Definition and Overview

Coronary atherectomy is a catheter-based endovascular surgery used to remove plaque buildup in blood vessels to restore normal blood flow. It is very similar and shares the same objectives with angioplasty; their only difference are the devices or tools they use. Angioplasty uses a catheter equipped with a small balloon at its tip to widen a narrowed blood vessel. Atherectomy, on the other hand, uses a flexible catheter with different tools including a sharp rotating blade, laser filament, or a grinding bit.

Atherectomy is used in interventional cardiology to prevent various cardiovascular disease, including stroke, heart attack, and vascular disease from occurring. These conditions are a direct result of severely narrowed blood vessels and blocked blood flow to the heart. In some cases, the procedure is followed by angioplasty and stenting.

Who Should Undergo and Expected Results

Patients suffering from atherosclerosis may benefit from coronary atherectomy. Atherosclerosis occurs when calcium, cholesterol, and fat build up in the arteries. Over time, they can accumulate in one or more areas, harden, and eventually cause a blockage. This prevents the flow of oxygen-rich blood to the heart resulting in cardiovascular disease.

Atherectomy can also be used to treat the following:

  • Carotid artery disease - Refers to the narrowing of carotid arteries, which supply blood to the brain and the rest of the head. The condition increases the risk of stroke.

  • Vertebral artery stenosis - Vertebral arteries supply oxygenated blood to the back part of the brain. If they are blocked or severely narrowed, the person may experience transient ischemic attack (ITA) or stroke symptoms including speech difficulty, dizziness, vision loss, and weakness of the legs and arms.

Atherectomy can be an alternative to angioplasty or bypass surgery depending on the severity of the condition and circumstances surrounding the case.

How is the Procedure Performed?

Before the procedure, the patient is given sedatives and local anaesthetic to numb the groin area where the flexible catheter is inserted. The patient will stay awake throughout the procedure but will not feel any pain.

The vascular surgeon will then start by threading a thin guide wire into a blood vessel in the groin. The atherectomy catheter that contains a grinding device or laser filament is then advanced to the blocked artery with the help of x-ray imaging. The plaque is then removed, which opens up the artery and restores normal blood flow to the heart. In some cases, a stent is left in place to provide structural support and prevent the artery from collapsing or narrowing again in the future.

There are four ways to perform atherectomy depending on the device used. These include:

  • Rotational atherectomy - Performed by using a cutting tip that is spun at high speed to grind the plaque into fine powder, which can be safely washed away in the bloodstream.

  • Orbital atherectomy - Performed the same way as rotational atherectomy using a slightly modified tip.

  • Laser atherectomy - Uses high-energy laser to vaporise the plaque material.

  • Directional atherectomy - Uses a cutting tip designed to gently shave the plaque buildup. The pieces collected are removed by the catheter’s suctioning system.

After the procedure, the catheter is removed and the skin wound is covered with a dressing. The patient is then transferred to a coronary care unit where his blood pressure and other vital signs are closely monitored. At least two-day hospital stay is usually mandatory or until the patient is stable. A follow-up visit within one to two weeks following discharge is then scheduled to ensure that no complications have occurred.

Possible Risks and Complications

Atherectomy is relatively safe but just like any other surgery, it has risks and possible complications, including:

  • Allergic reaction to the anaesthetic used

  • Arrhythmias

  • Bleeding around the heart

  • Chest pain

  • Embolisation - A blood clot may form during the procedure and travel through the bloodstream. This blood clot can then cause blockage to other blood vessels

  • Heart attack

  • Injury to the treated blood vessel

  • Severe complications that may require an emergency bypass surgery

References:

  • Ambler, GK; Radwan, R; Hayes, PD; Twine, CP (17 March 2014). “Atherectomy for peripheral arterial disease.”. The Cochrane database of systematic reviews. 3: CD006680. PMID 24638972. doi:10.1002/14651858.CD006680.pub2.

  • Douglas JS, King SB (2011). Percutaneous coronary intervention. In V Fuster et al., eds., Hurst’s The Heart, 13th ed., vol. 2, pp. 1430-1457. New York: McGraw-Hill.

  • Wasiak J, Law J, Watson P, Spinks A (December 2012). “Percutaneous transluminal rotational atherectomy for coronary artery disease”. Cochrane Summaries.

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