A
B
C
a distal protection filter is mandatory with this
device. The safety and efficacy of directional
atherectomy has been previously investigated
in prospective multicentre studies. One of these
studies, the DEFINITIVE AR trial, sought to
compare upfront directional atherectomy
combined with DCB versus a DCB-only strategy
in a randomised setting. 12 In this study, combined
treatment with atherectomy and DCB was
effective and safe; however, no added value was
observed in comparison with a DCB-only strategy
at one year of follow-up.
Rotational atherectomy
With rotational atherectomy techniques, tissue
is concentrically excised using specially designed
rotating tips or burrs. The size of the tips or burrs
therefore determine the extent of luminal gain.
Several systems are available for rotational
atherectomy, including the Rotarex ® S system
(Straub Medical), the Jetstream Atherectomy
device (Boston Scientific) and the Phoenix device
(Philips Volcano), the latter combining rotational
and directional features. The Rotarex ® S (Straub
Medical, Wangs, Switzerland) consists of an
external drive system, connected with the
Rotarex ® S catheter system. A helix inside the
catheter transmits the rotation to the catheter
head, which rotates with 10,000 rpm, thus
creating a negative suction force. This enables the
collection of fragmented tissue into an external
bag. Jetstream, on the other hand, is available
with two types of catheters, one equipped with
a single set of front cutting blades and one with
a second set of larger blades to increase the
capability of upfront debulking. This device also
References
1 Dangas GD et al. In-stent
restenosis in the drug-eluting
stent era. J Am Coll Cardiol
2010;56(23):1897–907.
2 Kassimis G et al. How should
we treat heavily calcified
coronary artery disease in
contemporary practice? From
atherectomy to intravascular
lithotripsy. Cardiovasc
Revascularization Med Mol
Interv 2019; pii: S1553-
8389(19)30040-5.
3 Seth A et al. Expert opinion:
Optimising stent deployment
in contemporary practice: The
role of intracoronary imaging
and non-compliant balloons.
Interv Cardiol Lond Engl
2017;12(2):81–4.
4 Abdel-Wahab M et al.
High-speed rotational
atherectomy before paclitaxel-
eluting stent implantation in
complex calcified coronary
lesions: the randomized
ROTAXUS (Rotational
Atherectomy Prior to Taxus
Stent Treatment for Complex
Native Coronary Artery Disease)
trial. JACC Cardiovasc Interv
2013;6(1):10–19.
5 Ali ZA et al. Optical coherence
tomography characterization
of coronary lithoplasty
for treatment of calcified
lesions: First description.
JACC Cardiovasc Imaging
2017;10(8):897–906.
6 Fakhry F et al. Endovascular
revascularization and
supervised exercise for
peripheral artery disease and
D
Figure 2
Digital subtraction
angiography (DSA)
images of an 84-year
old female patient, with
history of severe PAD,
who was referred to our
department with critical
limb ischaemia, Rutherford
stage 6. Baseline DSA
images demonstrated
a tight, heavily calcified
lesion of the right
common femoral artery
(blue arrows in A) and
a chronically occluded
superficial femoral artery.
Phoenix atherectomy
was performed in
B (blue arrows in B
showing bilateral
calcifications), combined
by AngioSculpt TM scoring
balloon (C) and Stellarex
DCB, with a good
angiographic result in D.
intermittent claudication: A
randomized clinical trial. JAMA
2015;314(18):1936–44.
7 Agarwal S, Sud K, Shishehbor
MH. Nationwide trends of
hospital admission and
outcomes among critical
limb ischemia patients: From
2003–2011. J Am Coll Cardiol
2016;67(16):1901–13.
8 Fitzgerald PJ, Ports TA, Yock PG.
Contribution of localized calcium
deposits to dissection after
angioplasty. An observational
study using intravascular
ultrasound. Circulation
1992;86(1):64–70.
9 Cambiaghi T et al. Fracture
of a Supera interwoven nitinol
stent after treatment of popliteal
artery stenosis. J Endovasc Ther
Off J Int Soc Endovasc Spec.
9
HHE 2019 | hospitalhealthcare.com
provides continuous aspiration and removal
of the excised tissue. The Phoenix device is
available in sizes of 1.8mm, 2.2mm and 2.4mm.
The 2.4-mm catheter possesses a deflecting
tip, facilitating a combined directional and
rotational atherectomy modus. The Phoenix
device possesses a front cutter, which is rotated
at high speed (10,000–12,000 rpm), also creating
a strong suction force, which allows continuous
aspiration of the fragmented plaque
components into an external bag. We and
others recently demonstrated the safety and
efficacy of the Phoenix atherectomy device in
femoropopliteal and below-the-knee lesions. 13,14
An example of a severely calcified lesion in the
common femoral artery of a patient with critical
limb ischaemia treated with Phoenix
atherectomy, combined with scoring balloon
angioplasty and DCB and without stent
placement is shown in Figure 2.
Conclusions
With an increasing number of patients suffering
from diabetes mellitus and renal failure or
haemodialysis, the proportion of patients with
complex and calcified coronary and peripheral
lesions is already high and is expected to rise even
more in the next decades. In addition, with an
increasing number of cardiopulmonary and
cerebrovascular comorbidities, the proportion of
patients at high risk for open cardiac or vascular
surgery is also expected to rise in coming years,
thus further establishing the role of coronary and
peripheral endovascular procedures as the first
option for the treatment of such patients. In order
to facilitate treatment of such complex fibrocalcific
lesions however, advanced treatment options, such
as high-pressure and scoring balloon angioplasty
together with directional, rotational or orbital
atherectomy techniques, have become mandatory
and implementation of such techniques will be
crucial to improve both acute success and
long-term outcomes. Many FDA-approved
atherectomy devices are currently available in
the market for coronary and/or for peripheral
use. From the practical point of view, such devices
are readily widely accepted by interventional
cardiologists and angiologists. Considering the
availability of diverse scoring balloon and
atherectomy devices, it may be advisable to
first gain expertise in the use of a single device,
optimally applicable for both coronary and
peripheral vessels with due attention to patient
selection and lesion characteristics.
2017;24(3):447–9.
10 Giusca S et al. Comparison
of ante- vs. retrograde
access for the endovascular
treatment of long and calcified
femoropopliteal occlusive
lesions. LINC Congress In Leipzig;
2019.
11 Lugenbiel I et al. Treatment
of femoropopliteal lesions
with the AngioSculpt scoring
balloon – results from the
Heidelberg PANTHER registry.
VASA Z Gefasskrankheiten
2018;47(1):49–55.
12 Zeller T et al. Directional
atherectomy followed by a
paclitaxel-coated balloon to
inhibit restenosis and maintain
vessel patency: Twelve-month
results of the DEFINITIVE AR
Study. Circ Cardiovasc Interv
2017;10(9): pii: e004848.
13 Davis T et al. Safety and
effectiveness of the Phoenix
Atherectomy System in lower
extremity arteries: Early and
midterm outcomes from the
prospective multicenter EASE
study. Vascular 2017;25(6):
563–75.
14 Giusca S et al. Endovascular
treatment with the Phoenix
Atherectomy System in patients
with chronic limb ischemia.
A series of seventy-four
consecutive patients. LINC
Congress In Leipzig; 2019.