We spoke to Dr. Spiliopoulos to learn more about his presentation at CIRSE 2022.
Debulking atherectomy improves patency: Pro
The mechanism of balloon angioplasty is based on plaque disruption and displacement within the arterial wall. Using balloon angioplasty, the atheroma is not removed but crushed and redistributed within and along the arterial wall. In the presence of eccentric, severely calcified atheromas, balloon angioplasty performs poorly, flow-limiting dissection or recoiling is common, and bail-out stenting is necessary to achieve immediate technical success [1, 2]. Atherectomy enables percutaneous atheroma removal, which could allow for improved acute luminal gain even following low-pressure angioplasty, resulting in minimal vessel barotrauma, and thus less negative remodelling and neointimal hyperplasia .
Overall, randomised and observational data indicate that atherectomy results in decreased dissection and bail-out stenting rates, while plaque removal seems to optimise vessel-wall drug uptake and enhance the anti-restenotic effect of drug-coated balloons (vessel preparation concept) [4, 5]. This appealing prospect of plaque removal and vessel preparation has led to extensive clinical investigation. At the same time, the use of atherectomy devices exponentially have increased over the past decade to surpass angioplasty and stenting to become the most frequently used endovascular intervention for femoropopliteal lesions in the United States . However, the question remains, can atherectomy increase patency outcomes of endovascular peripheral arterial interventions?
Although it seems quite logical to obtain better patency outcomes by removing the atheroma rather than displacing it, until 2017, published data from nine major prospective registries and five randomised controlled trials (RCT) were contradictive and did not support the superiority of percutaneous atherectomy over standard peripheral balloon angioplasty or stenting in terms of patency or limb salvage . However, in one RCT, atherectomy resulted in fewer re-interventions when treating femoropopliteal in-stent restenosis (six-month TLR: 26.5% vs. 48.2%; p<0.005) . Moreover, atherectomy groups in all five RCTs demonstrated consistently numerically superior one-year patency/TLR-free rates (ranging between 80% and 93%) compared to the control groups, suggesting that atherectomy could result in significantly superior patency outcomes if a larger number of patients were investigated . This numerical superiority in patency was also noted in two recently published multicentre RCTs investigating vessel preparation using infrapopliteal orbital and directional atherectomy followed by PCB angioplasty versus PCB angioplasty alone [8, 9]. Following these recent trials, Usai et al. conducted an updated systematic review on infrainguinal atherectomy plus PCB angioplasty, demonstrating excellent pooled one-year primary and secondary patency rates of 92% and 98%, respectively .
Atherectomy has also been proposed as a valid endovascular solution for hard, eccentric calcified lesions of “no-stenting” areas such as the distal crural vessels and pedal arch with the re-intervention-free rate exceeding 90%, as well as of traditionally surgical areas such as the common femoral artery, in which the three-year primary patency rate was approximately 85% and therefore comparable to open surgery [11, 12].
Currently available data indicate that debulking atherectomy minimises dissection and bail-out stent rates and offers numerically superior patency rates in native infrainguinal arterial lesions. Adequately powered multicentre RTCs are required to demonstrate statistical significance. Statistically superior patency rates were noted compared to balloon angioplasty when treating in-stent restenosis. Presumably, the “stentless” acute luminal gain obtained by debulking atherectomy may ultimately lead to improved long-term clinical outcomes and longer “surgery-free” intervals, typically required in younger patients, even if primary patency rates are similar. By analogy to coronary practice, the individualised choice of different atherectomy devices based on lesion type and anatomical location could further improve patency outcomes [12-14].
National and Kapodistrian University of Athens, Athens/GR
Dr. Spiliopoulos is an associate professor of interventional radiology, at the 2nd Department of Radiology, of the National and Kapodistrian University of Athens, “Attikon” University General Hospital, in Greece. His clinical work includes vascular IR, non-vascular IR, and interventional oncology procedures. He teaches radiology and interventional radiology for pre- and post-graduate courses at the University of Athens School of Medicine and participates as a primary investigator or co-investigator in clinical and experimental investigational protocols including multicentre, European, and global studies. Dr. Spiliopoulos is also an honorary senior lecturer in the Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, at the University of Aberdeen, in Scotland, UK.
After completing his fellowship in interventional radiology at Guy’s and St’ Thomas’ Hospitals, London, UK, he has worked as a consultant interventional radiologist at the Nobles Hospital, Isle of Man, UK and Aberdeen Royal Infirmary Hospital, in Aberdeen, UK. He is a holder of the European Boards of Interventional Radiology (EBIR), a certified Endovascular Specialist (EBIR-ES) and a Fellow of the Cardiovascular and Interventional Society Europe (FCIRSE) Radiology.
