Ducksoo

Kim,

Richard

MD

E. Kuntz,

Bertrand

#{149} Laurie

MD

W. Schlam,

MD

MD #{149}David H. Porter, MD Kent, MD Jeffrey B. Siegel, MD J. Skillman, MD

and

Meier

84%,

survival

and

difference

analysis

in 2- to 3-year

no

patency

rate

increases

size,

(DA) revessel

in contrast

face, resulting in decreased resistance to flow and less stimulus for thrombus formation. Elastic recoil is reduced after atherectomy, because the lumen is widened without stretching of the arterial wall. Moreover, in ec-

centric plaque

stenoses, protrudes

one wall, be superior

a.

of the

in which asymmetric into the lumen from

directed atherectomy to PTA. With PTA,

fractured,

ure

resulting

may the

of PTA.

in technical

Atherectomy

Recent

ization

mented

PTA

studies that

for the

DA

(7-11)

have

is a safe

treatment

mal

stenosis

residual

to

of peripheral

neous (DA

MA 02215, and Department (D.E.O.). From May 8; revision

LEG., D.H.P., D.E.O., J.B.S., B.W.S.), Cardiology Hospital, Harvard Medical School, 330 Brookline

of Radiology, the 1990 received

RSNA

January

Tel Aviv-Sourasky scientific

assembly.

24, 1992; accepted

Medical

Center,

Received

February

sites.

high

early

acceptable

AND

We retrospectively

alternative

(b) Postmini-

pa-

compli-

patency of peripheral

METHODS

Patients

docu-

The

Ave. Boston,

an

MATERIALS

reviewed

85 percuta-

reconstructive vascular procedures alone, n = 68; DA with PTA, n = 17)

to December

Departments of Radiology (D.K., Surgery (K.C.K., J.J.S.), Beth Israel

with

and

artery.

vascular disease, however, are unknown. We present our 4-year experience with DA and compare our results with those of published PTA series.

in 77 patients

I From the (R.E.K.), and

at both

disease, rates

tibial

demonstrates

cation rate. The long-term rates after DA treatment

at

183:773-778

Hospital, Tel Aviv, Israel 1991; revision requested reprint requests to D.K. C RSNA, 1992

posterior

angiogram

tency

the eccentric plaque, on the other hand, succeeds by removing plaque without dilating the normal wall. Although routine PTA may be used successfully to treat an eccentric stenosis by means of overdilation, this practice is associated with a higher probability of dissection and acute closure (4-6).

terms: Arteries, extremities, 92.721 Arteries, iliac, 98.721 #{149} Arteries, stenosis or obstruction, 92.721, 98.721 #{149} Arteries, surgery, 92.451, 98.451 #{149} Arteries, transluminal angioplasty, 92.128, 98.128 #{149}Catheters and catheter-

proximal

atherectomy

vascular

fail-

directed

b.

Figure 1. (a) Angiogram depicts short tubular (arrowhead) and weblike (arrow) stenoses

wall without disease is sometimes stretched and the hard plaque is not

Index

1992;

lumen

the

of the vessel and provide inadequate opposition to the residual elastic recoil of the vessel, compromising patency. A potential advantage of DA is its creation of a smooth luminal sur-

on the basis of lesion location or presence of calcification, eccentricity, or ulceration. Diabetic patients, however, had a higher restenosis rate than did patients who were not diabetic (P < .03).

Radiology

atherectomy plaque from

cause of underdilation or intimal dissection may lead to acute thrombosis

Kaplan-

revealed

MD

to percutaneous transluminal angioplasty (PTA), in which balloon inflation results in plaque fracture, arterial wall stretching, and “controlled” intimal dissection, initiating the cycle of injury, healing, and remodeling (1-3). With PTA, inhibited blood flow be-

plethysmogra-

respectively.

