Decisions in popliteal or below-knee atherectomy can be complicated by a wide array of devices and lesion types.
Limited data on the long-term durability of interventions, or direct comparisons of approaches, can also complicate the decision-making process, as do cost concerns.
In his Sunday, September 18 talk at VIVA, titled “Popliteal and Below-the-Knee Atherectomy – Which Tool in Which Circumstance and When Not to Bother,” James F. McKinsey, MD, aims to help clinicians navigate this quickly changing field, with updates on emerging technologies.
Directional atherectomy and laser devices continue to undergo innovation, with new devices introduced almost annually. The changing device picture can be confusing, acknowledged Dr. McKinsey of Mt. Sinai Health System in New York. “I am well versed with many of them because I have a high volume. But people with just a few cases a month may not be,” he said.
Lower volume practitioners “need to find at least one, if not two, devices that they are going to be comfortable with,” Dr. McKinsey said, noting that each is associated with a special technique and may require additional support or set-up costs, such as a laser box or a generator. “And it becomes a question of how many different things can you have on the shelf?”
Dr. McKinsey said his talk is aimed at helping practitioners decide which lesions to treat, and with which device – with close attention to the morphological characteristics of lesions. “It’s almost like an algorithm,” he said.
Increasingly, he noted, lower-limb atherectomy is being approached with more than one technique. There is a strong practice trend toward combining atherectomy with drug-coated balloon therapy, he said. “I think the idea of leaving nothing behind [in the vessel] before you do a drug-coated balloon has gotten much more support. People are coming in now and saying they want to prepare the artery by debulking it, then come back and do DCB.” A new rotational laser device, he says, has particular promise in combination with DCBs.
But combining approaches means cost increases at a time when “reimbursement is going down and the product costs and associated expenses are going up,” he said.
Also on the horizon is another, potentially game-changing technology: bioabsorbable stents. While these fall outside the scope of his talk, Dr. McKinsey said he’s assisted a number of lower-limb procedures in Europe this year using them. The technology is especially promising for “more complicated, more calcified lesions,” he said. “In Europe it is being used fairly extensively,” he noted, and likely to come online in the United States within a year or so.
As with the combined approaches, the introduction of drug-eluting bioabsorbable stents into the treatment of lower-limb lesions is also likely to incur high costs, Dr. McKinsey noted. What’s needed are longer-term studies that follow patients up to 5 years, to understand whether high upfront costs are offset by later benefits.
“We have to look at is not necessarily the cost of doing a case, but the cost of treating that patient. We may have a greater upfront cost, but if the intervention has greater durability, and the patient doesn’t have a repeat procedure, then society and healthcare providers do better,” he said.