Coping Strategies for Lower Extremity Arterial Calcification Lesions: Innovations in Endovascular Devices and Combination Techniques_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

 YAO Chen , MA Jinchen

Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, P. R. China;

Corresponding?author：

YAO Chen, Email: yaochen@mail.sysu.edu.cn

Keywords：

lower extremity arterial disease; endovascular treatment; peripheral arterial disease; intravascular imaging

DOI：

10.7507/1007-9424.202512052

Video：

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This review systematically elaborates on the application of innovative devices and assisted techniques in the endovascular treatment of lower extremity arterial calcified lesions, focusing on their use according to the depth of calcification. It details the technical principles and current application status of four atherectomy techniques (directional, rotational, orbital, and laser) targeted at intimal calcification. Furthermore, it provides an in-depth discussion on the mechanism of action and clinical evidence for intravascular lithotripsy (IVL) as a transformative technology capable of addressing deep medial layer calcification. The article also highlights the advances and value of combining intravascular imaging techniques, such as optical coherence tomography, with atherectomy for precision therapy. It shows that the application of these various innovative devices and combined techniques provides effective treatment options for lower extremity arterial calcified lesions. However, future research should focus on personalized treatment strategy selection, optimization of IVL technology, and long-term efficacy validation of new devices.

1.	Wang Z, Wang X, Hao G, et al. A national study of the prevalence and risk factors associated with peripheral arterial disease from China: the China hypertension survey, 2012–2015. Int J Cardiol, 2019, 275: 165-170.
2.	Roumeliotis S, Roumeliotis A, Dounousi E, et al. Biomarkers of vascular calcification in serum. Adv Clin Chem, 2020, 98: 91-147.
3.	Lanzer P, Hannan FM, Lanzer JD, et al. Medial arterial calcification: JACC state-of-the-art review. J Am Coll Cardiol, 2021, 78(11): 1145-1165.
4.	中華醫學會外科學分會血管外科學組. 下肢動脈硬化閉塞癥診治指南. 中華普通外科學文獻(電子版), 2016, 10(1): 1-18.
5.	Golledge J. Update on the pathophysiology and medical treatment of peripheral artery disease. Nat Rev Cardiol, 2022, 19(7): 456-474.
6.	Abela GS. Historical background, development, and future trends of lasers in cardiovascular disease // Abela GS. Lasers in cardiovascular medicine and surgery: fundamentals and techniques. Boston, MA: Springer US, 1990, 9-17.
7.	Rocha-Singh KJ, Zeller T, Jaff MR. Peripheral arterial calcification: prevalence, mechanism, detection, and clinical implications. Catheter Cardiovasc Interv, 2014, 83(6): E212-E220. doi: 10.1002/ccd.25387.
8.	Kang IS, Lee W, Choi BW, et al. Semiquantitative assessment of tibial artery calcification by computed tomography angiography and its ability to predict infrapopliteal angioplasty outcomes. J Vasc Surg, 2016, 64(5): 1335-1343.
9.	Patel MR, Conte MS, Cutlip DE, et al. Evaluation and treatment of patients with lower extremity peripheral artery disease: consensus definitions from Peripheral Academic Research Consortium (PARC). J Am Coll Cardiol, 2015, 65(9): 931-941.