IRECTIONAL

moves

phy, and clinical examination. The mean follow-up period was 13.5 months. The probability of 1-, 2-, and 3-year patency for lesions treated with atherectomy alone was 92%, 84%,

E. Orron,

Atherectomy:

D

Directional atherectomy alone or with supplemental percutaneous transluminal angioplasty was used to treat peripheral vascular lesions in 77 patients (85 procedures). Lesions involved 17 iliac arteries, 45 infrainguinal arteries, and 23 laser extremity vein bypass grafts. Technical success, defined as reduction of stenosis diameter to 30% or less of the normal vessel diameter, was achieved in 78 of 85 (92%) cases. The complication rate was 21% (18 of 85 procedures). Most complications were minor and were related to puncture sites. Patients underwent noninvasive follow-up studies, including measurement of ankle-brachial index and pressures,

#{149}

‘

Peripheral Directional 4-year Experience’

segmental

Dan

E. Gianturco,

Craig #{149} John

#{149} K.

48 men

treated

from

November

1987

1991. and

29 women

ranged

46 to 90 (mean, tion, 43 patients

68) years old. At presenta(56%) had claudication,

Abbreviations: minal angioplasty,

PTA

from 10

Ichilov

February

3. Address

4, DA

=

percutaneous directional

transluatherec-

tomy. 773

Figure

2. (a) Distal abdominal tory of claudication in the right iliac iliac

arteries artery

4-5-cm

on the segments,

linear

promise,

right side. (b) After 90-hour infusion reestablished patency of the right

defect

which

(c) Angiogram demonstrates

aortogram obtained in a 76-year-old man with 4-month hisleg and buttock shows occlusion of the common and external

was

(arrows)

in the right

thought

to be dissection

obtained the patent

external

of urokinase iliac arteries

iliac artery,

related

with

into the is revealed.

substantial

to manipulations

after removal of the linear defects with right iliac artery to have no intraluminal

occluded There

right is a

luminal

of the

com-

infusion

catheter.

an 11-F atherectomy defects or residual

catheter stenoses

of concern. Artifactual short curvilinear area of hyperlucency (arrows) over the right external iliac artery results from the superimposed bone of the pelvic brim. (d) Excised tissues. Histologic examination of these revealed atheromatous plaques and organized thrombi. Measure-

ment

(13%) had healing

and

rest

pain,

ulcers,

one

(1%)

ultrasound tomatic

16 (21%)

two

had

in vein

identified

(US) patients

(3%)

had

had

non-

atherectomy. tion of one,

gangrene,

cellulitis. Stenosis was bypass grafts at duplex scanning in five asymp-

U) intravenously

(6%).

ately

Forty-one

troducer

ceived

(53%)

had hypertension and 25 (32%) had diabetes meffitus as associated risk factors. Forty-seven patients (61 %) were smokers.

tomy Three

at a second site cases involved

tomy

at the same

lesions

(88%)

were

in length,

4 to 8 cm. One in length.

Two

and Two

same

limb. atherec-

Seventy-five

short

from

2 cm) also were with supplemental (22%). DA was

in the repeated

site.

3 cm

stenoses

seven short

treated.

less

stenoses

stenosis

ranged

measured

occlusions DA

than

insertion

patients

of the

had

intraarterially

to atherectomy

was

during

use

(1 and combined

of the

extraction atherectomy deduring a thrombolysis procedure 2), and one during PTA (Fig 3).

Most

patients

the night

before

Radiology

#{149}

Therapy received

and

325 mg the morning

of aspirin

of

medication

in-

re-

d.

immedi(Fig

was

least 6 months

in most

4). One

spasm anti-

continued

for at

patients.

in the proximal thigh in an antegrade fashion. DA requires an introducer sheath of the same size or I F larger than the catheter. The size of the atherectomy catheter is chosen so that the working diameter is

equal Technique Peripheral DA catheters (Simpson Peripheral AtheroCath; Peripheral Systems Mountain

View,

Calif)

size from 6 to 1 1 F were used. nique of Simpson atherectomy

well described 20

PTA in 17 patients to treat four dissec-

used

occurred

Pharmacologic

774

urokinase prior

after

Four

patient received urokinase during the procedure for treatment of thrombosis of a distal branch. Nifedipine and nitroglycerin

