title: Atherectomy offers no benefits over balloon angioplasty in tibial interventions for critical limb ischemia.
abstract: BACKGROUND
  Endovascular adjuncts, like atherectomy, were developed to improve outcomes of endovascular arterial interventions. The true impact of atherectomy on endovascular outcomes remains to be determined, and little data exist on the influence of atherectomy on tibial interventions. Our study compares early and late outcomes of tibial intervention with angioplasty vs atherectomy-assisted interventions.
  
  
  METHODS
  We completed a retrospective review of all tibial interventions between 2008 and 2010. Outcomes were analyzed using single and multivariate analysis, Cox regression, and Kaplan-Meier curves. Primary outcomes were primary, primary assisted, and secondary patency rates, as well as limb salvage and survival rates.
  
  
  RESULTS
  Over a 2-year period, 480 tibial interventions were completed for 421 patients. Eighty-seven percent (n = 418) of interventions were performed for critical limb ischemia (CLI) and 13% (n = 62) for claudication. The CLI cohort of 418 interventions was analyzed. These patients had a mean age of 71 years with a mean follow-up time of 16 ± 15 months (range, 0-59 months). Of the 418 interventions, 339 underwent percutaneous transluminal angioplasty (PTA): 333 PTA alone, six PTA + stent. The remaining 79 interventions received atherectomy: 33 laser, 13 directional, and 33 orbital either alone or in conjunction with PTA (11 atherectomy only, 68 atherectomy + PTA). The groups did not differ significantly in terms of demographics, risk factors, or technical success. The atherectomy group had more TASC B lesions (54% vs 38%; P = .013), while the PTA-alone group had more TASC D lesions (25% vs 13%; P = .004). TASC A and C lesions did not differ significantly between the groups. No significant differences existed with respect to the early (30-day) outcomes of loss of patency (11% vs 13%; P = .699), complications (8% vs 13%; P = .292), or major amputation (17% vs 13%; P = .344) in the PTA-alone group vs the atherectomy-assisted group. Kaplan-Meier analysis revealed no difference for all primary outcomes of PTA alone vs the atherectomy-assisted group at 12 and 36 months: primary patency (69%, 55% vs 61%, 46%; P = .158), primary assisted patency (83%, 71% vs 85%, 67%; P = .801), secondary patency (94%, 89% vs 95%, 89%; P = .892), limb salvage (79%, 70% vs 81%, 77%; P = .485), or survival (77%, 56% vs 80%, 50%; P = .944).
  
  
  CONCLUSIONS
  The adjunctive use of atherectomy offered no improvement in primary outcomes over PTA alone in either early or late outcomes in CLI patients who underwent endovascular tibial interventions. Considering the additional cost and increased procedural time, these findings put into question the routine use of adjunctive atherectomy.
authors.affiliation: Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va.
authors.forename: Kevin E
authors.initials: KE
authors.lastname: Todd
authors.forename: Sadaf S
authors.initials: SS
authors.lastname: Ahanchi
authors.forename: Christian A
authors.initials: CA
authors.lastname: Maurer
authors.forename: Jung H
authors.initials: JH
authors.lastname: Kim
authors.forename: Candice R
authors.initials: CR
authors.lastname: Chipman
authors.forename: Jean M
authors.initials: JM
authors.lastname: Panneton
mesh_terms: D000368:Aged; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D017073:Atherectomy / Q000009:adverse effects / Q000401:mortality; D003251:Constriction, Pathologic; D016638:Critical Illness; D005260:Female; D006801:Humans; D007511:Ischemia / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D016909:Tibial Arteries / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency