Overview of Atherectomy
Concepts: Is Debulking
Better?
Barry S. Weinstock, MD
Mid-Florida Cardiology Specialists
Orlando, FL
Director, Mid-Florida Cardiology
Vascular Intervention Center

Peripheral Vascular Atherectomy
Basic Concepts
Atherectomy involves removal of plaque by
various methods
Different mechanism compared to balloon
angioplasty and/or stenting
Plaque is compressed, vessel is stretched

Why Atherectomy?
Limitations of Balloon Angioplasty
Not all plaque is “compressible”, especially hard,
calcified plaque
Frequently results in dissection  “sub-optimal
result”
Risk of acute closure
Poor long-term patency, i.e. high restenosis rate
“Barotrauma” – vessel injury caused by pressure
of the balloon; may be a cause of restenosis

Why Atherectomy?
Limitations of Stenting
Not all plaque is “compressible”, especially hard,
calcified plaque
May result in incomplete stent expansion, a
predictor of restenosis
Stent restenosis is often a diffuse process for
which there is no approved (or effective) treatment
Stent fracture, particularly in dynamic vessels such
as the SFA, is common and associated with stent

Why Atherectomy?
Limitations of Stenting
Critical limb ischemia is often due to multi-level
disease but nearly always involves the (below-the-
knee) tibial vessels
Small diameter vessels (2-3 mm, similar to
coronary arteries) not ideal for angioplasty
Longer lesions (cm rather than mm!)
Chronic total occlusions are common
Severe calcification is common

Advantages of Atherectomy
Plaque can be removed instead of being compresse
Dissection is rare
No barotrauma
Atherectomy catheters can be optimized for specific
lesion types, e.g. soft plaque vs. calcific plaque
Adjunctive balloon angioplasty (if desired / needed)
can be achieved at much lower, safer pressures

Peripheral Atherectomy Options
ev3 FoxHollow SilverHawk Plaque Excision
CSI DiamondBack Orbital Atherectomy
Pathway Medical Technologies Jetstream G2
Spectranetics Excimer Laser
“Scoring Balloons” – not true atherectomy
Atherotomy – scores plaque but does not remove
plaque

FoxHollow SilverHawk
Directional Atherectomy –
plaque excision
Carbide cutter rotating at
8000 rpm “shaves” plaque and
collects plaque in nose-cone
for subsequent removal
Catheter can be oriented in
all directions for treatment of
concentric or eccentric plaque

FoxHollow SilverHawk

Orbital Atherectomy System
Diamondback Device
Drive shaft with eccentrically Controller
mounted abrasive crown Automatic
ximal and distal sanding action speed control
Fluid infusion
pump
Foot pedal for
procedure
control
Guide Wire
•Exclusive ViperWire™ Procedure

Diamond-Coated Crowns
CLASSIC CROWN SOLID CROWN
Speed: 80 - 200K RPM’s Speed: 60 - 120K RPM’s
1.5 x orbit 1.75 x orbit
Firm, Flexible wires Firm wire
own sizes: 1.25, 1.5, 1.75, 2.0, 2.25 Crown sizes: 1.5, 1.75, 2.0, 2.25

CSI DiamondBack

Spectranetics Excimer Laser
Multi-fiber laser catheter delivers 308 nm excimer
laser energy to ablate plaque
Maybe used as concentric or eccentric (directional)
device

Spectranetics Excimer Laser

Pathway Jetstream G2
Expandable cutting tip for debulking plaque and
aspirating atherosclerotic debris / thrombus
• Blades can be “up” or “down”
Distal ports at the tip provide independent infusion
and aspiration functions

Is Atherectomy Really Better?
Maybe…
Single-arm registries evaluating peripheral vascular
intervention for patients with critical limb ischemia
Good data for multiple devices!
Angioplasty, Laser, FoxHollow, Diamondback,
Stents, Cutting Balloon…
Problem: NO randomized trials comparing devices
in treatment of CLI patients!

Is Atherectomy Really Better?
So, without randomized trials, what’s a doctor to
do???
Be religious! (Do what you believe in!)
Be a pro! (Do what you’re good at!)
Be intelligent! (Do the smart thing!)
Use a device well-suited to the specific plaque
morphology… (more to follow…)

Thank you for your attention!
Barry S. Weinstock, MD