10.	王盛, 史振宇, 馮海. 下肢動脈疾病腔內減容規范化應用中國專家共識(2024版). 中國實用外科雜志, 2024, 44(12): 1328-1338.
11.	Bürckenmeyer F, Aschenbach R, Diamantis I, et al. Excimer laser atherectomy in complex peripheral artery disease: a prospective European registry. J Cardiovasc Surg (Torino), 2021, 62(2): 153-161.
12.	Shammas NW, Coiner D, Shammas GA, et al. Distal embolic event protection using excimer laser ablation in peripheral vascular interventions: results of the DEEP EMBOLI registry. J Endovasc Ther, 2009, 16(2): 197-202.
13.	Babaev A, Zavlunova S, Attubato MJ, et al. Orbital atherectomy plaque modification assessment of the femoropopliteal artery via intravascular ultrasound (TRUTH study). Vasc Endovascular Surg, 2015, 49(7): 188-194.
14.	Wardle BG, Ambler GK, Radwan RW, et al. Atherectomy for peripheral arterial disease. Cochrane Database Syst Rev, 2020, 9(9): CD006680. doi: 10.1002/14651858.CD006680.pub3.
15.	McKinsey JF, Zeller T, Rocha-Singh KJ, et al. Lower extremity revascularization using directional atherectomy: 12-month prospective results of the DEFINITIVE LE study. JACC Cardiovasc Interv, 2014, 7(8): 923-933.
16.	Bai H, Fereydooni A, Zhang Y, et al. Trends in utilization and outcomes of orbital, laser, and excisional atherectomy for lower extremity revascularization. J Endovasc Ther, 2022, 29(3): 389-401.
17.	Rocha-Singh KJ, Sachar R, DeRubertis BG, et al. Directional atherectomy before paclitaxel coated balloon angioplasty in complex femoropopliteal disease: The VIVA REALITY study. Catheter Cardiovasc Interv, 2021, 98(3): 549-558.
18.	Roberts D, Niazi K, Miller W, et al. Effective endovascular treatment of calcified femoropopliteal disease with directional atherectomy and distal embolic protection: final results of the DEFINITIVE Ca⁺⁺ trial. Catheter Cardiovasc Interv, 2014, 84(2): 236-244.
19.	Zeller T, Rastan A, Schwarzw?lder U, et al. Percutaneous peripheral atherectomy of femoropopliteal stenoses using a new-generation device: six-month results from a single-center experience. J Endovasc Ther, 2004, 11(6): 676-685.
20.	Hansen DD, Auth DC, Vracko R, et al. Rotational atherectomy in atherosclerotic rabbit iliac arteries. Am Heart J, 1988, 115(1 Pt 1): 160-165.
21.	Gandini R, Pratesi G, Merolla S, et al. A single-center experience with phoenix atherectomy system in patients with moderate to heavily calcified femoropopliteal lesions. Cardiovasc Revasc Med, 2020, 21(5): 676-681.
22.	Dukic D, Martin K, Lichtenberg M, et al. Novel therapeutic concepts for complex femoropopliteal lesions using the jetstream atherectomy system. J Endovasc Ther, 2024, 31(6): 1218-1226.
23.	Giusca S, Hagstotz S, Lichtenberg M, et al. Phoenix atherectomy for patients with peripheral artery disease. EuroIntervention, 2022, 18(5): e432-e442. doi: 10.4244/EIJ-D-21-01070.
24.	Maehara A, Mintz GS, Shimshak TM, et al. Intravascular ultrasound evaluation of JETSTREAM atherectomy removal of superficial calcium in peripheral arteries. EuroIntervention, 2015, 11(1): 96-103.
25.	Babaev A, Zavlunova S, Attubato MJ, et al. Orbital atherectomy plaque modification assessment of the femoropopliteal artery via intravascular ultrasound (TRUTH Study). Vasc Endovascular Surg, 2015, 49(7): 188-194.
