In the early 1990s atheroablation technology either by excimer laser or with atherectomy devices was introduced primarily to recanalize narrowed coronary or peripheral arteries. The initial premise was that by ablation of heavily burdened and calcified plaques, a larger lumen could be obtained. Further, the immediate recoil seen after balloon angioplasty and the recurrence rate of restenosis would diminish when compared to balloon angioplasty.

It was noted early on that atheroablative devices required an additional set of skills by the interventional cardiologist but more worrisome were the serious reports of procedural complications, including vessel perforation, dissection, and distal embolization, all without improvement in long-term patency rates. These complications led to a dramatic decline in the routine use of atheroablative devices; treatment then shifted towards vessel preparation to accommodate stent delivery, placement, and adequate stent expansion. For more than a decade, atheroablation became a niche procedure selected for use in heavily calcified lesions with atherectomy devices or for the treatment of saphenous vein graft, thrombus management, and total occlusion recanalization with excimer laser. However, the use of atheroablation as an adjunct to bare metal stents (BMS) was associated with high rates of restenosis, which led to a further decline in its use.

With the introduction of drug-eluting stents (DES), restenosis was no longer the issue. However, with growing concerns of DES thrombosis due to inadequate stent expansion and with increased DES use in more complex lesions, an emphasis was placed on vessel preparation, which re-introduced atheroablative devices for coronary applications. Meanwhile, the continued growth of endovascular intervention in the periphery for the treatment of femoro-popliteal and tibial arteries accumulated more data in support of atheroablation either as a stand-alone treatment or in conjunction with balloons, stents, or even with drug-coated balloons (DCB). To reflect the changes in peripheral intervention, we bring to this issue of CRM three interesting manuscripts on the use of atheroablative devices in the periphery.

The first details the results of a feasibility trial in which intravascular ultrasound assessed the safety of the excimer laser in treating chronic and subacute thrombotic occlusions in femoro-popliteal arteries . The second submission details the results of a new endovascular approach for the treatment of severely calcified lesions in the femoro-popliteal tract, based on the combination of directional atherectomy, followed by DCB, to prevent long-term restenosis and to reduce the need of stenting . In the third paper, a review, you will find the results of a retrospective analysis on the safety and outcome of SilverHawk atherectomy in the treatment of in-stent restenosis of the femoro-popliteal arteries .

Clearly, in 2012, we have entered into a new phase. However, will the use of atheroablative devices in the periphery be a déjà vu of what we’ve already seen in the coronaries in the 1990s? Let me speculate by saying that the future holds more promise for the use of atheroablative devices in the periphery. First, stents are not doing well in the peripheral arteries and are associated with more stent fractures, thrombotic events, and restenosis. Second, we don’t have an effective DES for the periphery like we do for the coronary. To date, only the Zilver PTX has emerged as an effective DES when compared to BMS or percutaneous transluminal angioplasty but not when compared to atheroablative devices. Third, as an alternative to stents in the periphery, the use of DCB will probably require better vessel preparation that can be obtained with the smart use of atheroablative devices. The manuscript of Cioppa et al. supports the use of atherectomy followed by DCB to achieve long-term patency. Since atherectomy and laser angioplasty are potent and effective in lesion preparation, each could be attractive when combined with an anti-restenosis device like a DES or a DCB.

Today, the use of atheroablative devices in the coronary arteries is < 5%. However, caring for an elderly population and a growth in the incidence of calcified coronary lesions make it conceivable that we will see an increase in the use of atheroablative devices in the coronary despite the availability of lower profile balloons and stents. The best treatment of heavily calcified vessels remains directional atherectomy. These devices are not only associated with less dissection when compared with balloon angioplasty, but they better facilitate the delivery of stents to the target lesion and enable better stent expansion. Even today atheroablation is underutilized for the treatment of severely calcified lesions; yet, with further training, second-generation interventional cardiologists can expect to use these devices at an increased rate. Excimer laser continues to demonstrate efficacy in saphenous vein grafts, thrombus management, and for chronic total occlusion recanalization when the wire crosses and the balloon does not. Nevertheless, its use will most likely be limited to centers that already have access to the technology.

So, what does the future hold for atheroablation? In 2012, we are witness to a new era of atheroablative device use, which may be a limited renaissance but is definitely not déjà vu.