Midterm patency following atherectomy for infrainguinal occlusive disease: a word of caution

There has been widespread initial enthusiasm for peripheral atherectomy using the SilverHawk device. We sought to evaluate our midterm patency following infrainguinal atherectomy. Nineteen consecutive patients underwent 23 separate atherectomy procedures on 20 limbs from March 2005 through June 2006 (11 males, age 66 +/- 14 years). The primary lesions were atherosclerotic (n = 18) and vein graft stenoses (n = 2). Three additional procedures were redo atherectomies for restenotic lesions. The TASC classification of the primary lesions was A in 3, B in 9, and C in 8. The median number of treated lesions per limb was 2 (range 1-4). The location of the most distal native vessel stenosis was the superficial femoral artery in 12, popliteal artery in six, and crural artery in two. Atherectomy was successful in 18 primary procedures and all three repeat atherectomy procedures. Touch-up balloon dilatation was used in five procedures. Complications included one groin hematoma and two perforations, treated with stenting in one and bypass grafting in one. Preoperative ankle-brachial index and transmetatarsal pulse volume recording were 0.51 +/- 0.16 and 3.3 +/- 0.8, respectively, which at 1-month improved to 0.80 +/- 0.16 and 2.4 +/- 0.4 (p < 0.001). Only two vessels remained patent at 12 months. Recurrence developed in 16 of the successful primary procedures, including both vein graft lesions and all three repeat atherectomy procedures. The mode of recurrence was restenosis in 14 and occlusion/thrombosis in five. Secondary interventions included balloon angioplasty/thrombolysis in two, stenting in three, redo atherectomy in three, vein bypass grafting in five, and observation alone in one. Major limb amputation was required in five patients. Primary patency rates per treated limb at 3, 6, and 12 months were 38%, 10%, and 10%. The corresponding assisted patency rates were 50%, 23%, and 10%. Our experience suggests a very poor midterm patency of excisonal atherectomy using the SilverHawk device, although a 74% limb salvage rate was maintained through secondary interventions. Liberal use of this technology is associated with high cost and frequent requirement of reintervention.