosis and target lesion revascularization rates by limiting postprocedural neointimal hyperplasia. However, dense calcification is thought to act as a barrier to successful deposition of antiproliferative drug. Atherectomy prior to DEB angioplasty is one approach to reduce mural calcification and improve the efficacy of drug delivery. VASCULAR DISEASE MANAGEMENT 2017;14(1):E6-E10 Key words: drug-eluting balloon angioplasty, atherectomy Copyright 2017 HMP Communications For Personal Use Only
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ENDOVASCULAR TECHNIQUES
Vascular Disease Management® January 2017 E6
Atherectomy Prior to Drug-Eluting–Balloon Angioplasty in a Calcified Vessel
Marcin K. Kolber, MD1; Robert A. Lookstein, MD2
From 1Mount Sinai Beth Israel and the 2Icahn School of Medicine at Mount Sinai, New York, New York.
Endovascular treatment options for peripheral
arterial disease (PAD) of the lower extremity
include percutaneous transluminal angioplasty
(PTA), stent placement, and atherectomy. However,
PTA alone with or without stenting is associated with
a significant risk of restenosis. Conventional PTA of
femoropopliteal lesions is associated with a restenosis
rate of 40% to 60% at 1 year.1 This is thought to be
a result of vessel trauma, as PTA relies of vessel wall
stretching and eccentric plaque fracture.2 Atherectomy
may debulk atherosclerotic lesions but still results in
late neointimal hyperplasia, possibly related to addi-
tional mechanisms of vessel injury during interven-
tion.3 Drug-eluting technologies, such as drug-eluting
balloons (DEB) and drug-eluting stents (DES) reduce
neointimal hyperplasia via the deposition of antip-
roliferative drug into the medial layer of the treated
artery.2 However, dense atherosclerotic calcification
limits mural drug deposition and probably reduces the
extremity revascularization presented with disabling
right lower-extremity claudication (one-half block).
Antegrade access was obtained in the right common
femoral artery and a long 7 Fr sheath was placed.
Right lower-extremity angiography revealed occlu-
sion of the mid right superficial femoral artery (SFA)
with distal reconstitution via collaterals at the right
popliteal artery and patent 3-vessel runoff to the foot
(Figure 1A and 1B). Parallel linear opacities were
noted along the expected course of the distal SFA
that were compatible with eccentric calcified plaque.
Intra-arterial heparin was administered. A 0.014"
Figure 1. Angiography demonstrates occlusion of the mid-SFA. Note parallel linear opacities were along the expected course of the SFA compatible with eccentric calcified plaque (A). Delayed DSA demonstrates reconstitution of the popliteal artery via collaterals and three-vessel runoff (B). A crossing microwire is advanced through the lesions (C). Rotational atherectomy device is deployed (D). Predilatation is performed to 4mm (E). Overlapping DEB angioplasty is performed (final balloon of 3 is shown) (F). Completion DSA demonstrates a patent SFA and popliteal artery (G).
A B C D
E F G
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ENDOVASCULAR TECHNIQUES
Vascular Disease Management® January 2017 E8
wire was used to cross the long segment occlusion,
over which a crossing catheter was advanced, and
the crossing wire was replaced with a stiff support
microwire (Figure 1C). A rotational atherectomy
catheter with active aspiration (Jetstream Atherec-
tomy System, Boston Scientific) was advanced to the
level of the occlusion. One-pass atherectomy was per-
formed in the blades-down position, followed by an
additional pass in the blades-up position (Figure 1D).
Angiography was repeated through the sheath and
revealed improved flow through the previously oc-
cluded segment. A 4 mm balloon was used to predi-
late along the length of the SFA and popliteal artery
(Figure 1E). A 6 mm x 120 mm IN.PACT Admi-
ral DEB (Medtronic) was advanced over the wire to
the popliteal artery, and distal SFA and inflation was
maintained for approximately 3 minutes. The process
was repeated with 2 additional DEBs more proximally
to the level of the mid SFA (Figure 1F). Final digital
subtraction angiography revealed a patent treated ves-
sel and the procedure was terminated.
DISCUSSIONGiven the perceived advantages of drug-eluting tech-
nologies in maintaining long-term vessel patency, our
preference is to utilize DEB and DES when feasible.
Long-segment steno-occlusive disease of the femo-
ropopliteal axis poses challenges to both approaches.
