Clinical Impacts and Procedural Risks of Rotational Atherectomy for Heavily Calcified Femoropopliteal Lesions.

BACKGROUND

Whether atherectomy-assisted drug-coated balloon (DCB) therapy provides durable benefit in severely calcified femoropopliteal (FP) lesions remains uncertain.

OBJECTIVES

In this study, we wanted to compare clinical outcomes of rotational atherectomy plus DCB vs DCB alone in severely calcified FP lesions.

METHODS

In this multicenter retrospective study, 582 de novo FP lesions with Peripheral Arterial Calcium Scoring System grades 3 to 4 were evaluated. After propensity score matching, 153 lesion pairs treated with DCB alone or rotational atherectomy plus DCB were analyzed. The primary endpoint was 2-year primary patency. Hierarchical Cox models adjusted for baseline, procedural, and acute angiographic factors.

RESULTS

The median follow-up duration was 439 days (IQR: 232-760). Rotational atherectomy use resulted in significantly lower postprocedural residual stenosis (16.7% [95% CI: 14.9-18.4] vs 20.3% [95% CI: 17.8-22.9]; P = 0.019) and fewer lesions with residual stenosis >30% (9/153 lesions, 5.9% [95% CI: 3.1-10.8] vs 22/153 lesions, 14.4% [95% CI: 9.7-20.8]; P = 0.012). One-year primary patency was higher in the rotational atherectomy group (86.2% [95% CI: 80.0-92.3] vs 75.1% [95% CI: 67.8-82.4]; P = 0.01), but this difference attenuated at 2 years (64.4% [95% CI: 52.4-76.4] vs 57.1% [95% CI: 47.1-65.9]; P = 0.07). In hierarchical Cox models, rotational atherectomy use remained independently associated with improved patency after adjusting for acute angiographic results (HR: 0.56; 95% CI: 0.31-1.00; P = 0.05). Procedural complications were markedly higher with rotational atherectomy, driven by distal embolization.

CONCLUSIONS

Although rotational atherectomy improves acute luminal results, the early patency benefit is not durable and is offset by increased procedural risk, supporting selective rather than routine use.