The Role of Atherectomy in the Treatment of Peripheral Artery Disease

Abstract

Background

Peripheral arterial disease (PAD) is a prevalent and increasingly common condition associated with high morbidity and a growing number of patients worldwide. Atherectomy, a minimally invasive technique to remove or modify atherosclerotic plaques, has gained popularity as an adjunct to vessel preparation before balloon angioplasty, particularly in combination with drug-coated balloons (DCB). Its therapeutic role in PAD appears promising but requires further investigation.

Materials and Methods

A systematic literature search was conducted in the PubMed database. Randomized controlled trials, meta-analyses, registry data, and guideline recommendations regarding atherectomy in PAD were included. The aim was to evaluate evidence on efficacy, safety, and clinical relevance across different anatomical regions and different atherectomy devices.

Results and Conclusion

Atherectomy shows promise as an adjunctive technique in the endovascular treatment of PAD, particularly for complex and calcified lesions in the femoropopliteal segment. While some observational and registry data suggest improved procedural success, luminal gain and reduced need for bailout stenting, randomized controlled trials yield mixed results regarding long-term patency and clinical benefit. In below-the-knee interventions, evidence remains limited and complication rates are of concern.

Overall, atherectomy represents a valuable tool within a tailored treatment approach but requires further clinical validation through high-quality trials to clearly define its therapeutic role.

Key Points

• Atherectomy improves vessel preparation especially in complex femoropopliteal lesions

• Randomized trials show promise but no consistent long-term benefit.

• Below-the-knee use is limited; complication rates remain relatively high.

• Device selection and operator experience are critical for procedural success.

• Atherectomy is valuable in selected cases, pending further evidence.

Citation Format

• Limbrock M, Sunderdiek U, Haage P et al. The Role of Atherectomy in the Treatment of Peripheral Artery Disease. Rofo 2025; DOI 10.1055/a-2718-7990

Zusammenfassung

Hintergrund

Die periphere arterielle Verschlusskrankheit (pAVK) ist eine häufige und zunehmend verbreitete Erkrankung mit hoher Morbidität. Die Atherektomie, ein minimal-invasives Verfahren zur Plaqueentfernung und -modifikation, findet Anwendung als ergänzende Maßnahme vor einer Ballonangioplastie, oft in Kombination mit medikamentenbeschichteten Ballons (DCB). Ihr Nutzen in der pAVK-Therapie ist vielversprechend, muss jedoch weiter erforscht werden.

Methoden

Es wurde eine systematische Literaturrecherche in der PubMed-Datenbank durchgeführt. Berücksichtigt wurden randomisierte kontrollierte Studien, Metaanalysen, Registerdaten sowie aktuelle Leitlinien zur Atherektomie bei pAVK. Ziel war es, Evidenz zu Wirksamkeit, Sicherheit und klinischem Stellenwert in verschiedenen Gefäßregionen und zu unterschiedlichen Atherektomie-Systemen zusammenzufassen.

Ergebnisse und Schlussfolgerung

Die Atherektomie zeigt sich als vielversprechende ergänzende Technik in der endovaskulären Behandlung der pAVK, insbesondere bei komplexen und stark verkalkten Läsionen im femoropoplitealen Bereich. Während Beobachtungsstudien und Registerdaten auf verbesserte Ergebnisse bezüglich des Interventionserfolgs, des gewonnenen Lumens und einen geringeren Bedarf und Stentimplantationen hinweisen, liefern randomisierte Studien uneinheitliche Ergebnisse in Bezug auf die Langzeitoffenheit. Für infrapopliteale Interventionen ist die Evidenzlage begrenzt und die Komplikationsraten sind höher als femoropopliteal.

Insgesamt stellt die Atherektomie ein wertvolles Instrument innerhalb eines individualisierten Behandlungsansatzes dar, erfordert jedoch weitere Validierung durch qualitativ hochwertige Studien, um ihre therapeutische Rolle klarer zu definieren.

Kernaussagen

• Atherektomie verbessert die Gefäßpräparation, insbesondere bei komplexen femoropoplitealen Läsionen.

• Randomisierte Studien zeigen vielversprechende, aber keine einheitlichen Langzeitergebnisse.

• Einsatz crural ist aufgrund erhöhter Komplikationsraten eingeschränkt.

• Auswahl des geeigneten Atherektomie-Systems und die Erfahrung des Anwenders sind wichtig für den Erfolg.

• Atherektomie ist in ausgewählten Fällen sinnvoll, bedarf jedoch weiterer Evidenz.

Keywords

peripheral artery disease - atherectomy - arteries - angiography

Publication History

Received: 04 May 2025

Accepted after revision: 05 October 2025

Article published online:
11 November 2025

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