EVIDENCE-BASED REVIEW

Directional Atherectomy with Antirestenotic

Therapy for Femoropopliteal Artery Disease:
A Systematic Review and Meta-Analysis
Yanhua Zhen, MM, Zhihui Chang, MD, Chuanzhuo Wang, MD,
Zhaoyu Liu, MD, and Jiahe Zheng, MD

ABSTRACT

Systematic literature searches using Embase, PubMed, and Cochrane Library for directional atherectomy with antirestenotic therapy
(DAART) in femoropopliteal artery disease (FPAD) from January 2003 to February 2018 were conducted to evaluate clinical safety and
effectiveness. A meta-analysis was conducted using Stata software for the event rate of technical success, bailout stent placement,
primary patency, and target lesion revascularization (TLR) at 12 months. Five studies with 189 patients who received DAART were
included in the meta-analysis. Pooled rates of technical success and bailout stent placement were 90.4% (95% confidence interval [CI]
86.3%–94.6%) and 4.8% (95% CI 0.7%–8.9%), respectively. Primary patency and TLR at 12 months were 85.3% (95% CI 79.6%–
91.1%) and 5.5% (95% CI 1.9%–9.1%), respectively. Meta-analysis of 3 comparative studies demonstrated that DAART was not su-
perior in performance in clinical endpoints, including technical success, bailout stent placement, primary patency, and TLR at 12 months
(relative risk [RR] 1.111, 95% CI 0.896–1.377, P ¼ .337; RR 0.400, 95% CI 0.120–1.332, P ¼ .135; RR 1.136, 95% CI 0.841–1.535,
P ¼ .405; and RR 0.722, 95% CI 0.291–1.789, P ¼ .482). The data did not suggest that DAART was an improvement over paclitaxel-
coated balloon angioplasty for FPAD. The theoretical advantages of DAART still require further confirmation.

ABBREVIATIONS

CI ¼ confidence interval, DA ¼ directional atherectomy, DAART ¼ directional atherectomy with antirestenotic therapy, FPAD ¼
femoropopliteal artery disease, PCB ¼ paclitaxel-coated balloon, POBA ¼ plain old balloon angioplasty, RCT ¼ randomized
controlled trial, RR ¼ relative risk, TLR ¼ target lesion revascularization

Endovascular therapy has become the first-line approach for
peripheral arterial disease (1,2). It has the advantages of
minimal invasiveness, faster recovery, and fewer compli-
cations compared with surgical treatment (3). However,
plain old balloon angioplasty (POBA) and stent placement
have a high incidence of restenosis owing to elastic recoil
and intimal hyperplasia (4). In recent years, paclitaxel-
coated balloon (PCB) angioplasty has shown superior
antirestenotic results and has been widely used in
femoropopliteal artery disease (FPAD). Katsanos et al (5)
reported that PCB angioplasty could reduce by more than
From the Department of Radiology, Shengjing Hospital of China Medical
University, 36, Sanhao Street, Heping District, Shenyang 110004, China.
Received September 11, 2018; final revision received June 15, 2019;
accepted June 17, 2019. Address correspondence to J.Z.; E-mail:
zhengjh120624@126.com
None of the authors have identified a conflict of interest.
© SIR, 2019
J Vasc Interv Radiol 2019; 30:1586–1592
https://doi.org/10.1016/j.jvir.2019.06.012
half the rates of restenosis and target lesion revascularization
(TLR) in FPAD, regardless of stent placement. However, in
PCB randomized controlled trials (RCTs) (6), patients were
excluded if they had flow-limiting dissection or high re-
sidual stenosis, so high-level evidence outside of non-
randomized world registries is lacking. In addition, owing to
the poor results following pretreatment with POBA, stents
often have to be placed in complex FPAD in instances such
as severe calcification, long lesions > 10–15 cm, and total
occlusive lesions (7).
Atherectomy offers a way to improve the chances to
avoid stent placement for FPAD (8), although it did not
show superiority in terms of vessel patency or limb salvage
compared with POBA (9). The rate of bailout stent place-
ment was 10%–43% after POBA and only 0–6.3% after
atherectomy with the SilverHawk (Medtronic, Minneapolis,
Minnesota) device (10). Moreover, atherectomy can modify
the plaque morphology and the mechanical properties of the
baseline disease, which allows better drug penetration and
diffusion into the vessel wall, so vessel preparation with
atherectomy theoretically might further improve the clinical
outcomes of PCB (11). At the present time, 4 different

