Directional atherectomy and balloon angioplasty for lower extremity arterial disease

This study was undertaken to evaluate the use of directional atherectomy, balloon angioplasty, and video angioscopy in highly selected patients with superficial and popliteal artery stenoses. Directional atherectomy and balloon angioplasty for superficial femoral and popliteal artery stenosis (> 80%) were performed in 96 limbs (88 patients) between 1990 and 1994. All procedures were performed by the authors with angioscopy and C-arm angiography. Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) categorical classification of chronic limb ischemia and run off scoring was utilized pre- and postoperatively to assess outcome. The indicators for atherectomy were moderate claudication (category 2, 15% of limbs), severe claudication (category 3, 65%), ischemic rest pain (category 4, 12%), and tissue loss (category 5, 12%). Morbidity was 6.0% with no perioperative mortality. All technically and (angiographically) successfully treated patients demonstrated postoperative improvement. Clinical assessment, vascular laboratory studies (outcome criteria), and/or angiography were monitored at follow-up visits. Intraoperative failures occurred in 6% of limbs due to inability to pass a guide wire (3%), impacted atherectomy catheter (1%), or vessel perforation (2%). In the remaining 90 limbs, 23% failed due to either progression of disease (7.7%) or restenosis at the original site (15.3%). Seventy-one percent of limbs maintained their postoperative categorical improvement at a mean follow up of 24 months. Combining atherectomy and balloon angioplasty may be more durable than angioplasty or atherectomy alone. A long-term prospective study of the role of directional atherectomy and balloon angioplasty by vascular surgeons appears to be warranted utilizing SVS/ISCVS guidelines for lower extremity chronic ischemia categories, run-off score, and outcome criteria for patency.