Group,

of 85

transluminal vice, one

(Fig

sheath.

platelet

lesions treated included the iliac (n = 17), femoropopliteal (n = 42), and posterior tibial (,i = 3) arteries (Fig 1). Twenty-three of the cases involved femoropopliteal or femorotibial vein bypass grafts. Five patients underwent atherecArterial

tions:

All patients, with the excepreceived heparin (3,000-5,000

were used to prevent or treat vessel when indicated. After atherectomy,

Lesions

cm

:=:

is in centimeters.

elsewhere

the atherectomy

low cutting

device

chamber

ranging

(7,12-14). consists

with

in

The techhas been

Briefly,

of a hol-

a window

along

one side. Inflation of a balloon opposite the window pushes the window against

mural shaves

plaque.

The rapidly

off plaque

dow,

and forces

lection

chamber.

A retrograde

rotating

cutter

protruding into the winit into a hollow distal colapproach

from

the

ipsilat-

to or slightly

greater

than

the diam-

eter of an adjacent normal portion of the artery, with correction for angiography magnification. The working diameter of the catheter equals the diameter of the cutter housing plus the diameter of the

inflated correct

support working

balloon. diameter

because

undersizing

residual

stenosis

may

(8,15).

Criteria

for Technical

We defined of the in one

technical

of less normal view.

leave

and increase

restenosis

stenosis

Selection of the is important,

than

vessel Technical

Success success

30%

excessive

the risk of

of the

lumen, failure

as residual diameter

as measured was defined

eral common femoral artery is used for treatment of iliac lesions, and an ante-

as inability to cross the lesion or failure to reduce residual stenosis to less than 30%.

grade

Patients without improvement at clinical or noninvasive follow-up examination were recorded as clinical failures.

ficial Vein

femoral femoral, bypass

approach

is used

popliteal, and tibial grafts are punctured

for superlesions. directly

June

1992

Late

Results

Follow-up

ranged mean

evaluation

intervals

from 1 to 48 months, with of 13.5 months. Our purpose

a

was to report our results with DA and compare them with results of PTA. To determine the effects of DA alone, we separated the patients who underwent DA from those who underwent

combined DA and PTA. Of the 68 patients who underwent only atherectomy,

two

died

follow-up had

and

eight

evaluation.

restenosis

were

Five

lost

to

patients

documented

angio-

graphically (Fig 8). Restenosis occurred in the iliac artery in one case

(at 7 months), ral artery months,

bypass

graft in two respectively). had clinical of recurrent

months, patients dence

treated a.

b. 3. (a) Angiogram obtained in a 60-year-old teal artery (arrow). (b) After PTA, a focal intraluminal probably as a result of dissection. (c) After resection tomy catheter, only a small residual defect remains.

c. woman shows severe stenosis of the poplifilling defect (arrow) has developed, of the dissected intima with a 7-F atherec-

Figure

Follow-up All patients

clinical

were

evaluated

examination,

by means

ankle-brachial

of

index,

segmental pressures, and plethysmography immediately before and after atherectomy, intervals

after

with

3 and thereafter.

treated

6 months, and Evaluation

bypass

grafts

at 6-month of patients

also included

color flow duplex US examination. Follow-up angiography was performed in cases of recurrent clinical symptoms, decrease in the ankle-brachial index of 0.15 or greater, or a twofold increase in peak systolic

velocity

as determined

pier spectral

analysis

Statistical

Analysis

Clinical,

graphic fluence

with

Dop-

(16).

demographic,

variables were tested on long-term patency

was

0.20.

There

lesions. had

Four

of these

clinical

to be significant.

