Atherectomy devices are essential tools for treating calcified or fibrotic lesions in peripheral arteries, enhancing vessel compliance and facilitating effective revascularization.

Types of Atherectomy Devices

• Directional Atherectomy:
  • SilverHawk™ Plaque Excision System by Medtronic
  • Removes plaque via a rotating blade and collects it in a nosecone
  • Suitable for large vessels like the superficial femoral artery (SFA)
• Orbital Atherectomy:
  • Diamondback 360® Peripheral Orbital Atherectomy System by CSI
  • Eccentrically mounted diamond-coated crown sands plaque
  • Effective in calcified lesions
• Rotational Atherectomy:
  • Jetstream™ Atherectomy System by Boston Scientific
  • Features rotating blades and aspiration to remove debris
  • Useful for mixed morphologies including thrombus
• Laser Atherectomy:
  • Turbo-Elite™ Laser Atherectomy Catheter by Philips
  • Uses excimer laser technology to ablate plaque
  • Effective for in-stent restenosis and total occlusions

Bioresorbable stents provide temporary scaffolding to maintain vessel patency and gradually dissolve, potentially reducing long-term complications associated with permanent implants.

Key Features

• Made from materials like polylactic acid (PLA)
• Designed to resorb over 1-2 years
• Aim to restore natural vessel function

Available Devices

• Esprit™ Bioresorbable Vascular Scaffold by Abbott
  • Indicated for SFA lesions
  • Available in various diameters and lengths
  • Clinical trials ongoing to establish efficacy
• Magmaris® Resorbable Magnesium Scaffold by Biotronik
  • Constructed from magnesium alloy
  • Resorbs within 12 months
  • Limited availability pending further studies

Note: Bioresorbable stents are still under investigation for peripheral use and are not widely adopted in clinical practice yet.

Chronic Total Occlusions (CTOs) in peripheral arteries require specialized guidewires to navigate and cross the occluded segments safely.

Types of CTO Wires

• Astato® Guidewires by Asahi Intecc
  • High tip load for penetrating tough lesions
  • Available in various stiffness levels
  • Hydrophilic coating for enhanced trackability
• V-14™ ControlWire® Guidewire by Boston Scientific
  • 0.014" diameter with a supportive core
  • Radiopaque for better visualization
  • Hydrophilic tip for crossing occlusions
• Glidewire Advantage® Peripheral Guidewire by Terumo
  • Combines a stiff body with a flexible tip
  • Hydrophilic coating reduces friction
  • Available in 0.018" and 0.035" diameters

The Crosser® System by Bard Peripheral Vascular is designed to facilitate the endoluminal crossing of CTOs in peripheral arteries.

Key Features

• Utilizes high-frequency vibration to penetrate occlusions
• Compatible with 0.014" or 0.018" guidewires
• Available in lengths suitable for various peripheral vessels
• Can reduce the need for subintimal dissection

Procedure Overview

• Advance the Crosser® catheter over the guidewire to the CTO
• Activate the device to deliver mechanical energy
• Gently advance to cross the occlusion
• Once crossed, proceed with angioplasty and stenting as needed

Balloon angioplasty is a cornerstone of peripheral interventions, used to dilate stenotic or occluded vessels.

Types of Balloons

• Standard PTA Balloons:
  • Various sizes to match vessel diameter
  • Used for initial lesion dilation
  • Examples: Mustang® Balloon (Boston Scientific), Admiral® Xtreme (Medtronic)
• Drug-Coated Balloons (DCB):
  • Coated with antiproliferative drugs like paclitaxel
  • Reduce restenosis rates by inhibiting neointimal hyperplasia
  • Examples: Lutonix® DCB (BD), IN.PACT™ Admiral™ DCB (Medtronic)
• Scoring and Cutting Balloons:
  • Have a modified surface to score the plaque
  • Facilitate controlled vessel expansion
  • Examples: AngioSculpt® (Philips), Chocolate® PTA Balloon (Medtronic)

Manufacturers and Specifications

Key manufacturers offer a range of balloon sizes and lengths to accommodate different vessel anatomies:

