Directional Atherectomy of the Femoropopliteal Artery: A Case Series

Purpose: Occlusive or stenotic disease of the femoropopliteal arteries is a frequent problem found in vascular surgical practice. Catheter-based plaque excision technologies offer a treatment strategy with comparable results to other endovascular techniques. Our purpose was to evaluate the outcomes of a series of patients treated by means of directional atherectomy, with regards to vessel patency rates in the medium and long terms, and investigate any factors effecting procedural outcomes.

Materials and Methods: A database of cases in Melbourne, Australia, by two surgeons between May 2017 and August 2019 was examined. Patients with de novo femoropopliteal disease were treated with the HawkOne Directional Atherectomy System (Medtronic). A retrospective review of prospectively collected data in electronic medical records was undertaken. Primary outcomes included freedom from target lesion revascularization and the incidence of major adverse events (MAEs), defined as index limb loss, cardiac events, renal failure or death at 30 days postprocedure. Univariate cox proportional hazard modeling was used to identify independent predictors of restenosis or reocclusion.

Results: A total of 103 patients were identified. Eight patients had a procedure on both limbs, leaving a total of 111 limbs. The cohort total time at risk was 826.1 months. Median follow-up was 7 months (range, 2 weeks–25 months). Freedom from target lesion revascularization at 6 months was 96.39% and at 12 months was 91.89%. There were no recorded MAEs. Patients initially presenting with a chronic total occlusion had a higher hazard ratio (HR) (HR, 4.36; 95% confidence interval (CI), 1.46–13.04) of restenosis or reocclusion after revascularization relative to those presenting with stenosis. Those who had intraprocedural vessel dissection regardless of flow limitation had a higher risk of restenosis or reocclusion (HR, 8.34; 95% CI 2.23–31.15). After adjusting for index lesion, patients with vessel diameters 6 to 7 mm were 87% less likely to have restenosis or occlusion compared with those with vessel diameters between 4 and 5.5 mm (HR, 0.14; 95% CI 0.04–0.54).

Conclusions: Our results are comparable to international series on the subject. Midterm results using directional atherectomy are promising, but complete follow-up data are needed. Patients initially presenting with a CTO are at higher risk of restenosis or reocclusion after revascularization. Larger vessel diameters are less likely to develop restenosis on follow-up.