Use and abuse of atherectomy: where should it be used?

Surgical bypass has long been considered the "gold standard" for treatment of peripheral arterial disease. Endovascular therapy with percutaneous transluminal angioplasty and adjunctive stenting has recently become a primary treatment of lower extremity peripheral arterial disease. However, there has been concern regarding the long-term patency of percutaneous interventions and the increased need for reintervention. An alternative to standard percutaneous transluminal angioplasty and stent is the excision of the obstructing arterial plaque using atherectomy devices. There are several different types of atherectomy devices including directional atherectomy devices, such as the SilverHawk Atherectomy (EV3, Minneapolis, MN) device, orbital atherectomy devices, such as the CSI DiamondBack 360 (CSI, Minneapolis, MN) rotational atherectomy device, such as the Pathway Jetstream (Pathway Medical Technologies, Inc., Kirkland, WA), the Rotablator device (Boston Scientific, Natick, MA), and laser atherectomy devices, including the Spectranetics Excimer Laser (Spectranetics, Colorado Springs, CO). All of these devices will be reviewed. Multiple series, including our experience with atherectomy devices, will be discussed. Overall, atherectomy devices have an important emerging role for complex lesions, especially those extending into tibial vessels. Atherectomy devices have the distinct advantage of removing the obstructing atherosclerotic or intimal hyperplastic lesions without the disadvantage of a foreign body such as a stent in the artery. If reintervention is required after atherectomy, this can be generally accomplished at the same site with low risk of complications or discomfort to the patient. Finally, atherectomy also does not preclude use of bypass for the treatment of peripheral arterial disease nor, in most cases, change the anastomotic sites if surgical bypass is required, in contrast to stenting.