Atherectomy devices and other instruments, such
as balloons and stents, have been developed for the
treatment of PADs. Balloons and stents are sometimes
insufficient when used alone due to the variations in
anatomical structures and status of the plaques and calcifications in the vascular structures. In general,
atherectomy devices are used in circumstances such
as high rates of occlusions in the vasculatures caused
by the stenosis and hard calcific plaques. Nonetheless,
balloons or stents can be used in cases with low levels
of stenosis or soft lesions.[
11]
In the last 20 years, endovascular treatment options
have been the primary modality against claudication
and even in critical ischemia of the extremities in
several clinics.[12] It has been shown that endovascular
treatment has some advantages, such as fast return
of the patients to daily activities, decreased time
of hospital stay, minimal morbidity, lower hospital
charges, and decreased rate of complications to the
lower extremity.[13]
It was stated in the DEFINITIVE-LE study that
directional atherectomy, which mechanically removes
the plaque burden and opens the lumen of the vessel
without leaving a stent inside the vessel, is safe and
effective in the treatment of the patients, including
both the those with claudication and critical leg
ischemia.[14] In addition, drug-coated balloons and
plain old balloon angioplasty (POBA) were compared
in several clinical trials, such as LEVANT 1 and 2,
IN.PACT SFA, and ILLIMENATE.[15-18] Thus, it
is now known that drug-coated balloons are superior to POBA in treating short to intermediate lesions.
Additionally, drug-coated balloons are superior
in anatomical outcomes, such as primary patency,
binary stenosis, late lumen loss, and target lesion
revascularization, compared to POBA.[19-22]
Minimally invasive endovascular treatments
include PTA, PTA with additional stent placement,
cold-balloon PTA or cryoplasty, and atherectomy
with directional, laser, or orbital volume removal
methods.[23]
The principal action of atherectomy devices is
reducing the plaque burden by shaving or pulverizing
the plaque by piercing or sanding it. In the meantime,
this procedure causes minimal barotrauma in the vessel.
We can classify the acute complications as dissection
or acute occlusion. Potential complications of the
atherectomy devices are hematoma, pseudoaneurysm,
distal embolization, and tearing of the vessel.[23,24]
In our study, 130 patients with SFA and distal
lesions underwent atherectomy with PTA, and
23 patients with iliac lesions had pure PTA without
atherectomy. Percutaneous transluminal angioplasty
was used for residual stenosis or plaque stabilization
after the plaque load was reduced by atherectomy
in SFA and complicated lesions. In the group with
29 popliteal and distal lesions, the lesion in the distal
popliteal artery was approached as an SFA lesion in
11 patients, and an atherectomy was performed on
the distal part of the popliteal lesion up to the distal
bifurcation, and PTA or only PTA was performed on
the area up to the distal bifurcation not to cause injury
to the vessel wall.
It is important to know that complicated lesions
may cause unfavorable outcomes, particularly in
long-term management. In cases with critical leg
ischemia, endovascular revascularization increases the
rate of survival of the extremity.[24]
Our study mostly contains patients with SFA and
distal popliteal lesions. Percutaneous endovascular
treatment is more suitable for these patients as it
decreases the time of hospital stay and reduces the rate
of mortality and morbidity. However, chronic long
segment occlusions in arterial vasculature, widespread
calcifications, and involvement of more than one
segment cause a decrease in the success of percutaneous
endovascular interventions.[25]
In the BASIL study done in the United Kingdom,
a comparison between the efficacy of bypass surgery and angioplasty in the treatment of patients with
severe leg ischemia was evaluated.[13] They determined
that there was no difference between the six-month
survival and amputation rates between the two
groups; however, cost of the treatment was higher in
the surgery group. The immediate primary success
rate of endovascular therapies was 75%.[26]
In our clinic, we use surgical therapy as an option
in appropriate patients. The patients who underwent
surgical therapy were not included in this study.
The patients who could not tolerate graft insertion
due to severely infected ulcers, had unregulated
diabetes mellitus, preferred endovascular treatment,
and had suitable lesions underwent endovascular
therapies. Medical treatment is another option
in these patients, particularly in diabetic patients
with foot ulcers and PAD, and adjuvant therapies,
such as platelet rich plasma (PRP), have been found
to be beneficial.[27] We used medical treatment,
including antiaggregant drugs, antithrombotic
drugs, and cilostazol in the management of some
patients.
The cost of the treatment was not evaluated in our
study; however, the mean hospital stay of the patients
in our study was 2.3 (range, 1-4) days, which is less
than the 5.7 days of hospital stay needed after the
bypass.
Due to the low rate of long-term patency rates
of standard balloon angioplasty and stents, several
studies have used drug-eluting stents and drugcoated
balloons to search for an effective endovascular
treatment modality. Dake et al.[28] suggested in their
study that the patency rates of paclitaxel-coated stents
used in SFA stenosis were significantly greater than
the ones that only PTA was used, and the patency
rates were 83.1% and 32.8% respectively. In the last
few years, drug-coated balloons have been thought to
be effective in percutaneous interventions; however, no
significant difference between drug-coated balloons
and conventional balloons has been found.[29,30]
Rosenfield et al.[20] found that 12-month patency
rates of drug-coated balloon angioplasty and standard
balloon angioplasty methods are 65.2% and 52.6%,
respectively. In our study, we used drug-coated balloons
only to eliminate future complications and increase the
patency rates.