• Boston Scientific
  • Mustang® PTA Balloon
    • Diameters: 2mm to 12mm
    • Lengths: 20mm to 220mm
    • High-rated burst pressures up to 20 atm
• Medtronic
  • IN.PACT™ Admiral™ DCB
    • Diameters: 4mm to 7mm
    • Lengths: 40mm to 150mm
    • Paclitaxel drug coating for sustained release
• BD (Bard)
  • Lutonix® 035 DCB
    • Diameters: 4mm to 7mm
    • Lengths: 40mm to 150mm
    • Designed for femoropopliteal arteries

Stenting in peripheral arteries helps maintain vessel patency post-angioplasty, with various types available depending on the lesion and vessel characteristics.

Types of Stents

• Self-Expanding Stents:
  • Made from nitinol, allowing flexibility and conformability
  • Examples: Supera® Peripheral Stent System (Abbott), Zilver® PTX® Stent (Cook Medical)
• Balloon-Expandable Stents:
  • Provide precise placement and high radial strength
  • Examples: Omnilink Elite® Stent System (Abbott), Express® LD Iliac Stent (Boston Scientific)
• Covered Stents (Stent Grafts):
  • Consist of a stent with a graft material covering
  • Useful for treating aneurysms or preventing embolization
  • Examples: Viabahn® Endoprosthesis (Gore), Fluency® Plus Stent Graft (BD)

Manufacturers and Specifications

• Abbott
  • Supera® Peripheral Stent System
    • Designed for SFA and proximal popliteal arteries
    • Diameters: 4mm to 7mm
    • Lengths: 20mm to 200mm
• Cook Medical
  • Zilver® PTX® Drug-Eluting Stent
    • Paclitaxel-coated self-expanding stent
    • Diameters: 5mm to 7mm
    • Lengths: 40mm to 140mm
• Gore
  • Viabahn® Endoprosthesis
    • Covered stent with heparin-bonded surface
    • Diameters: 5mm to 13mm
    • Lengths: 25mm to 250mm

Advanced imaging techniques enhance the safety and efficacy of peripheral interventions by providing detailed visualization of vessel anatomy.

Intravascular Ultrasound (IVUS)

• Provides cross-sectional images of the vessel
• Helps in assessing plaque morphology and vessel size
• Devices:
  • Philips Volcano Visions® PV .035 Digital IVUS Catheter
  • Boston Scientific's Peripheral IVUS Catheters

Optical Coherence Tomography (OCT)

• High-resolution imaging modality
• Limited use in peripheral vessels due to larger diameters and need for blood clearance

Angiography

• Standard imaging technique using contrast injection
• Provides real-time visualization of blood flow and vessel patency

Embolic protection devices are used to capture and remove debris that may dislodge during interventions, reducing the risk of distal embolization.

Types of Devices

• Filter-Based Systems:
  • SpiderFX™ Embolic Protection Device by Medtronic
  • FilterWire EZ™ System by Boston Scientific
  • Capture debris in a distal filter during intervention
• Occlusion Balloon Systems:
  • GuardWire™ Temporary Occlusion System by Medtronic
  • Block blood flow during the procedure, with aspiration of debris before deflating the balloon

Indications

• Carotid artery stenting
• Saphenous vein graft interventions
• High-risk peripheral interventions where embolization could have significant consequences

Thrombectomy devices are used to remove thrombus from peripheral vessels, restoring blood flow in cases of acute limb ischemia.

Types of Thrombectomy Devices

• Mechanical Thrombectomy:
  • Trellis™ Peripheral Infusion System by Covidien
  • AngioJet™ Thrombectomy System by Boston Scientific
  • Uses mechanical action to break up and remove thrombus
• Aspiration Thrombectomy:
  • Penumbra Indigo® System by Penumbra Inc.
  • Utilizes vacuum aspiration to remove clot material

Indications

• Acute limb ischemia due to thrombotic occlusion
• Thrombosed dialysis grafts or fistulas
• Pulmonary embolism interventions (specific devices)

EVAR is a minimally invasive procedure used to treat abdominal aortic aneurysms (AAA) by placing a stent graft within the aneurysm to exclude it from blood flow, reducing the risk of rupture.

