Peripheral and Coronary Atherectomy - Plaque Removal Procedure

What is Atherectomy?

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Atherectomy is the physical removal of atherosclerotic plaque from the vessel wall using specialized devices at the catheter tip. Plaque can be removed through cutting, scraping, grinding, or vaporization. This procedure complements and prepares the vessel for balloon angioplasty and stenting rather than serving as an alternative.

History of Atherectomy

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Atherectomy techniques began developing in the late 1980s. The first rotational atherectomy system (Rotablator) received FDA approval in 1988. Since then, technology has evolved significantly, with safer and more effective devices being developed. Today, atherectomy has become one of the indispensable tools in interventional cardiology.

Why is Atherectomy Necessary?

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During the atherosclerosis process, plaques accumulating in the vessel wall can become calcified over time. These hard, calcified plaques:

• May not expand with balloon inflation
• Can prevent stent placement
• May prevent full stent expansion
• Can make optimal results difficult to achieve

Atherectomy is used to solve these problems. Through mechanical removal of calcified plaque:

• The vessel lumen widens
• A suitable bed is prepared for the stent
• Stent expansion improves
• Long-term outcomes improve

Types of Atherectomy

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Rotational Atherectomy (Rotablator)

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Rotational atherectomy is the most commonly used atherectomy method and is particularly preferred for coronary arteries.

Working Principle:

• Uses a diamond-coated oval burr (tip)
• The burr rotates at 140,000-180,000 revolutions per minute
• Works on the differential cutting principle
• Ablates hard, calcified tissue while not damaging flexible healthy tissue

Advantages:

• Very effective in severely calcified lesions
• Creates micron-sized particles (5-10 microns)
• Extensive clinical experience over many years

Disadvantages:

• Risk of slow flow phenomenon
• Burr size selection is critical
• Can be technically challenging

Indications:

• Severely calcified coronary lesions
• Lesions that cannot be crossed with balloon
• Expected inadequate stent expansion
• Ostial lesions

Orbital Atherectomy (Diamondback 360)

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Orbital atherectomy is a newer technique developed as an alternative to rotational atherectomy.

Working Principle:

• Uses a diamond-coated crown
• Crown rotates with eccentric (off-center) motion
• Contacts the wall through centrifugal force
• Abraded area expands as speed increases

Advantages:

• Single crown for different ablation sizes
• Less thermal damage
• Provides continuous flow (forward movement)
• Easier learning curve

Disadvantages:

• Less clinical experience
• May not be suitable for some anatomical situations

Indications:

• Severely calcified coronary and peripheral lesions
• Alternative to rotational atherectomy
• Patients with advanced calcification

Directional Atherectomy (Silverhawk, TurboHawk)

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Directional atherectomy is a method used primarily in peripheral arteries.

Working Principle:

• A rotating blade cuts the plaque
• Cut plaque accumulates in a cone at the device tip
• Plaque is physically removed from the vessel
• Directional feature allows targeted cutting

Advantages:

• Plaque is completely removed
• Histological examination is possible
• Minimal stent requirement
• Large vessel diameter can be achieved

Disadvantages:

• Perforation risk
• Requires larger guide catheter
• Learning curve

Indications:

• Femoropopliteal artery disease
• In-stent restenosis
• Infrapopliteal artery disease
• Critical limb ischemia

Laser Atherectomy (Excimer Laser)

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Laser atherectomy is an ablation method using excimer laser technology.

Working Principle:

• Xenon-chloride excimer laser (308 nm wavelength)
• Photoacoustic and photothermal effect
• Breaks down plaque at molecular level
• Controlled ablation depth

Advantages:

• Very effective in in-stent restenosis
• Can be used in lesions containing thrombus
• Helpful in chronic total occlusions
• Precise ablation control

Disadvantages:

• Expensive technology
• Requires special training
• Limited penetration depth

Indications:

• In-stent restenosis
• Thrombotic lesions
• Chronic total occlusion (CTO)
• Saphenous vein graft lesions

Coronary Atherectomy Indications

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Definite Indications

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Severely Calcified Lesions:

• Visible calcification on angiography
• 270-360 degree calcium arc on IVUS/OCT
• Anticipated inadequate balloon expansion

Lesions That Cannot Be Crossed with Balloon:

• Lesions where standard or low-profile balloons cannot pass
• Situations where balloon cannot advance after guidewire passage

Inadequate Stent Expansion:

• Inadequate stent expansion despite high-pressure balloon inflation
• Post-dilation failure

Relative Indications

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Ostial Lesions:

• Coronary artery origin lesions
• Areas with high elastic recoil risk

Bifurcation Lesions:

• Calcified bifurcation lesions
• Plaque modification for optimal stent strategy

Left Main Coronary Lesions:

• Calcified left main coronary disease
• Situations where optimal stent expansion is critically important

Peripheral Atherectomy Indications

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Lower Extremity Artery Disease

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Femoropopliteal Segment:

• Severely calcified lesions
• Long segment disease
• In-stent restenosis
• When stentless strategy is preferred

Infrapopliteal Segment (Below the Knee):

• Critical limb ischemia
• Calcified tibial lesions
• Diabetic foot syndrome
• Revascularization for wound healing

Other Peripheral Regions

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Renal Artery:

• Calcified renal artery stenosis
• Plaque preparation before stent

Iliac Artery:

• Severely calcified iliac lesions
• Bilateral disease

Pre-Atherectomy Evaluation

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Angiographic Assessment

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• Lesion location and length
• Degree of calcification (mild, moderate, severe)
• Vessel diameter and reference segment
• Collateral circulation
• Status of the distal bed

Intravascular Imaging

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IVUS (Intravascular Ultrasound):

• Calcium arc and thickness
• Lumen and vessel diameters
• Plaque composition
• Stent expansion assessment

OCT (Optical Coherence Tomography):

• High-resolution imaging
• Intimal calcification detail
• Plaque morphology
• Stent strut coverage

Patient Preparation

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Medical Therapy:

• Dual antiplatelet therapy (aspirin + P2Y12 inhibitor)
• Adequate hydration
• Statin therapy

Laboratory Tests:

• Complete blood count
• Kidney function (creatinine, eGFR)
• Coagulation tests
• Electrolyte panel

Risk Assessment:

• Cardiac risk score
• Contrast nephropathy risk
• Bleeding risk

How is Atherectomy Performed?

