What You See Is What You Get

Editor's note: Watch Dr. Walker's related video editorial.

In the August issue of Vascular Disease Management, Dr. George provides a case report in which he utilized the Pantheris atherectomy device (Avinger) to treat a patient with peripheral vascular disease. This device utilizes optical coherence tomography (OCT) as its “eyes” and a directional atherectomy device to remove obstructive atheroma, dissections, and organized thrombus. The theory behind the potential advantage of this device is that it will allow physicians to optimally cross obstructive lesions, then remove only pathological tissues while sparing injury to the media and adventitia. Prior atherectomy trials have shown that restenosis and complications increase dramatically when media and adventitia are removed, suggesting deeper injury is harmful. It appears that OCT guidance may allow physicians to see the tissues to be removed or spared, hence the title, “what you see is what you get.”

The Pantheris device is the product of Dr. John Simpson’s vision of a device that may facilitate successful interventional therapy of atherosclerotic disease with less vessel injury and no need to implant vascular scaffolds. He has theorized that this may yield safer more durable outcomes. Initial histological results of the removed tissue have shown less media and adventitial specimens. There are of course many obstacles to achieving improved outcome goals, such as blurred margins between normal and diseased tissue, vascular motion, and dense calcium, but Dr. Simpson has a long history of solving complex interventional problems. He gave us the first “over-the-wire” balloon, the first independent steerable coronary guidewire, the first dedicated crossing tool, the first re-entry tool, the first closure tool, and the first atherectomy tool, to name a few of his many breakthrough contributions to the interventional community. Many of those devices were controversial initially but all have been successfully utilized to help patients and have left an indelible mark on interventional therapies.

In theory, the Pantheris device may not only allow improved crossing and more precisely directed atherectomy, it may lessen the amount of radiation exposure to the patient and the treating physician as the atherectomy and crossing can be performed with OCT guidance with less use of flouroscopy. Subsequent OCT cross-sectional imaging may provide a more accurate assessment of the adequacy of therapy than conventional angiography. In its present iteration, treatment takes more time and skill than PTA/stenting and there is an initial required capital expenditure. 

When I first witnessed Avinger’s Ocelot crossing devices and Pantheris atherectomy device being utilized, I was mesmerized by this futuristic scientific application. It remains to be seen if this will improve outcomes and prove to be cost effective, particularly now when great advances are being made in preventing restenosis, but I would never bet against Dr. Simpson’s visions.