26.	Giannopoulos S, Secemsky EA, Mustapha JA, et al. Three-year outcomes of orbital atherectomy for the endovascular treatment of infrainguinal claudication or chronic limb-threatening ischemia. J Endovasc Ther, 2020, 27(5): 714-725.
27.	張瑞星, 張鉦. 準分子激光冠狀動脈斑塊消融術應用. 國際心血管病雜志, 2023, 50(2): 69-73.
28.	Tepe G, Brodmann M, Werner M, et al. Intravascular lithotripsy for peripheral artery calcification: 30-day outcomes from the randomized Disrupt PAD Ⅲtrial. JACC Cardiovasc Interv, 2021, 14(12): 1352-1361.
29.	Sanders KM, Schneider PA, Conte MS, et al. Endovascular treatment of high-risk peripheral vascular occlusive lesions: a review of current evidence and emerging applications of intravascular lithotripsy, atherectomy, and paclitaxel-coated devices. Semin Vasc Surg, 2021, 34(4): 172-187.
30.	Brodmann M, Werner M, Brinton TJ, et al. Safety and performance of lithoplasty for treatment of calcified peripheral artery lesions. J Am Coll Cardiol, 2017, 70(7): 908-910.
31.	Brodmann M, Werner M, Holden A, et al. Primary outcomes and mechanism of action of intravascular lithotripsy in calcified, femoropopliteal lesions: results of Disrupt PAD Ⅱ. Catheter Cardiovasc Interv, 2019, 93(2): 335-342.
32.	Tepe G, Brodmann M, Bachinsky W, et al. Intravascular lithotripsy for peripheral artery calcification: mid-term outcomes from the randomized Disrupt PAD Ⅲ trial. J Soc Cardiovasc Angiogr Interv, 2022, 1(4): 100341. doi: 10.1016/j.jscai.2022.100341.
33.	Corl JD, Clair D, Mwipatayi P, et al. FORWARD PAD IDE/Feasibility studies: primary endpoint analysis of a novel non-balloon-based peripheral IVL catheter. JACC Cardiovasc Interv, 2025, 18(3): 398-399.
34.	Dubosq M, Patterson BO, Azzaoui R, et al. Protocol adaptation of optical coherence tomography in lower limb arteries revascularization. Ann Vasc Surg, 2019, 57: 257-260.
35.	Divakaran S, Parikh SA, Hawkins BM, et al. Temporal trends, practice variation, and associated outcomes with ivus use during peripheral arterial intervention. JACC Cardiovasc Interv, 2022, 15(20): 2080-2090.
36.	Lee JT, Fang TD, White RA. Applications of intravascular ultrasound in the treatment of peripheral occlusive disease. Semin Vasc Surg, 2006, 19(3): 139-144.
37.	Schwindt AG, Bennett JG, Crowder WH, et al. Lower extremity revascularization using optical coherence tomography-guided directional atherectomy: final results of the evaluation of the pantheris optical coherence tomography imaging atherectomy system for use in the peripheral vasculature (VISION) study. J Endovasc Ther, 2017, 24(3): 355-366.
38.	Yazu Y, Fujihara M, Takahara M, et al. Intravascular ultrasound-based decision tree model for the optimal endovascular treatment strategy selection of femoropopliteal artery disease-results from the ONION Study. CVIR Endovasc, 2022, 5(1): 52. doi: 10.1186/s42155-022-00328-9.
39.	Allan RB, Puckridge PJ, Spark JI, et al. The impact of intravascular ultrasound on femoropopliteal artery endovascular interventions: a randomized controlled trial. JACC Cardiovasc Interv, 2022, 15(5): 536-546.
40.	Krishnan P, Sharma R, Avadhani S, et al. IVUS improves outcomes with SUPERA stents for the treatment of superficial femoral-popliteal artery disease. J Endovasc Ther, 2025, 32(2): 475-480.
41.	Kurata N, Iida O, Takahara M, et al. Clinical impact of the size of drug-coated balloon therapy on restenosis rate in femoropopliteal lesions. J Endovasc Ther, 2023, 30(2): 269-280.