Dr. Spiliopoulos has published more than 180 peer-reviewed PubMed articles and 17 book chapters. He is a reviewer of 17 scientific PubMed journals and has given over 100 invited lectures at national and international congresses. He is an elected member of the Standards of Practice Committee for CIRSE, associate editor in two PubMed scientific journals, a member of the editorial board of four international peer review journals and an editorial consultant for the Journal of the American College of Cardiology: Cardiovascular Interventions. Dr. Spiliopoulos has received over 20 international awards and distinctions for his research in interventional radiology. His ongoing research interests include the endovascular management of peripheral arterial disease and dialysis vascular access, personalised vascular medicine, and loco-regional treatments of solid organ malignancies.
- Spiliopoulos S, Karamitros A, Reppas L, Brountzos E. Novel balloon technologies to minimize dissection of peripheral angioplasty. Expert Rev Med Devices. 2019;16(7):581-588.
- Katsanos K, Spiliopoulos S, Reppas L, Karnabatidis D. Debulking Atherectomy in the Peripheral Arteries: Is There a Role and What is the Evidence? Cardiovasc Intervent Radiol. 2017;40(7):964-977.
- Mittleider D, Russell E. Peripheral atherectomy: applications and techniques. Tech Vasc Interv Radiol. 2016;19(2):123–35.
- Chowdhury M, Secemsky EA. Atherectomy vs Other Modalities for Treatment During Peripheral Vascular Intervention. Curr Cardiol Rep. 2022;24(7):869-877.
- Bosiers M. Is vessel prep necessary before treating the superficial femoral artery? J Cardiovasc Surg (Torino). 2019;60(5):557-566.
- Magnowski A, Lindquist JD, Herzog EC, Jensen A, Dybul SL, Trivedi PS. Changes in national endovascular management of femoropopliteal artery disease: an analysis of the 2011-2019 Medicare data. J Vasc Interv Radiol. 2022 Jun 25:S1051-0443(22)01017-X.
- Dippel EJ, Makam P, Kovach R, et al. Randomized controlled study of excimer laser atherectomy for treatment of femoropopliteal in-stent restenosis: initial results from the EXCITE ISR trial (EXCImer laser randomized controlled study for treatment of femoropopliteal in-stent restenosis). JACC Cardiovasc Interv. 2015;8:92–101.
- Zeller T, Giannopoulos S, Brodmann M, et al. Orbital Atherectomy Prior to Drug-Coated Balloon Angioplasty in Calcified Infrapopliteal Lesions: A Randomized, Multicenter Pilot Study. J Endovasc Ther. 2022 Jan 27:15266028211070968. doi: 10.1177/15266028211070968. Epub ahead of print.
- Rastan A, Brodmann M, Böhme T, Macharzina R, Noory E, Beschorner U, et al. Atherectomy and drug-coated balloon angioplasty for the treatment of long infrapopliteal lesions: a randomized controlled trial. Circ Cardiovasc Interv 2021;14:e010280.
- Usai MV, Lillu A, Asciutto G, Austermann MJ, Schwindt AG. Systematic review of atherectomy of inguinal arteries for atherosclerotic lesions. J Cardiovasc Surg (Torino). 2022;63(1):2-7.
- Cioppa A, Franzese M, Gerardi D, et al. Three-year outcome of directional atherectomy and drug coated balloon for the treatment of common femoral artery steno-occlusive lesions. Catheter Cardiovasc Interv. 2022;99(4):1310-1316.
- Palena LM, Saad PF, Piccolo E, Gabellini T, Baldazzi G, Ciofani L, Paola LD. Below the ankle orbital atherectomy in chronic limb-threatening ischemia patients as a bailout strategy for limb salvage: Early clinical experience. Cardiovasc Revasc Med. 2022 Mar 24:S1553-8389(22)00126-9. doi: 10.1016/j.carrev.2022.03.015. Epub ahead of print.]
- Babaev A, Halista M, Bakirova Z, Avtushka V, Matsumura M, Maehara A. Directional versus orbital atherectomy of femoropopliteal artery lesions: Angiographic and intravascular ultrasound outcomes. Catheter Cardiovasc Interv. 2022 Jul 16. doi: 10.1002/ccd.30339. Epub ahead of print.
- Doshi R, Thakkar S, Patel K,et a. Short term outcomes of rotational atherectomy versus orbital atherectomy in patients undergoing complex percutaneous coronary intervention: a systematic review and meta-analysis. Scand Cardiovasc J. 2021; 55(3):129-137.