Rotational atherectomy for below the knee lesions in critical limb threatening ischemia: Is it a wild goose chase?

Abstract

Aim: Treatment of infrapopliteal peripheral arterial disease is still challenging. Rotational atherectomy (RA) is a novel option that aims removal of calcium from the lumen and improvement in outcomes. Material and Methods: Data of 27 patients (19 males, 8 females; mean age: 59.8±13.7 years; range, 25 to 79 years) with infrapopliteal occlusions treated by RA between January 2017 and December 2019 was retrospectively collected. The Global Limb Anatomic Staging System (GLASS) and the Rutherford classification (RC) were used for evaluation. The objective performance goals of Conte et al. (major adverse limb event [MALE] and major adverse cardiovascular event [MACE]) were used for assessing outcome performance. Visits were scheduled at 1, 6, 12, 18, and 24 months after treatment. In each visit, symptoms, RC, wound status, smoking status, lifestyle modifications, and medications were questioned, laboratory tests and Doppler ultrasonography were carried out, and the next visit was planned. Results: Device success was 88.89%, whereas procedural success was 100%. Unanticipated amputation rate was 11.1% in the 12-month follow-up. Over half of the patients (66.67%) showed RC improvement with a mean change of 3±1.17. Thirty-day safety endpoints were as follows: MALE, MACE, and amputation rates were 12.5%, 0%, and 8.33%, respectively. One-year efficacy endpoints were as follows: freedom from MALE+perioperative death was 71.42%, amputation-free survival was 76.19%, freedom from reintervention (amputation was 75%, limb salvage was 80%, and survival was 90.47%. Associations between RC (5-6) and calcification, chronic renal insufficiency and amputation, being a nonsmoker and failure to improve RC, and smoking and high infrapopliteal GLASS were found. Smoking cessation came with RC improvement in every case. Nonquitters experienced worsening more often compared to quitters (0% vs. 25%). Conclusion: Rotational atherectomy is feasible and effective in infrapopliteal chronic total occlusions. Closer follow-up is suggested for nonsmokers and patients with chronic renal insufficiency or advanced GLASS stages as they are prone to unfavorable clinical results. Quitting smoking should be underlined with its potential positive clinical effect even after the procedure.