1. Wang Z, Wang X, Hao G, et al. A national study of the prevalence and risk factors associated with peripheral arterial disease from China: the China hypertension survey, 2012–2015. Int J Cardiol, 2019, 275: 165-170.
2. Roumeliotis S, Roumeliotis A, Dounousi E, et al. Biomarkers of vascular calcification in serum. Adv Clin Chem, 2020, 98: 91-147.
3. Lanzer P, Hannan FM, Lanzer JD, et al. Medial arterial calcification: JACC state-of-the-art review. J Am Coll Cardiol, 2021, 78(11): 1145-1165.
4. 中華醫學會外科學分會血管外科學組. 下肢動脈硬化閉塞癥診治指南. 中華普通外科學文獻(電子版), 2016, 10(1): 1-18.
5. Golledge J. Update on the pathophysiology and medical treatment of peripheral artery disease. Nat Rev Cardiol, 2022, 19(7): 456-474.
6. Abela GS. Historical background, development, and future trends of lasers in cardiovascular disease // Abela GS. Lasers in cardiovascular medicine and surgery: fundamentals and techniques. Boston, MA: Springer US, 1990, 9-17.
7. Rocha-Singh KJ, Zeller T, Jaff MR. Peripheral arterial calcification: prevalence, mechanism, detection, and clinical implications. Catheter Cardiovasc Interv, 2014, 83(6): E212-E220. doi: 10.1002/ccd.25387.
8. Kang IS, Lee W, Choi BW, et al. Semiquantitative assessment of tibial artery calcification by computed tomography angiography and its ability to predict infrapopliteal angioplasty outcomes. J Vasc Surg, 2016, 64(5): 1335-1343.
9. Patel MR, Conte MS, Cutlip DE, et al. Evaluation and treatment of patients with lower extremity peripheral artery disease: consensus definitions from Peripheral Academic Research Consortium (PARC). J Am Coll Cardiol, 2015, 65(9): 931-941.
10. 王盛, 史振宇, 馮海. 下肢動脈疾病腔內減容規范化應用中國專家共識(2024版). 中國實用外科雜志, 2024, 44(12): 1328-1338.
11. Bürckenmeyer F, Aschenbach R, Diamantis I, et al. Excimer laser atherectomy in complex peripheral artery disease: a prospective European registry. J Cardiovasc Surg (Torino), 2021, 62(2): 153-161.
12. Shammas NW, Coiner D, Shammas GA, et al. Distal embolic event protection using excimer laser ablation in peripheral vascular interventions: results of the DEEP EMBOLI registry. J Endovasc Ther, 2009, 16(2): 197-202.
13. Babaev A, Zavlunova S, Attubato MJ, et al. Orbital atherectomy plaque modification assessment of the femoropopliteal artery via intravascular ultrasound (TRUTH study). Vasc Endovascular Surg, 2015, 49(7): 188-194.
14. Wardle BG, Ambler GK, Radwan RW, et al. Atherectomy for peripheral arterial disease. Cochrane Database Syst Rev, 2020, 9(9): CD006680. doi: 10.1002/14651858.CD006680.pub3.
15. McKinsey JF, Zeller T, Rocha-Singh KJ, et al. Lower extremity revascularization using directional atherectomy: 12-month prospective results of the DEFINITIVE LE study. JACC Cardiovasc Interv, 2014, 7(8): 923-933.
16. Bai H, Fereydooni A, Zhang Y, et al. Trends in utilization and outcomes of orbital, laser, and excisional atherectomy for lower extremity revascularization. J Endovasc Ther, 2022, 29(3): 389-401.
17. Rocha-Singh KJ, Sachar R, DeRubertis BG, et al. Directional atherectomy before paclitaxel coated balloon angioplasty in complex femoropopliteal disease: The VIVA REALITY study. Catheter Cardiovasc Interv, 2021, 98(3): 549-558.
18. Roberts D, Niazi K, Miller W, et al. Effective endovascular treatment of calcified femoropopliteal disease with directional atherectomy and distal embolic protection: final results of the DEFINITIVE Ca⁺⁺ trial. Catheter Cardiovasc Interv, 2014, 84(2): 236-244.
19. Zeller T, Rastan A, Schwarzw?lder U, et al. Percutaneous peripheral atherectomy of femoropopliteal stenoses using a new-generation device: six-month results from a single-center experience. J Endovasc Ther, 2004, 11(6): 676-685.
20. Hansen DD, Auth DC, Vracko R, et al. Rotational atherectomy in atherosclerotic rabbit iliac arteries. Am Heart J, 1988, 115(1 Pt 1): 160-165.
21. Gandini R, Pratesi G, Merolla S, et al. A single-center experience with phoenix atherectomy system in patients with moderate to heavily calcified femoropopliteal lesions. Cardiovasc Revasc Med, 2020, 21(5): 676-681.
22. Dukic D, Martin K, Lichtenberg M, et al. Novel therapeutic concepts for complex femoropopliteal lesions using the jetstream atherectomy system. J Endovasc Ther, 2024, 31(6): 1218-1226.
