An Algorithm for the Use of Embolic Protection During Atherectomy for Femoral Popliteal Lesions
Prakash Krishnan1, Arthur Tarricone1, K Raman Purushothaman1
1Department of Interventional Cardiology, Mount Sinai Medical Center, New York, New York.
Insights
Atherectomy for femoropopliteal lesions can cause embolic debris. Using distal embolic protection filters is recommended for chronic total occlusions, in-stent restenosis, and calcified or atherosclerotic lesions to prevent complications.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Peripheral Artery Disease
Background:
- Atherectomy for femoropopliteal lesions generates more embolic debris compared to angioplasty alone.
- Distal embolic protection devices (EPDs) are effective in capturing macroemboli, but consensus on their use during atherectomy is lacking.
- Identifying specific lesion characteristics that predict embolic events is crucial for optimizing EPD utilization.
Purpose of the Study:
- To develop an algorithm for using distal embolic protection during atherectomy for femoropopliteal lesions.
- To identify angiographic and vascular anatomical predictors of distal embolization (DE) following atherectomy.
- To evaluate the accuracy of angiography in assessing plaque morphology.
Main Methods:
- Retrospective analysis of patients with peripheral artery disease undergoing atherectomy with distal EPD.
- Evaluation of potential predictors for distal embolization (DE).
- Pathological analysis of plaque collected from the SilverHawk atherectomy device to validate angiographic assessments.
Main Results:
- Significant differences in lesion length, LDL levels, vessel runoff, chronic total occlusion (CTO), in-stent restenosis (ISR), and calcified lesions were observed between patients with and without DE.
- Logistic regression identified lesion length, reference vessel diameter, CTO, runoff vessels, and ISR as strong predictors of macroemboli.
- Angiography demonstrated high accuracy in assessing plaque morphology, including calcium, atherosclerotic plaque, and thrombus/ISR.
Conclusions:
- Peripheral angiography findings such as chronic total occlusion, in-stent restenosis, thrombotic, calcific lesions (>40 mm), and atherosclerotic lesions (>140 mm) indicate the need for filter use during atherectomy.
- Concomitant use of distal embolic protection filters is essential to prevent embolic complications in identified high-risk lesions.
- The study provides evidence-based criteria for the judicious use of distal embolic protection during femoropopliteal atherectomy.
Objectives:
This study sought to identify an algorithm for the use of distal embolic protection on the basis of angiographic lesion morphology and vascular anatomy for patients undergoing atherectomy for femoropopliteal lesions.
Background:
Atherectomy has been shown to create more embolic debris than angioplasty alone. Distal embolic protection has been shown to be efficacious in capturing macroemboli; however, no consensus exists for the appropriate lesions to use distal embolic protection during atherectomy.
Methods:
Patients with symptomatic lower extremity peripheral artery disease treated with atherectomy and distal embolic protection were evaluated to identify potential predictors of DE. Plaque collected from the SilverHawk nose cone subset was sent to pathology for analysis to evaluate the accuracy of angiography in assessing plaque morphology.
Results:
Significant differences were found in lesion length (142.1 ± 62.98 vs. 56.91 ± 41.04; p = 0.0001), low-density lipoprotein (82.3 ± 40.3 vs. 70.9 ± 23.2; p = 0.0006), vessel runoff (1.18 ± 0.9 vs. 1.8 ± 0.9; p = 0.0001), chronic total occlusion (131 vs. 10; p = 0.001), in-stent restenosis (33 vs. 6; p = 0.0081), and calcified lesions (136 vs. 65; p < 0.001). In simple logistic regression analysis lesion length, reference vessel diameter, chronic total occlusion, runoff vessels, and in-stent restenosis were found to be strongly associated with macroemboli. Angiographic assessment of plaque morphology was accurate. Positive predictive value of 92.31, negative predictive value of 95.35, sensitivity of 92.31, and specificity of 95.35 for calcium; positive predictive value of 95.56, negative predictive value of 100, sensitivity of 100, and specificity of 92.31 for atherosclerotic plaque. Thrombus/in-stent restenosis was correctly predicted.
Conclusions:
Chronic total occlusion, in-stent restenosis, thrombotic, calcific lesions >40 mm, and atherosclerotic lesions >140 mm identified by peripheral angiography necessitate concomitant filter use during atherectomy to prevent embolic complications.
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