Lipoprotein apheresis: still needed in many patients, or soon a historical practice?

Lipoprotein apheresis (LA) has long been used as an ultima ratio therapy for patients with extreme lipid-driven cardiovascular risk. One perspective maintains that, despite major advances in lipid-lowering pharmacology and the emergence of gene-silencing therapies, LA remains indispensable for selected patients with homozygous familial hypercholesterolaemia, severe hypercholesterolaemia refractory to maximal therapy, and isolated lipoprotein(a) [Lp(a)]-mediated progressive cardiovascular disease. An opposing view argues that modern and emerging pharmacological agents-PCSK9 inhibitors, inclisiran, bempedoic acid, evinacumab, and targeted Lp(a)-lowering antisense and small interfering RNA agents-have already rendered LA obsolete in almost all patients, with its remaining niche closing rapidly as outcome data accumulate. This combined manuscript juxtaposes the two positions in a streamlined form and concludes with a balanced conclusion of the future role of LA.