Atherectomy

An atherectomy is a minimally invasive surgical procedure to remove plaque from inside an artery.

Arteries are the blood vessels that carry oxygen-rich blood from the heart to all parts of the body. Healthy arteries are normally flexible and smooth on the inside. However, plaque (deposits of cholesterol, calcium, and fibrous tissue) can build up on the inner walls of the arteries, a condition called atherosclerosis. The plaque can cause the arteries to harden, stiffen and narrow, reducing or completely blocking the flow of blood through them. This can result in arterial conditions such as peripheral artery disease (PAD) and coronary artery disease (CAD).

An atherectomy is a procedure to treat atherosclerosis and its associated conditions using a thin, long tube called a catheter which is attached to a device to remove plaque from the artery and restore normal blood flow.

Types of Atherectomy

There are 4 types of atherectomy based on the type of device used with the catheter to remove the plaque from the blood vessel.

• Directional atherectomy: A catheter with a sharp blade on the end is used to gently shave off the plaque.
• Rotational atherectomy: A catheter with a spinning cutting tip is used to grind the plaque into a powder that is then washed away into the bloodstream.
• Laser atherectomy: In this type, the catheter tip is supplied with a device that emits laser energy to vaporize plaque material.
• Orbital atherectomy: This type utilizes a high-speed rotational device similar to rotational atherectomy but with a tip that is slightly modified.

Indications

Atherectomy is indicated to treat narrowed arteries associated with PAD and CAD that cannot be treated with:

• Angioplasty and stenting: A procedure where a thin tube with a balloon and/or stent (a small mesh tube) is inserted through a large artery in the leg to widen the area of blockage.
• Bypass surgery: A procedure where the blood vessel is re-directed around the blockage.

Atherectomy is sometimes used as a complement to angioplasty and stenting where hardened plaque is first removed to an extent to allow the insertion of the balloon and stent, which are then expanded to widen the artery and improve the blood flow.

Preparation for Atherectomy

Preoperative preparation for atherectomy may involve the following steps:

• A thorough history and physical examination
• Routine blood work and imaging
• Refraining from blood thinners, aspirin, or NSAIDs
• Informing your doctor of any allergies to medications, anesthesia, or contrast dye
• Refraining from solids or liquids at least 8 hours prior to surgery
• Arranging for someone to drive you home after surgery
• Signing a consent form after the risks and benefits of the surgery have been explained

Surgical procedure

Atherectomy is performed under local anesthesia. A thin guide wire is threaded into the blocked artery with the help of a small needle that is inserted into a blood vessel in the groin area. This guides the catheter to the blockage, at which point a dye is injected into the artery, and X-rays are taken to view the path of the artery.

Your surgeon then inserts an atherectomy catheter attached with a blade, grinding bit, or laser filament at its tip through the guide wire to the narrowed part of the artery to scrape away the plaque. Your surgeon may pass the catheter several times to cut away major parts of the hardened plaque. A collecting chamber or suction system at the tip of the catheter removes the plaque particles as they are scraped off. Once the hardened plaque is removed, your surgeon inserts a stent, a tiny mesh tube, to support and keep the artery wall wide open, preventing it from narrowing again. Once the treatment is complete, the catheter is removed.

Postoperative care

Following the procedure, you are advised to lie flat for some time. If bleeding occurs from the insertion site, you need to have pressure applied to stop the bleeding. You may develop swelling, pain or bruising at the catheter insertion site. Medications are provided to address these. You will be asked to drink plenty of fluids to eliminate the dye injected into your body.

You should be able to go home the day after the surgery and can return to your normal activities in a day or two, but you should refrain from engaging in certain strenuous activities. Instructions on surgical site care and bathing will be provided to keep the insertion site clean and dry. Refrain from using a bathtub, hot tub, or pool until the puncture site is healed. A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

The possible risks and complications of an atherectomy may include:

• Bleeding
• Bruising
• Infection
• Re-blockage of the artery due to plaque formation
• Heart attack due to closure of the artery
• Damage or injury to the artery
• Embolization
• Adverse reaction to local anesthetic or contrast dye

Summary

Minimally invasive atherectomy surgery can provide significant relief from symptoms of atherosclerosis and its associated conditions. However, it is extremely important to follow a healthy lifestyle to ensure atherosclerosis does not recur.

Atherectomy can be used as an alternative to angioplasty for the treatment of peripheral artery disease and coronary artery disease. The procedure carries several benefits, including minimal pain, a shorter hospital stay, quick recovery time, and reduced risk of infection and blood loss.