Debulking procedures: potential device specific indications

During the past decade, the endovascular treatment of peripheral arterial disease has become more widespread due to the impressive extension of the endovascular toolbox to include different atherectomy technologies. The promise of atherectomy is to avoid the "barotraumas" defined as complications of traditional angioplasty such as dissection, elastic recoil, and disruption of the internal elastic lamina resulting in overwhelming neointima and smooth muscle cell proliferation. The oldest atherectomy technologies are the excimer laser and the Rotablator. The excimer laser technology is based on the principle of photoablation converting occlusive material into microbubbles being immediately dissolved into the blood. The Rotablator and the newer diamondback device are high speed rotational "sanding" devices particularly developed for the treatment of highly calcified plaque particularly in small vessel lesions, such as the popliteal and infrapopliteal segments. The Silverhawk system, currently the most widespread used device, is a directional atherectomy device particularly designed for eccentric and not severely calcified infrainguinal lesions whereas a variation of this device, the Rockhawk, is dedicated for the treatment of calcified plaques. The Jetstream system is the latest approved rotational atherectomy device focusing on native arteries with a reference vessel diameter of 4-6 mm in its current version; uniquely this device also has an aspiration capability making the device not only an atherectomy device but potentially also a thrombectomy device. This article will review the different indications for the use of these atherectomy devices including tips and specific device limitations.