23. Giusca S, Hagstotz S, Lichtenberg M, et al. Phoenix atherectomy for patients with peripheral artery disease. EuroIntervention, 2022, 18(5): e432-e442. doi: 10.4244/EIJ-D-21-01070.
24. Maehara A, Mintz GS, Shimshak TM, et al. Intravascular ultrasound evaluation of JETSTREAM atherectomy removal of superficial calcium in peripheral arteries. EuroIntervention, 2015, 11(1): 96-103.
25. Babaev A, Zavlunova S, Attubato MJ, et al. Orbital atherectomy plaque modification assessment of the femoropopliteal artery via intravascular ultrasound (TRUTH Study). Vasc Endovascular Surg, 2015, 49(7): 188-194.
26. Giannopoulos S, Secemsky EA, Mustapha JA, et al. Three-year outcomes of orbital atherectomy for the endovascular treatment of infrainguinal claudication or chronic limb-threatening ischemia. J Endovasc Ther, 2020, 27(5): 714-725.
27. 張瑞星, 張鉦. 準分子激光冠狀動脈斑塊消融術應用. 國際心血管病雜志, 2023, 50(2): 69-73.
28. Tepe G, Brodmann M, Werner M, et al. Intravascular lithotripsy for peripheral artery calcification: 30-day outcomes from the randomized Disrupt PAD Ⅲtrial. JACC Cardiovasc Interv, 2021, 14(12): 1352-1361.
29. Sanders KM, Schneider PA, Conte MS, et al. Endovascular treatment of high-risk peripheral vascular occlusive lesions: a review of current evidence and emerging applications of intravascular lithotripsy, atherectomy, and paclitaxel-coated devices. Semin Vasc Surg, 2021, 34(4): 172-187.
30. Brodmann M, Werner M, Brinton TJ, et al. Safety and performance of lithoplasty for treatment of calcified peripheral artery lesions. J Am Coll Cardiol, 2017, 70(7): 908-910.
31. Brodmann M, Werner M, Holden A, et al. Primary outcomes and mechanism of action of intravascular lithotripsy in calcified, femoropopliteal lesions: results of Disrupt PAD Ⅱ. Catheter Cardiovasc Interv, 2019, 93(2): 335-342.
32. Tepe G, Brodmann M, Bachinsky W, et al. Intravascular lithotripsy for peripheral artery calcification: mid-term outcomes from the randomized Disrupt PAD Ⅲ trial. J Soc Cardiovasc Angiogr Interv, 2022, 1(4): 100341. doi: 10.1016/j.jscai.2022.100341.
33. Corl JD, Clair D, Mwipatayi P, et al. FORWARD PAD IDE/Feasibility studies: primary endpoint analysis of a novel non-balloon-based peripheral IVL catheter. JACC Cardiovasc Interv, 2025, 18(3): 398-399.
34. Dubosq M, Patterson BO, Azzaoui R, et al. Protocol adaptation of optical coherence tomography in lower limb arteries revascularization. Ann Vasc Surg, 2019, 57: 257-260.
35. Divakaran S, Parikh SA, Hawkins BM, et al. Temporal trends, practice variation, and associated outcomes with ivus use during peripheral arterial intervention. JACC Cardiovasc Interv, 2022, 15(20): 2080-2090.
36. Lee JT, Fang TD, White RA. Applications of intravascular ultrasound in the treatment of peripheral occlusive disease. Semin Vasc Surg, 2006, 19(3): 139-144.
37. Schwindt AG, Bennett JG, Crowder WH, et al. Lower extremity revascularization using optical coherence tomography-guided directional atherectomy: final results of the evaluation of the pantheris optical coherence tomography imaging atherectomy system for use in the peripheral vasculature (VISION) study. J Endovasc Ther, 2017, 24(3): 355-366.
38. Yazu Y, Fujihara M, Takahara M, et al. Intravascular ultrasound-based decision tree model for the optimal endovascular treatment strategy selection of femoropopliteal artery disease-results from the ONION Study. CVIR Endovasc, 2022, 5(1): 52. doi: 10.1186/s42155-022-00328-9.
39. Allan RB, Puckridge PJ, Spark JI, et al. The impact of intravascular ultrasound on femoropopliteal artery endovascular interventions: a randomized controlled trial. JACC Cardiovasc Interv, 2022, 15(5): 536-546.
40. Krishnan P, Sharma R, Avadhani S, et al. IVUS improves outcomes with SUPERA stents for the treatment of superficial femoral-popliteal artery disease. J Endovasc Ther, 2025, 32(2): 475-480.
41. Kurata N, Iida O, Takahara M, et al. Clinical impact of the size of drug-coated balloon therapy on restenosis rate in femoropopliteal lesions. J Endovasc Ther, 2023, 30(2): 269-280.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Latest ArticlesCoping Strategies for Lower Extremity Arterial Calcification Lesions: Innovations in Endovascular Devices and Combination Techniques

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