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Procedure Preparation

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1. Vascular Access:

   • Femoral artery (most common)
   • Radial artery (for coronary)
   • Brachial artery (selected cases)

2. Anticoagulation:

   • Heparin or bivalirudin
   • ACT (Activated Clotting Time) target: 250-300 seconds

3. Guide Catheter:

   • 6-8 French size
   • Type selection providing good support
   • Coaxial placement in target artery

Rotational Atherectomy Technique

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Burr Selection:

• Initial burr/artery ratio: 0.5-0.6
• Gradual increase may be needed
• Maximum burr/artery ratio: 0.7-0.8

Ablation Techniques:

• Pecking motion (intermittent advancement)
• 15-20 seconds ablation per pass
• Pull back if platform speed decreases
• Slow, controlled advancement

Rotablator Tips:

• Adequate flush solution (Rotaglide)
• Avoid deceleration
• Prevent burr entrapment
• Frequent angiographic control

Orbital Atherectomy Technique

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Crown Selection:

• Classic or micro crown
• Selection based on vessel diameter

Ablation Techniques:

• Start at low speed (80,000 rpm)
• Gradual speed increase (120,000 rpm)
• Back-and-forth motion
• Saline infusion

Post-Procedure Steps

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1. Control Angiography:

   • Lumen gain assessment
   • Complication control
   • Distal flow evaluation

2. Balloon Angioplasty:

   • Pre-dilation with non-compliant balloon
   • Optimal lumen diameter achievement

3. Stent Implantation:

   • Appropriate size and length selection
   • High-pressure implantation
   • Post-dilation (if necessary)

4. Final Assessment:

   • Stent optimization with IVUS/OCT
   • Minimal stent area control
   • Edge dissection control

Atherectomy Outcomes

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Acute Success Criteria

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• Residual stenosis <30% (with stent)
• TIMI 3 flow
• Uncomplicated procedure
• Stable patient discharge

Clinical Results

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Coronary Atherectomy:

• Procedural success: 90-95%
• Major complication rate: 2-5%
• 1-year target lesion revascularization: 10-15%

Peripheral Atherectomy:

• Procedural success: 85-95%
• Primary patency (1 year): 60-80%
• Limb salvage rate: 90-95% (in critical ischemia)

Long-Term Follow-up

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• Regular clinical evaluation
• Symptom inquiry
• Non-invasive tests (if needed)
• Repeat angiography (if indicated)

Complications and Management

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Distal Embolization

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Risk Factors:

• Large plaque burden
• Soft plaque component
• Aggressive ablation

Prevention:

• Appropriate burr size selection
• Gradual advancement
• Adequate anticoagulation
• Distal protection devices (peripheral)

Treatment:

• Vasodilator infusion
• Aspiration thrombectomy
• GP IIb/IIIa inhibitors

Slow Flow / No-Reflow

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Mechanism:

• Microvascular obstruction
• Particle embolization
• Vasospasm

Treatment:

• Intracoronary adenosine
• Nitroprusside
• Verapamil
• Nicorandil

Vessel Perforation

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Risk Factors:

• Oversized device
• Eccentric lesion
• Thin vessel wall

Classification (Ellis):

• Type I: No extravasation
• Type II: Pericardial or myocardial blush
• Type III: Active extravasation (jet)

Treatment:

• Prolonged balloon inflation
• Covered stent
• Pericardiocentesis (if tamponade)
• Emergency surgery (rare)

Coronary Spasm

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Prevention:

• Intracoronary nitroglycerin
• Verapamil infusion
• Slow and controlled ablation

Treatment:

• Intracoronary nitrate
• Calcium channel blocker
• Warm saline flush

Post-Procedure Care

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Hospital Follow-up

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• Vascular access site monitoring
• Cardiac monitoring
• Hydration (contrast nephropathy prevention)
• Troponin follow-up

Post-Discharge

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Medical Therapy:

• Dual antiplatelet therapy (6-12 months)
• Statin (high dose)
• Antihypertensive (if needed)
• Diabetes control

Lifestyle:

• Smoking cessation
• Regular exercise
• Healthy diet
• Weight control

Follow-up Program:

• 1 month: Clinical follow-up
• 3-6 months: Non-invasive evaluation
• Annual: Risk factor control

Frequently Asked Questions

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When Should You See a Doctor?

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Seek medical attention immediately in the following situations:

1. Chest pain or tightness
2. Shortness of breath
3. Leg pain, numbness, or coldness
4. Claudication (pain increasing with walking)
5. Rest pain in the leg
6. Non-healing wounds on feet or toes
7. Swelling, bleeding, or pain at the access site after the procedure

Appointment and Contact

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You can schedule an appointment for atherectomy evaluation or information about peripheral and coronary vascular diseases.

📍 Avrasya Hospital - Beştelsiz Mah. 101. Sokak No:107, Zeytinburnu, Istanbul, Turkey

📞 Phone: +90 212 665 50 50 (Ext: 4012)