Procedure Overview

• Access is typically gained via the femoral arteries.
• Guidewires and catheters are used to navigate to the abdominal aorta.
• A stent graft is deployed to line the aorta and exclude the aneurysm sac.
• Imaging is used to confirm proper placement and seal.

Devices and Manufacturers

• Medtronic
  • Endurant™ II/IIs Stent Graft System
    • Designed for various anatomies, including challenging necks.
    • Available in a range of diameters and lengths.
• Cook Medical
  • Zenith® Flex AAA Endovascular Graft
    • Features a modular design with suprarenal fixation.
    • Wide range of sizes for patient-specific customization.
• Gore
  • GORE® EXCLUDER® AAA Endoprosthesis
    • Known for its low-profile delivery system.
    • Offers options for both straight and bifurcated configurations.

Considerations

• Patient selection is crucial; anatomical suitability must be assessed.
• Regular follow-up imaging is required to monitor for endoleaks or graft migration.
• Advantages include reduced recovery time and lower morbidity compared to open surgery.

Carotid artery stenting is an alternative to carotid endarterectomy for treating carotid artery stenosis, reducing the risk of stroke by improving blood flow to the brain.

Procedure Overview

• Access is typically via the femoral artery.
• An embolic protection device is often used to capture dislodged plaque.
• A balloon catheter is used to pre-dilate the stenosis.
• A stent is deployed to scaffold the artery and maintain patency.
• Post-dilation may be performed to optimize stent apposition.

Devices and Manufacturers

• Boston Scientific
  • Carotid WALLSTENT® Monorail® Endoprosthesis
    • Self-expanding stent with high radial force.
    • Available in various diameters and lengths.
  • FilterWire EZ™ Embolic Protection System
    • Distal filter device to capture embolic debris.
• Abbott Vascular
  • ACCULINK™ Carotid Stent System
    • Designed for flexibility and conformability.
  • ACCUNET™ Embolic Protection System
    • Offers proximal protection during the procedure.

Considerations

• Patient selection should consider comorbidities and anatomical factors.
• Embolic protection devices are essential to minimize the risk of stroke during the procedure.
• Experience and expertise of the operator contribute to procedural success.

Pulmonary embolectomy is a percutaneous procedure to remove large or life-threatening blood clots from the pulmonary arteries in patients with pulmonary embolism (PE).

Procedure Overview

• Access is usually via the femoral or jugular vein.
• Catheters are advanced into the pulmonary arteries under fluoroscopic guidance.
• Thrombectomy devices are used to aspirate or fragment the thrombus.
• Hemodynamic parameters are monitored throughout the procedure.

Devices and Manufacturers

• Inari Medical
  • FlowTriever® System
    • Mechanical thrombectomy device specifically designed for PE.
    • Utilizes large-bore catheters for clot retrieval without thrombolytics.
• Penumbra
  • Indigo® Aspiration System with Lightning®
    • Vacuum aspiration system with intelligent clot detection technology.
    • Can be used in peripheral and pulmonary vasculature.

Considerations

• Ideal for patients with contraindications to thrombolytics or high bleeding risk.
• Requires coordination with a multidisciplinary PE response team.
• Post-procedural monitoring in an intensive care setting may be necessary.

The LimFlow procedure is a novel endovascular therapy aimed at treating end-stage critical limb-threatening ischemia (CLTI) by creating a venous arterialization to restore blood flow to the foot.

Procedure Overview

• Access is obtained in both arterial and venous systems.
• An arteriovenous (AV) crossing is created in the proximal lower leg.
• Specialized catheters and ultrasound guidance are used to align and connect the artery and vein.
• The venous system below the AV anastomosis is stented to facilitate arterial flow to the foot.
• Valves in the veins may be disrupted to allow for forward flow.

Devices and Manufacturers

• LimFlow SA
  • LimFlow System
    • Includes arterial and venous catheters, ultrasound-guided crossing tools, and dedicated stents.
    • Designed specifically for percutaneous deep vein arterialization (pDVA).

Considerations

• Intended for patients with no conventional revascularization options.
• Aims to promote wound healing and limb salvage.
• Requires careful patient selection and post-procedure wound care.
• Clinical trials are ongoing to establish long-term outcomes.