RESULTS

of poor

Although complications

Technical success was achieved 92% (78 of 85) of cases. The mean nosis measured on cut-film angio-

3

distal

in ste-

In the

cases (at 11 and 17 Two additional or duplex US evidisease in the

51 remaining

pa-

tients, the mean ankle-brachial has been maintained without

crease

of 0.15 or greater,

toms

and

physical

index de-

and

symp-

examination

have

in symp-

runoff,

with

reduced

(Fig

6; Tables

long-term 1, 2)

term patency was der, hypertension,

(P

patency =

not affected or smoking;

calcified,

or ulcerated

pearance;

or lesion

location

frainguinal, (Table 1).

rates

Long-

.03).

eccentric,

or vein

to pre-

the

prevalence was high,

of overall occurring in

(21%), most They included

and moderate hematomas small branch occlusion distal embolization (n

was

one

case

of

by genap-

(iliac,

bypass

in-

grafts)

DISCUSSION

(n =

=

have ranged from 90% to 100%. Recently, von Polnitz et al (10) reported technical success in 90% (54 of 60) of atherectomy patients, with clinical

mi-

patency

=

tients

who

were

followed

1),

year.

Graor

and

Whitlow

(n 3)

of retro-

bleeding that required and there were three

puncture-site pseudoaneurysms that required surgical repair. Two of the complications occurred in one procedure.

spectively, for lesions treated with atherectomy alone (n = 68) and 78%, 67%, and 57%, respectively, for lesions treated with atherectomy and PTA (n = 17) (Fig 5, Table 2) (P = .21). Among patients treated with atherectomy alone, diabetes was associated

In this study, the technical success rate for atherectomy was 92%, which is comparable to reported rates, which

18 of 85 procedures these were minor.

peritoneal transfusion,

Results

Number

patients

amputation.

(Fig 7). There

#{149}

seven

improvement

nor 11), and

183

or

for their inby using

2), on the basis of 78 technically successful cases (19). A P value of .05 or less

Volume

restenoses

the same hospitalfailure occurred in

toms. All technical failures occurred in our early experience. In two cases of superficial femoral atherectomy, technical success was achieved, but there was insufficient clinical improvement,

Table

Technical

no

71 % before mean imindex

seven cases because of residual stenosis greater than 30%; this occurred in three femoropoliteal and four iliac

Complications

considered

were

occlusions during ization. Technical

log-rank statistics for dichotomous vanables and Cox proportional hazards analysis for continuous variables (Table 1) (17,18). Probability of freedom from restenosis (patency) was determined by using the Kaplan-Meier technique (Figs 5, 6;

was

reduced from after DA. The in ankle-brachial

was

DA to 14% provement

vent

angio-

limb.

femo-

(at 1 and 12 and in a vein

suggested restenosis. The probability of 1-, 2- and 3-year patency was 92%, 84%, and 84%, re-

because and

superficial

not

grams

Evaluation

in the

in two cases respectively),

in 72%

a 30-day

simple shorter plicated segment patients

tery means

(18 of 25) of the

patency

rate

lesions (stenoses than 5 cm) and lesions (length greater than with superficial

stenosis

or occlusion

of atherectomy.

up

pa-

for

1

(9) reported of 100%

for

or occlusions 93% for cornof occluded 5 cm) in 112 femoral ar-

treated After

by

a mean

Radiology

#{149} 775

follow-up

time

of 12 months,

the

femoropopliteal mately 54%

patency rate was 93% for simple lesions and 84% for complicated le-

Our

sions.

In a well-controlled study

for iliac and for

prospective

by Johnston

et al (20),

2- and

3-year

patency

rates

probability

lesions was femoropopliteal

86% at 2 and rates achieved years compare

the

2-year patency rates for common iliac and external iliac lesions approached 68% and 63%, respectively, whereas the

expected

reported

for

for

shows

that

pendent

lesions were approxi50%, respectively.

and

of patency

83%

probability mellitus

3 years. The patency with DA for up to 3 favorably with those PTA.

Statistical of DA

the

not

location

various

1, 2).

Vein brointimal

bypass graft hyperplasia

analyzed

on expected

of patency, a significant

had

in our

factors

outcome

Tables

tant

analysis was

Of

to determine

at 2 years, lesions, was

success

on lesion

study.

only diabetes effect (Fig

stenoses are

to conventional

6;

with fioften resis-

PTA

(21-23).

de-

Table

1

of Selected

Association

Angiographic from Restenosis

Variables

Clinical with

and Freedom

Variable

P

Diabetes .

