Luminal Gain after Atherectomy Measured by Intravascular Ultrasound (IVUS) and Impact on Mid-Term Results

Background

While atherectomy is commonly used in peripheral vascular interventions, multiplanar data regarding the degree of luminal gain from the atherectomy procedure itself is lacking. We assessed immediate percent luminal gain, measured by intravascular ultrasound (IVUS) in different atherectomy devices. We also evaluated short-term patency measured by duplex ultrasound (DUS) and mid-term clinical follow-up.

Methods

We prospectively collected data on 156 consecutive lower extremity revascularizations for 145 unique patients (11 bilateral staged interventions). Atherectomy was always followed by balloon angioplasty, with selective use of stenting. Indications for intervention were symptoms (Rutherford class 3–6) combined with lesions 70% area stenosis assessed by IVUS. IVUS also identified lesion length, calcification, and percent stenosis pre- and immediately post-atherectomy. This difference represented percent luminal gain by atherectomy alone. Follow-up DUS was performed at 30 days to identify residual/recurrent stenosis > 70%. Patients were followed up clinically to determine incidence of improvement, clinically driven target lesion revascularizations (cdTLRs), need for open surgery, and amputations.

Results

Patients were treated for Rutherford class 3–5 ischemia. Two hundred sixty (260) lesions were treated in 156 limbs, including 51 in-stent restenosis (ISR) and 55 total occlusions. Two hundred nine (80.1%) lesions were in femoral-popliteal distribution. Median luminal gain was 26.4 (interquartile range 23; 31) % and was significantly higher in tibial than femoral-popliteal vessels (P = 0.009). Stenting was required in 46 (22.2%) of femoral-popliteal lesions and no tibial segments. Stenosis > 70% assessed by DUS at 30 days was present in 2.3% of treated lesions. Mean follow-up was 15.2 ± 3.3 months. CdTLR was performed in 53 cases (34%), including 3 (1.9%) open revascularization and major amputation in 2 (1.3%) legs, both Rutherford Class 4–5. Due to the tight range of luminal gain across all procedures, we saw no effect of the degree of luminal gain on the occurrence or timing of cdTLR (hazard ratio 1.006 (95% confidence interval 0.978–1.036), P = 0.660). CdTLR was related to initial presence of occlusion, lesion length, and ISR as the initial indication for intervention.

Conclusion

Atherectomy consistently results in median luminal gain of 26.4%, which is similar between different atherectomy devices and depends on the baseline vessel size. In this series stent placement was infrequent, with no stents placed in the tibial position. CdTLR was not influenced by degree of calcification or percent luminal gain attributed to atherectomy. There was improvement in the majority of patients across all Rutherford categories, with a low rate of open intervention and amputation, which was restricted to patients with chronic limb-threatening ischemia.