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Clinical Impacts and Procedural Risks of Rotational Atherectomy for Heavily Calcified Femoropopliteal Lesions
Takahiro Tokuda1, Naoki Yoshioka2, Akiko Tanaka3
1Department of Cardiology, Nagoya Heart Center, Nagoya, Japan.
Insights
Rotational atherectomy with drug-coated balloons (DCB) improves initial results for severely calcified femoropopliteal lesions but doesn't offer durable patency. The increased procedural risks, including distal embolization, suggest selective use is preferred over routine application.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Severely calcified femoropopliteal lesions pose treatment challenges.
- The long-term efficacy of atherectomy-assisted drug-coated balloon (DCB) therapy in these lesions is not well-established.
Purpose of the Study:
- To compare clinical outcomes of rotational atherectomy plus DCB versus DCB alone in patients with severely calcified femoropopliteal lesions.
- To evaluate the durability of patency and procedural safety of combined therapy.
Main Methods:
- A multicenter retrospective study analyzed 153 matched pairs of de novo femoropopliteal lesions (Peripheral Arterial Calcium Scoring System grades 3-4).
- Patients received either DCB alone or rotational atherectomy followed by DCB.
- The primary endpoint was 2-year primary patency, analyzed using hierarchical Cox models.
Main Results:
- Rotational atherectomy significantly reduced residual stenosis post-procedure (16.7% vs 20.3%).
- One-year primary patency was higher with rotational atherectomy (86.2% vs 75.1%), but this benefit diminished by 2 years (64.4% vs 57.1%).
- Procedural complications, particularly distal embolization, were markedly higher in the rotational atherectomy group.
Conclusions:
- Rotational atherectomy improves acute luminal results in severely calcified femoropopliteal lesions.
- The early patency advantage is not durable, and the increased procedural risk does not support routine use.
- Selective application of rotational atherectomy in conjunction with DCB may be considered for specific cases.
Background:
Whether atherectomy-assisted drug-coated balloon (DCB) therapy provides durable benefit in severely calcified femoropopliteal (FP) lesions remains uncertain.
Objectives:
In this study, we wanted to compare clinical outcomes of rotational atherectomy plus DCB vs DCB alone in severely calcified FP lesions.
Methods:
In this multicenter retrospective study, 582 de novo FP lesions with Peripheral Arterial Calcium Scoring System grades 3 to 4 were evaluated. After propensity score matching, 153 lesion pairs treated with DCB alone or rotational atherectomy plus DCB were analyzed. The primary endpoint was 2-year primary patency. Hierarchical Cox models adjusted for baseline, procedural, and acute angiographic factors.
Results:
The median follow-up duration was 439 days (IQR: 232-760). Rotational atherectomy use resulted in significantly lower postprocedural residual stenosis (16.7% [95% CI: 14.9-18.4] vs 20.3% [95% CI: 17.8-22.9]; P = 0.019) and fewer lesions with residual stenosis >30% (9/153 lesions, 5.9% [95% CI: 3.1-10.8] vs 22/153 lesions, 14.4% [95% CI: 9.7-20.8]; P = 0.012). One-year primary patency was higher in the rotational atherectomy group (86.2% [95% CI: 80.0-92.3] vs 75.1% [95% CI: 67.8-82.4]; P = 0.01), but this difference attenuated at 2 years (64.4% [95% CI: 52.4-76.4] vs 57.1% [95% CI: 47.1-65.9]; P = 0.07). In hierarchical Cox models, rotational atherectomy use remained independently associated with improved patency after adjusting for acute angiographic results (HR: 0.56; 95% CI: 0.31-1.00; P = 0.05). Procedural complications were markedly higher with rotational atherectomy, driven by distal embolization.
Conclusions:
Although rotational atherectomy improves acute luminal results, the early patency benefit is not durable and is offset by increased procedural risk, supporting selective rather than routine use.