.03

Sex

.79

Hypertension

.60

Smoking Eccentric Calcified Ulcerated Lesion Balloon

.35 .97 .99 .10

appearance appearance appearance location inflation

.26 .21

Table 2 Effect of Diabetes and Vessel Location on Probability of Freedom from Restenosis after Atherectomy

a. Figure

4.

artery

(arrow)

C.

(a) Angiogram

progressed

in an 80-year-old

to lower

thrombolysis demonstrated.

nosis.

shows

short

segmental

woman

with

leg ischemia.

(b) After

with 80,000 U of urokinase, (c) Postatherectomy study

Histologic

examination

occlusion blue

toe

syndrome

recanalization moderate reveals

of the specimen

of the distal of the femoral

eccentric restoration

showed

superficial

of 1-month

artery

underlying of the lumen

atherosclerotic

femoral

duration,

which

by means

of

stenosis (arrow) and no residual

is

plaque

with

Duration

of Patency (mo)

Variable

12

24

36

Diabetes No diabetes Vein bypass

83 92

46 87

46 87

graft Iliac artery Femoropopliteal artery

92

79

79

83

83

IDA

94

86

86

Overall

92

84

84

Note-Numbers

are percentages

the expected probability sufficient data available.

ste-

thrombus.

reflecting

of patency.

IDA

=

in-

1-

>.

U C

Ci C .75

a)

-

.75

-

.5

-

.25

-

.1-’

Co 0.

4-, Co

0. .4-

.4-

0

.5

0 -

4-,

>.

.,1

4-,

‘-I -‘-I

CO

-r1

.25

CO

.0

-

0 0

C-

0

C0

0-

0-

I

c

12

18

24

30

36

42

0

49

I

I

6

12

I

18

776

Radiology

#{149}

I

30

I

36

I

I

42

48

months

months 5. Figures 5, 6. (5) Results of atherectomy tients (curve 0) versus those in diabetic

I

24

6. without patients

PTA (curve (curve 1) (P

=

1) and with .03).

PTA (curve

2) (P

=

.21).

(6) Results

of atherectomy

in nondiabetic

June

pa-

1992

Laissy results

et al (24) recently reported of PTA in 13 grafts. Two

10 percutaneous

procedures

in disruption

of the

graft,

diate

repair

was

surgical

Atherectomy,

through

hyperplastic intima, may be a more effective method to treat vein graft stenosis. In our study with graft DA,

the of the

resulted and

imme-

required. removal

of the

there

were

tions,

including

puncture

only site

minor

complica-

a hematoma

two

at the

and

a clinically

insignifi-

cant

embolization.

The

technical

suc-

cess rate was 100%. The expected probability of patency of vein bypass grafts was 79% at 2 and 3 years after atherectomy.

Complications related tomy in our series were and loss.

did not result Complications

in three

cases

repair).

The

to atherecmanageable

in death required

or limb surgery

(for pseudoaneurysm majority

of complications

were hematomas, presumably related to the larger arterial sheaths (7-12 F). Transfusion was required in only one patient (retroperitoneal hematoma). There were three embolizations associated with SA. One of the embolizations represented an escaped plaque fragment that was noticed on a postatherectomy angiogram. This was

treated by reintroducing the tomy catheter and successfully

atherecre-

trieving the fragment by using standard atherectomy technique (Fig 7).

One of the embolizations was treated with urokinase. The third one, as mentioned, occurred during graft DA and was clinically insignificant and required no treatment. Other reported complications

following

include

local

surgical

intervention

embolization sure during

a.

b.

Figure

7.

tomy

(a) Femoral

of a stenosis

(arrows)

in the

angiogram

in the middle proximal

obtained

portion

superficial

in a 70-year-old

man

of the superficial

femoral

artery,

immediately

femoral

as a result

artery

after

shows

of escape

of an

atherec-

a filling excised

defect

athero-

matous retrieval tion

fragment from the cutter housing during removal of the atherectomy catheter. (b) After of the fragment during a second pass with the atherectomy catheter, digital subtracangiography confirms no residual stenosis of concern. There was no evidence of distal

embolization.

atherectomy

dissections

not

requiring

(8,9,25),

(8,10), and the hospital

distal

abrupt dostay (8).

