Pre-congress symposiumXIII Panamerican Congress on Vascular and

Endovascular SurgeryRio - 2014

PERCUTANEOUS ATHERECTOMY

Daniel Mendes Pinto

Vascular Surgery

Diabetic Foot Center

Hospital Felício Rocho – Belo Horizonte – Brazil

VascularBH Instituto

Ballon angioplastyhas problems.

Bail-out stents 10-40%

reocclusion1 yearup to 80%

Recoil

Dissection

Nitinol stents fem-pop lesions...

Fracture rate

Long-lesions

Calcified lesions

knee and inguinal joint-areas

Low long-term results!

• patients excluded of many trials

• bad results with isolated balloon angioplasty

• stents: fractures, residual stenosis

Heavy calcified lesions

Common femoral lesion

Options:

• Surgical endarterectomy

• Drug-coated balloon

• Plain angioplasty

• Stent ???

New technologies

Drug-coated balloons

Drug-eluting nitinol stent

Bioabsorbable stent

Newer generation nitinol stents

Promissing results

Similar patency

???

High cost, similar patency

Atherectomy

Laser Atherectomy

Directional Atherectomy

Rotational Atherectomy

Directional atherectomy

Turbohawk® Covidien

• 4 inner blades

• monorail

• 0,014” guide-wire

• atherosclerotic plaque: nosecone

Directional atherectomy: good results published!

TALON Registry (JEVT 2006;13:592)

• 601 pts

• stents: 6,3%

• freedom from revascularisation:

1 y: 80%

• 94,7% sucess in BTK-lesions

But, there are some doubts...

Todd et al. J Vasc Surg 2013;58:941

• 480 tibial interventions

Conclusão:

No benefit with Atherectomy compared to Angioplasty

Considering the high cost, there is no indication for routine use of atherectomy devices.

Directional atherectomy

DEFINITIVE-LE[McKinsey et al. JACC 2014;7(8):923]

• 799 pts (598 claudicants)• 20%: adjuntive PTA• 3,2%: stents

• perforation: 5,3%• distal embolization: 3,8%

• 1,6% - additional intervention

• filter protection: 22,4%• 3,6% - embolization

• primary patency 1y: 78%• no difference: diabetics X non-diabet

Conclusion

• Results comparable to those contemporary

technologies

• Advantage of rarely leving a permanent implant in arteries

• Many anatomic locations

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8

LEVANT IDrug coated

balloonpp 67%

mean length: 8,1 cm

DEFINITIVE-LEAtherectomy

pp 75%mean length: 8,1

cm

DURABILITY IIProtegé

pp 77,2%mean length:

8,9 cm

RESILIENTLifestent pp 81,3%

mean length: 6,2 cm

STRIDESDrug eluting

stentpp 68%

mean length: 9,0 cm

ZILVER RCTZilver PTXpp 83,1%

mean length: 8,9 cm

ITALIAN REGISTRYDrug coated

balloonpp 83,7%

mean length: 7,6 cm

Directional atherectomy Results – femoro-popliteal lesions

Primary patency - 1 year

McKinsey JF. JACC 2014;7(8):923

Directional atherectomayInfrapopliteal lesions - CLI

4%

12%

21%

3.6%

THUNDER ITALIANREGISTRY

PACIFIER DEFINITIVE-LE

Bail-out Stents

Drug-coated balloons

Directional atherectomy

Is the filter protection needed?

DEFINITIVE- Ca++

o 168 calcificed femoro-popliteal lesions

Embolic events

Full basket

Filter

Atherectomy device's tip

2.3%

1.2%

84%

97%

Roberts D. Cath Cardiovasc Int 2014;84:236

Distal embolization

Directional atherectomy

Adjunctive treatments

• Cioppa A et al. Cardiovasc Revasc Med 2012;13:219

• Sixt S et al. J Vasc Surg 2013;58:682

AtherectomyFilter

protectionDrug-coated

balloon

• Better patency• No stents

• Less embolization

But at a higher cost...

DEFINITIVE-AR

ADCAT Trial

PHOTOPAC

LIBERTY 360

Orbital atherectomy

CONFIRM series

(Das T et al. Cathet Cardiovasc Interv 2014;83:115)

• 3115 pts

• primary patency: 74 – 93%

• embolization rate: 2 a 4,6%

• perforation: 2,8%

• adjunctive measures

o ballon angioplasty: 39%

o stents: 2,5%

Diamond Backy 360

Pathway

Laser atherectomy

• LACI study (Laird, JEVT 2006)

• CELLO study (Dave, JEVT 2009)

• primary patency: 56 – 92%

• infrequently used as the only therapy

Conclusion

• Atherectomy leads to embolization: this is a real world problem

• Despite the high cost, it’s useful in calcified lesions and to reduce the necessity of stents

• Drug-coated balloons: renew the interest in atherectomy