Stents are avoided in long segments and at stress points
unless persistent significant stenosis or flow-limiting
dissection is seen post angioplasty. Our approach with
heavily calcified vessels that would otherwise benefit
from DEB angioplasty is to pretreat the vessel with
a rotational or orbital atherectomy system to debulk
eccentric calcium and improve drug delivery. Fol-
lowing atherectomy, the native lesion is treated as
with standard DEB angioplasty: predilatation is per-
formed 1 mm to 2 mm undersized to the reference
vessel diameter, and the DEB is sized equivalent to
the reference vessel diameter and kept inflated for
1-3 minutes. When the treated lesion length exceeds
3. Mintz GS, Kimura T, Nobuyoshi M, Leon MB. Intravas-cular ultrasound assessment of the relation between early and late changes in arterial area and neointimal hyper-plasia after percutaneous transluminal coronary angio-plasty and directional coronary atherectomy. Am J Cardiol. 1999;83(11):1518-1523.
4. Fanelli F, Cannavale A, Gazzetti M, et al. Calcium bur-den assessment and impact on drug-eluting balloons in peripheral arterial disease. Cardiovasc Intervent Radiol. 2014;37(4):898-907.
5. Axel DI, Kunert W, Goggelmann C, et al. Paclitaxel inhib-its arterial smooth muscle cell proliferation and migration in vitro and in vivo using local drug delivery. Circulation. 1997;96(2):636-645.
6. Herten M, Torsello GB, Schonefeld E, Stahlhoff S. Criti-cal appraisal of paclitaxel balloon angioplasty for fem-oral-popliteal arterial disease. Vasc Health Risk Manag. 2016;12:341-356.
7. Fitzgerald PJ, Ports TA, Yock PG. Contribution of local-ized calcium deposits to dissection after angioplasty. An observational study using intravascular ultrasound. Circula-tion. 1992;86(1):64-70.
8. Scheinert D, Schulte KL, Zeller T, Lammer J, Tepe G. Paclitaxel-releasing balloon in femoropopliteal lesions using a BTHC excipient: twelve-month results from the BIOLUX P-I randomized trial. J Endovasc Ther. 2015;22(1):14-21.
9. Scheinert D, Duda S, Zeller T, et al. The LEVANT I (Lutonix paclitaxel-coated balloon for the prevention of femoropopliteal restenosis) trial for femoropopliteal
revascularization: first-in-human randomized trial of low-dose drug-coated balloon versus uncoated balloon angio-plasty. JACC Cardiovasc Intervent. 2014;7(1):10-19.
10. Zeller T, Beschorner U, Pilger E, et al. Paclitaxel-coated balloon in infrapopliteal arteries: 12-month results from the BIOLUX P-II randomized trial (BIOTRONIK’S-first in man study of the Passeo-18 LUX drug releasing PTA balloon catheter vs. the uncoated Passeo-18 PTA balloon catheter in subjects requiring revasculariza-tion of infrapopliteal arteries). JACC Cardiovasc Intervent. 2015;8(12):1614-1622.
11. Cioppa A, Stabile E, Popusoi G, et al. Combined treat-ment of heavy calcified femoro-popliteal lesions using directional atherectomy and a paclitaxel coated balloon: One-year single centre clinical results. Cardiovasc Revasc Med. 2012;13(4):219-223.
12. Razavi MK, Mustapha JA, Miller LE. Contemporary sys-tematic review and meta-analysis of early outcomes with percutaneous treatment for infrapopliteal atherosclerotic disease. J Vasc Intervent Radiol. 2014;25(10):1489-1496, 96 e1-3.
13. Tepe G, Schnorr B, Albrecht T, et al. Angioplasty of fem-oral-popliteal arteries with drug-coated balloons: 5-year follow-up of the THUNDER trial. JACC Cardiovasc Inter-vent. 2015;8(1 Pt A):102-108.
14. Werk M, Langner S, Reinkensmeier B, et al. Inhibition of restenosis in femoropopliteal arteries: paclitaxel-coated versus uncoated balloon: femoral paclitaxel randomized pilot trial. Circulation. 2008;118(13):1358-1365.
15. Liistro F, Grotti S, Porto I, et al. Drug-eluting balloon in peripheral intervention for the superficial femoral artery: the DEBATE-SFA randomized trial (drug eluting bal-loon in peripheral intervention for the superficial femoral artery). JACC Cardiovasc Intervent. 2013;6(12):1295-1302.
16. Werk M, Albrecht T, Meyer DR, et al. Paclitaxel-coated balloons reduce restenosis after femoro-popliteal angio-plasty: evidence from the randomized PACIFIER trial. Circ Cardiovasc Interv. 2012;5(6):831-840.
17. Laird JR, Schneider PA, Tepe G, et al. Durability of treat-ment effect using a drug-coated balloon for femoropopli-teal lesions: 24-month results of IN.PACT SFA. J Am Coll Cardiol. 2015;66(21):2329-2338.
18. Rosenfield K, Jaff MR, White CJ, et al. Trial of a paclitax-el-coated balloon for femoropopliteal artery disease. New Engl J Med. 2015;373(2):145-153.