In our early experience, we had seven technical failures secondary to incomplete removal of material, resuiting in a greater than 30% residual stenosis. This was due mainly to use of the first-generation atherectomy catheter, which had a relatively small working diameter and no extended

collection duction

chamber. With the introof the extended collection

chamber

and

wire” larger

of technical tially reduced.

diameter the

the

new

“over-the-

atherectomy catheter working diameter),

failures has been substanIn addition, the larger

of the

new

(with the number

support

“over-the-wire”

balloon

on

device

in-

creases the working diameter relative to the catheter shaft size, allowing use of smaller sheaths, and may reduce the incidence of hematomas and pseudoaneurysms.

There are some drawbacks to DA. Procedure time is longer than that with PTA. We found that once the learning curve for performing atherectomy

had

atherectomy

procedure

mately a.

b.

Figure

8.

(a) Angiogram

severe

stenosis

row) is evident stenosis

1_1..__

at the

1Q

(arrow)

obtained

of the distal

after atherectomy. previous

#{163}

atherectomy

c. in a 74-year-old

superficial

(c) Five-month site

(arrow).

woman

femoral

artery.

follow-up

shows

a short

(b) Mild

angiogram

segmental

residual

shows

stenosis

smooth

irregular

(an-

re-

20 minutes

corresponding the Simpson more balloon vessels

been

PTA

took

an

approxi-

longer than procedure.

atherectomy

expensive catheter, are more

completed, the Also,

catheter

than an angioplasty and tortuous iliac difficult to negotiate

is

with the stiffer Simpson catheter (26). The new over-the-wire atherectomy catheter may help with these obstades. An over-the-bifurcation contralateral approach has not been feasible due to the stiffness of the cutter housing. This precludes DA of common femoral or proximal superficial femoral artery lesions. Catheter improvements and use of the retrograde popliteal approach for access are p05sible future remedies for these problems. Presently, our group favors DA over PTA for treatment of short stenoses

in the

infrainguinal

arteries

and

1.

2.

3.

ies.

DA

has

been

shown

to be

effective

4.

warrant

continued

long-term

of DA and prospective randomized trials for accurate comparison DA and PTA. U Acknowledgments: tine Crotty, RN,

forming

meticulous

and

The authors Francis Sousa,

noninvasive

follow-up

7.

9.

10.

11.

eval12.

15.

artery disease?-a assessment. J Am Coil

Cardiol 1989; 13:969-987. Simpfendorfer C, Belardij, Bellamy C, et aL Frequency, management and follow-up of patients with acute coronary ocafter

Kosmider

percutaneous

M, Amiel

influence

the

1988;

Maynar

61:96G-1OIG.

M, Reyes

AmJ

Cardiol

M, Gaspard

1987;

P, Didier

outcome

of translumi1983; 67:497-

T, Selmon

MR,

Robertson

Kuffer C, Spengel FA, Hansen R, et al. Simpson’s atherectomy of the peripheral arteries: early results and foilow-up. ROFO 1990; 1553:6-7. Schwarten DE, Katzen BT, Simpson JB, WB.

taneous AJR 1988;

Simpson

transluminal

catheter

removal

for percu-

V, et al.

Per-

as an alternative

Early detection of saphenous vein arterial bypass graft stenosis by color-assisted du-

plex sonography: 17.

18.

19.

a prospective

1990; 154:857-861. Coldman AJ, Elwood

data. Can Med

1071. Hokins ates:

B.

A.

Survival

Cox models.

22.

23.

24.

25.

sur-

1979; 121:1065-

analysis

with covariCalif:

BMDP

angioplasty.

JVIR

1990;

Johnston

KW,

Rae

M, Hogg.Johnston

et al.

