Initial Results With Atherectomy for Non-reconstructable Limb Threatening Peripheral Vascular Disease

Abstract

Background Removal of the atherosclerotic plaque by atherectomy rather than compression by balloon angioplasty has held the interest of vascular surgeons since the introduction of remote loop endarterectomy instruments in the 1950s. Methods We have reviewed our experience with a directional atherotome (SilverHawk; eV3, Plymouth, MN, USA) for patients who had advanced, TransAtlantic Inter-Society Consensus Stages III and IV (Rutherford categories 4, 5, and 6) occlusive disease. The patients were not candidates for bypass operations or had failed bypass and/or stenting. From August 2007 through April 2009, we used the SilverHawk device in 16 men, aged 48 through 81, median age 66 years (standard deviation = 8.75). Risk factors include diabetes (9) and history of smoking (12). The indications for the procedure were nonhealing wounds in six, tissue necrosis in four, and ischemic rest pain in six patients. Results Eleven patients had atherectomy of occluded popliteal or tibial arteries. There were no intraoperative complications, specifically embolization or arterial wall perforation. One patient developed a common femoral pseudoaneurysm at the arteriotomy site. In each patient, completion arteriograms showed target lesion revascularization. Follow-up was from 8 to 54 months with a median of 26.5 months. Below-knee amputations on the site of the intervention were required in two patients at 1 month and 9 months. Transmetatarsal amputations were done in two patients following the vascular intervention, one of which was planned preoperatively. Both transmetatarsal amputation sites healed. In five of six patients, relief of rest pain was obtained, and healing of wounds occurred in the remaining six patients. Conclusion Under the special circumstances of advanced limb ischemia, atherectomy may provide limb salvage in patients who no longer have the option of a bypass operation.