SLR - June 2020 - Ryan D. Bangart
Outcomes of Atherectomy for Lower Extremity Ischemia in an Office Endovascular Center
Reference: Lai, Samuel H, et al. Outcomes of Atherectomy for Lower Extremity Ischemia in an Office Endovascular Center. Journal of Vascular Surgery. 2020 Apr; Vol 71(4): 1276-1285.
Scientific Literature Review
Reviewed By: Ryan D. Bangart, DPM
Residency Program: Creighton University – Phoenix, AZ
Podiatric Relevance: As the patient population in the US ages, and comorbidities such as diabetes and hypertension grow, the need for vascular intervention will increase. The podiatric surgeon is often one of the first to identify the need for vascular intervention, as seen by symptoms of claudication or delayed/non-healing wounds. This article highlights an outpatient procedure that is performed in an endovascular center. It evaluates atherectomy with angioplasty, as previous studies studied each individually. This provides information that can be used to educate patients on what they can expect from a vascular surgery intervention.
Methods: Fifty-two limbs in 282 patients underwent atherectomy with angioplasty and stent placement over a 5-year period. Atherectomy was performed by orbital atherectomy (OA) for calcified lesions or laser atherectomy (LA) for soft plaques, flush occlusions, or intra-stent stenosis. Choice of intervention was operator dependent. Follow up at three, six, nine and 12 months was performed with imaging used to evaluate vessel stenosis. The safety and efficacy of infra-inguinal revascularization with atherectomy in an office endovascular center was evaluated. Success was defined as <30 percent residual stenosis. Secondary success was evaluated by length of patency of vessels when treated via OA or LA.
Results: Success, as documented above was achieved in 571/594 vessels. Restenosis occurred in 130/571 vessels, of which 114 required secondary intervention due to clinical symptoms. Patency of vessels after OA were 92 percent after 12 months and 91 percent after 29 months. Those treated by LA showed 80 percent and 76 percent respectively. Twenty-three limbs were amputated, two of which were not planned prior to endovascular intervention. No 30-day mortality was encountered following the procedure. Fifty-five patients expired during the study period. Three perforations, two abrupt vessel closures, and one embolization occurred in the study group for a total of six complications.
Conclusions: Atherectomy via OA or LA was shown to be a safe and effective option. OA had better long-term results but cannot be directly correlated. As stated in the methods, LA was selected for different types of occlusions or plaques than OA, such as intra-stent stenosis. Either option is acceptable for treatment of infra-inguinal stenosis. Complications that occurred during the study are not out of the ordinary when compared to prior endovascular cohort studies. Patients who receive a referral with an explanation of what to expect are more likely to follow through on the referral. Podiatric surgeons with knowledge of other aspects of medicine will inspire confidence in their patients.