Five-year percutaneous

results

of a prospective study transluminal angioplasty.

of

Ann Surg 1987; 206:403-413. Castaneda-Zuniga WR, Formanek A, Tadavarthy M, et al. The mechanism of balloon angioplasty. Radiology 1980; 135:565571. ThompsonJF, McShane MD, Gazzard V, et aL Limitations of percutaneous transluminal angioplasty in the treatment of femorodistal graft stenoses. Ear J Vasc Surg 1989; 3:209-211. Wilms G, Baert AL, Nevelsteen A, et al. Balloon angioplasty of venous structures. J Belge Radiol 1989; 72:273-277. Laissy ll’ Peillon C, Clavier E, et aL Transluminal angioplasty of failing infrainguinal arterialby-pass grafts: Initial and long-term Intervent

results Radiol

Maynar

M, Cabrera

terial

26.

Examining

AssocJ

Berkeley,

ous transluminal 1:5-15.

21.

AJR

Software, 1983; 576-594. of Practice Committee of the of Cardiovascular and IntervenRadiology. Guidelines for percutane-

tional

20.

JM.

study.

Statistical Standards Society

GC,

Braden L, SimpsonjS. Directional atherectomy: new approaches for treatment of obstructive coronary and peripheral vascular disease. Circulation 1990; 81(suppl 3):1V79-1V91. Graor RA, Whitlow PL. Transluminal atherectomy for occlusive peripheral vascular disease. J Am Coil Cardiol 1990; 15: 1551-1558. von Polnitz A, Nerlich A, Bergen H, Hoffing B. Percutaneous peripheral atherectomy: angiographic and clinical follow-up of 60 patients. J Am Coil Cardiol 1990; 15:682-

R, Cabrera

atherectomy

treatment for postangioplasty obstructive intimal flaps. Radiology 1989; 170:10291031. Maynar M, Reyes R, Cabrera V, et aL Percutaneous atherectomy with Simpson atherectomy device in the management of arterial stenosis. Semin Intervent Radiol 1988; 5:247-255. Polak JF, Donaldson MC, Dobkin GR, et aL

vival

nal dilatation? Circulation 499. Newman GE, Miner DC, Sussman SK, et al. Peripheral artery atherectomy: description of technique and report of initial results. Radiology 1988; 169:677-680. Hinohara

16.

transluminal

Early occlusion and dissection in coronary angioplasty: apropos of 855 patients. Arch Mal Coeur 1989; 82:1505-1509. [French) Meier B, Gruentzig AR, Hoilman J, et al. Does length or eccentricity of coronary ste-

Cutdliff

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C, et

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uations.

7’7R .

Haudenschild

Wailer BF. “Crackers, breakers, stretchers, drillers, scrapers, shavers, burners, welders and melters”: the future treatment of ath-

noses

of

thank ChrisRN, for per-

DP,

coronary angioplasty. 59:267-269.

evalua-

tion

diol

14.

68:1136-1140.

clusions

8.

for treating dissections caused by other percutaneous modalities, including PTA and the transluminal extraction atherectomy catheter (14). In conclusion, we believe that the patency rates presented in this study

TA, Faxon

erosclerotic coronary clinical-morphologic

6.

catheter through a 12-F sheath, we prefer to treat most iliac stenoses with PTA, to decrease puncture site cornplications in the groin. We do, however, perform DA for focally eccentric or restenosis lesions in the iliac arter-

anglomodels of ath1982; 2:125-

Simpson JB, Selmon MR. Robertson GC, et al. Transluminal atherectomy for ocdusive peripheral vascular disease. Am J Car-

cutaneous

Sanborn

1983;

in

atherectomy

C, et

aL The mechanism of transluminal angloplasty: evidence for formation of aneurysm in experimental atherosclerosis. Circulation

requires

11-F

VJ, Haudenschild of transiuminal

133.

5.

of the

Faxon DP, Weber al. Acute effects

plasty in three experimental erosclerosis. Atherosclerosis

vein bypass grafts. Since atherectomy has such a favorable outcome and low morbidity, we now regularly perform DA for asymptomatic vein bypass graft stenoses detected with color flow duplex US. Because iliac DA often use

13.

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