- What are the indications for atertectomy?
- What are the potential complications?
- What does the preparation for the treatment look like?
- What are the effects of atherectomy?
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Aterectomy belongs to the group of minimally invasive percutaneous procedures. Its purpose is to remove or reduce the volume of atherosclerotic plaques that narrow the lumen of the vessels and restrict blood flow. What are the indications for atherectomy and how is the procedure performed? What are the complications?
Aterectomyis an endovascular (endovascular) procedure as the entire procedure takes place in the lumen of the vessel. The only violation of tissue continuity is the percutaneous vascular access. The puncture site is most often the femoral artery. This part of the procedure uses local anesthesia. A catheter is inserted into the artery through which the atherects are placed in the immediate vicinity of the target atherosclerotic plaque. Proper placement of the device is possible thanks to the fluoroscopic inspection of the X-ray machine. Imaging of vascular stenosis is possible thanks to a simultaneous examination with the use of a contrast agent - angiography. Due to the mechanism of atherosclerotic plaque removal, we can distinguish several types of arterectomy. The most important of them are:
- Directional cutting atherectomy(DCA - directional coronary atherectomy) - removal of atherosclerotic plaque is possible thanks to the cutting element moving along the long axis of the vessel, which gradually "cuts" it into smaller fragments accumulating in a special chamber of the device.
- High-speed atherectomy(HSRA); rotablation - in this case, the breaking of the atherosclerotic plaque is carried out using a special, rotating head. Driven by an air turbine, it "drills" through the constrictions. The surface of the head is equipped with diamond microparticles. Rotablation is mainly used in the case of hard, highly calcified plaques located on a long distance. Its execution may precede the stent insertion. An indication may also be a re-stenosis of the so-called restenosis, i.e. restenosis related to the hypertrophy of the inner membrane of the artery in response to endothelial damage through a previously implanted stent.
- Laser aterectomy- uses a high-energy, monochrome light beam to dissolve (vaporize) the plaque without damaging the surrounding tissue.
- Orbital aterectomy- one of the newestmethods somewhat similar to rotablation; the device covered with a diamond rim rotates in the lumen of the vessel with high frequency circular movements (in an orbit) and "rubs" the atherosclerotic plaque.
Significant progress is being made with the instruments used in atherectomy. The next generations of devices allow to increase the effectiveness, broaden the indications and reduce the risk of complications by reducing the pressure trauma to the vessel and improving the methods of draining the remains of damaged plaques.
What are the indications for atertectomy?
Aterectomy is indicated primarily in the group of peripheral arterial diseases, which are most often caused by atherosclerosis. The flagship example is chronic lower limb ischemia caused by the narrowing of the arteries by atherosclerotic plaques. Blocking the flow causes ischemia, the typical symptom of which is pain in the form of the so-called intermittent claudication (pain in the lower limb associated with exercise, which disappears after a short rest). In advanced stages, ischemia of peripheral tissues may cause ulceration and necrotic changes.
Atherectomy procedures have also found their place in interventional cardiology. They can be used in ischemic heart disease as an alternative method of clearing the coronary arteries. However, they are not performed routinely in this indication. Currently, the standard is PTCA (percutaneous trans luminal coronary angiplasty), i.e. percutaneous coronary angioplasty, most often associated with the implantation of the so-called stent.
The indications for atherectomy are considered individually. Its use depends on factors such as the structure and hardness of the lamina (heavily or slightly calcified), the degree and length of the constriction, and the location.
What are the potential complications?
Like any medical procedure, atherectomy carries a certain risk of complications. It is worth mentioning that in the case of endovascular procedures it is small. Among the complications we can distinguish:
- related to the injection site - hematoma, pseudoaneurysm, arteriovenous fistula;
- perforation of the examined vessel, its dissection and the formation of pseudoaneurysm (as a result of blood extravasation);
- arterial embolism distal to the site of atherectomy stenosis; fragments of the plaque to be removed can be material blocking the lumen of the vessel;
In the case of atherectomy performed within the coronary vessels, there is a negligible (not exceeding 0.5%) risk of serious arrhythmias that may be fatal.
As mentionedabove, in the case of atherectomy, simultaneous angiography is performed to visualize the location and shape of the stricture, which allows for the selection of an appropriate treatment method. This test involves administering an iodine-based contrast agent to the patient. The related complications include:
- allergic reactions to iodine (up to and including anaphylactic shock) - a history of severe, documented anaphylactic reaction to iodine is an absolute contraindication to the administration of an ionic contrast agent (if you know about the presence of such an allergy, be sure to inform your doctor before this type of examination! ); life-threatening reactions are very rare;
- contrast nephropathy - acute kidney damage under the influence of a contrast agent; rare; more common in patients with risk factors such as older age, renal failure, diabetes, heart failure or the use of nephrotoxic drugs; there are standards of periprocedural management to prevent this complication.
What does the preparation for the treatment look like?
Basic elements of patient preparation for the procedure:
- collecting medical history and documentation;
- laboratory tests to diagnose possible deviations and distinguish patients from the risk group of complications, e.g. kidney function testing as part of the prevention of contrast nephropathy;
- the patient should be on an empty stomach (at least 8-10 hours from the last meal);
- adequate hydration;
- only on the recommendation of a doctor: possibly discontinuation of nephrotoxic and anticoagulant drugs;
- before the procedure: thorough body wash and hair removal in the area of the injection site;
- supply of medications aimed at calming and reducing the patient's pain.
What are the effects of atherectomy?
Aterectomy, like angioplasty (or these methods in combination), gives good treatment results and is very effective in restoring arteries. Neither of these methods will have long-term effect unless surgical treatment is followed by lifestyle modification and mitigation of atherosclerosis risk factors (mainly smoking). Otherwise, the atherosclerosis may recur and continue to cause ischemic symptoms.