Unlike the angioplasty and stenting, which push
the plaque to the vessel wall, atherectomy, which uses
directional and rotational movements in combination with physical or ablative technics, takes out the plaque
burden out of the vessel. Atherectomy can be used
alone or in combination with stenting or angioplasty.
Restenosis after the atherectomy operation has not
been fully understood; however, there are some
links between few mechanisms.[33] Plasma proteins,
C-reactive protein, serum amyloid A and fibrinogen
are sensitive, specific and sensitive reaction markers
of the acute phase,[31] cytokine-dependent indirectly
they indicate the inflammatory process of the arterial
wall.[32] Restenosis is mainly due to excessive neointima
formation.[33] In our study, no restenosis cases occurred
in the early period (first 24 h after the operation). The
usage of intraoperative and postoperative antiaggregant
and antithrombotic agents was considered to have
prevented early restenosis.
Percutaneous intervention causes mechanical
trauma to the vessel. Vascular stimulants induce
vascular inflammation. The proliferation of smooth
muscle cells and extracellular matrix cause neointimal
thickening and restenosis.[34] Besides the antithrombotic
prescription for the postoperative mechanical trauma,
diet, and hyperlipidemic agents, aiming to control
LDL to below 100 and triglyceride to below 200,
were preoperatively prescribed to the patients with
hyperlipidemia.
Risks associated with superficial atherectomy
femoral, popliteal, anterior tibial, posterior tibial, and
peroneal arteries include arterial dissection, arterial
perforation, arterial tear, arterial spasm, arteriovenous
fistula, bleeding, emboli, arterial thrombosis, urgent
or nonurgent need for arterial bypass surgery,
complications of the incision site, restenosis of the
treated segment, occlusion in the peripheric vessels,
and vascular complications.[35,36] The most common
vascular complication is distal embolization; however,
the prevalence of the distal embolization can be
reduced with the postoperative usage of acetil salisilic
acid (ASA) and clopidogrel.[37,38]
Doppler USG-guided popliteal intervention in the
prone position was shown to be an alternative to the
femoral intervention in patients with iliac and SFA
lesions but not in popliteal or distal lesions. For this
operation, USG was used to examine the popliteal
arterial calcification before the operation. In our study,
distal embolic protection devices were not used.
Some recommendations to optimize the outcome
of peripheral atherectomy and minimize the risk
of procedural complications are as follows: using the contralateral access in cases other than distal
lesions, preferring the antegrade approach for better
management, making slow and methodical cuts,
advancing the cutting blade slowly, and ensuring
adequate anticoagulation (aiming for an activated
clotting time between 275 and 300 sec) to avoid
thrombotic complications during the procedure.[39,40]
The success of endovascular treatments depends
on the localization, length, and degree of stenosis.
Literature includes many studies that demonstrate
the high patency rates of iliac artery stents in the long
term, but it is still controversial in the distal region.[41]
Drug-coated balloons were related to distal embolism
in some studies. However, Fukai et al.[42] revealed that
drug-coated balloon-induced distal embolisms were
not common in femoropopliteal lesions. We mostly
used drug-coated balloons in upper knee lesions and
avoided their use in patients with distal gangrenous
lesions.
In our cases with an antegrade or retrograde
approach, thrombotic complications were tried to be
avoided by administering 1 mL of intravenous heparin
after sheath placement to the patient without activated
clotting time follow-up. All patients were checked for
the presence of a thrombus on the sheath tip while the
postoperative sheath was withdrawn. Furthermore,
the patients’ postprocedure foot color and fingers were
checked for distal microembolism.
We did not encounter any problems in 125 patients.
In 28 patients, progression of the disease was observed
in the leg or ischemic wound between 30 and 65
postoperative days. Twenty-three (%15) patients
required amputation; 20 of the 40 patients with
necrotic wounds showed progression of necrosis
leading to amputation after approximately 30 days.
Amputations were minor (finger amputation) in five
patients and major (below the knee) amputation in 18
patients. These patients with progressive disease had
femoropopliteal, distal, and multiple lesions. Most
of these patients had advanced calcified lesions with
a poor distal vascular bed. More than half of these
patients were diabetic.
When it is necessary to share the scope with
other departments in the operating room, it can be
challenging to determine the surgery day and schedule
the patients into one day.
In conclusion, certain interventional endovascular
procedures can be performed with the C-arm
fluoroscopy. We evaluated the success of our procedures as the satisfaction of the physician and
the patient, the short postoperative stay, and, most
importantly, the absence of major complications.
Moreover, the ergonomics of all the materials used
during the procedures, including the use of the C-arm
scopy, and their of use facilitated the procedures.
In the era of modern hybrid operating rooms, we
recommend its use for arterial lesion treatment C-arm
for surgeons in centers lacking experienced hybrid
theaters I wanted to show that arterial intervention
can be done with fluoroscopy.
Acknowledgement: Author conveys sincere gratitude
to Prof. Dr. Murat Ugurlucan, Dr. Fulya Yılmaz, and Dr.
Didem Melis Öztaş for their help during the preparation of
the manuscript.
Ethics Committee Approval: The study protocol was
approved by the Bozyaka Training and Research Hospital
Ethics Committee (Date/no: 13.10.2021/ 2021/176). The
study was conducted in accordance with the principles of the
Declaration of Helsinki.
Patient Consent for Publication: A written informed
consent was obtained from each patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.