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Volume 30 ▪ Number 10 ▪ October ▪ 2019
atherectomy methods are available for peripheral arterial
disease: directional, rotational, orbital, and laser atherec-
tomy (12–15). Directional atherectomy (DA) is the most
commonly used method, and directional atherectomy with
antirestenotic therapy (DAART) in the form of PCB an-
gioplasty has been investigated in FPAD in recent years
(16). However, as available data about DAART for FPAD
are limited by low patient numbers, limited RCTs, and
inconsistent methods between studies, it is necessary to re-
view the results of DAART in FPAD systematically. The
purpose of this meta-analysis was to evaluate the safety and
effectiveness of DAART in FPAD comprehensively.
MATERIALS AND METHODS
This systematic review and meta-analysis complied with the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses statement (17). Institutional review board
approval was not required for this systematic review and
meta-analysis.
Search Strategy and Selection Criteria
A literature search of PubMed, Embase, and Cochrane Li-
brary was conducted from January 2003 to February 2018.
Search terms used for this analysis were “atherectomy,”
“antirestenotic therapy,” “drug-coated balloon,” “drug-
eluting balloon,” “paclitaxel-coated balloon,” “peripheral
arterial disease,” “femoropopliteal,” “femoral artery,” or
“popliteal artery.” In addition, the results of the search were
augmented by the references of the studies. The inclusion
criteria were as follows: (a) studies including patients with
femoral and/or popliteal artery disease who received
DAART and (b) studies in English. Exclusion criteria were
as follows: (a) reviews, case reports, and conference ab-
stracts; (b) studies including patients with in-stent reste-
nosis; and (c) studies that used duplicated data.
Endnote X7 (Clarivate Analytics, Philadelphia, Pennsyl-
vania) was used to check and delete duplicate studies. Two
reviewers (Y.Z., Z.C.) independently browsed and screened
the titles and abstracts of the studies and conducted pre-
liminary screening based on the exclusion criteria. After the
initial screening, full texts of the remaining possible articles
were reviewed, and the studies included in the systematic
review were finalized.
Data Extraction, Definition, and Quality
Assessment
Two reviewers extracted the data from included studies
independently, and any disagreement over the extracted data
was resolved by consensus. The following data were
extracted from each study: first author, year published, study
design (prospective cohort, RCT, or retrospective study),
brands of DA device and PCBs, distal protection, baseline
demographics (men, age, smoking, hypertension, hyperlip-
idemia, diabetes mellitus), lesion characteristics (severe
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1587
calcification, occlusion, length, location), technical success,
bailout stent placement, distal embolization and arterial
perforation, primary patency, and TLR at 12 months.
Technical success was defined as < 30% residual stenosis
after DAART or PCB without post-dilation or bailout stent
placement in the treated segment for perforation, flow-
limiting dissection, and stenosis. Bailout stent placement
was allowed in the case of a suboptimal result after repeated
prolonged balloon inflation for flow-limiting dissection or
residual stenosis > 50%. Primary patency at 12 months was
assessed by duplex ultrasound with rates calculated using
peak systolic velocity ratio  2.0–2.5.
The quality of the studies was independently evaluated by
2 reviewers (Y.Z., Z.C.) based on the Downs and Black
quality assessment checklist (18) for both RCTs and
observational studies. This review used 27 items, with a
maximum score of 32. Studies with total scores < 15, 15–
19, and > 20 were considered to be low, moderate, and
high-quality studies. Discrepancies between 2 reviewers
were resolved by consensus.
Statistical Analysis
All data analysis, summaries, and hypothesis tests were
performed using Stata 11.0 software (StataCorp LLC, Col-
lege Station, Texas) (19). For each outcome, the incidence
and 95% confidence interval (CI) were calculated. Q test
and I2 statistics were used for heterogeneity testing, and I2 >
50% was considered significant heterogeneity, whereas I2 <
50% was considered low heterogeneity (20). Egger test was
used to assess publication bias (21), and Stata module
metaninf was used for sensitivity analysis. P < .05 was
considered statistically significant.
RESULTS
Literature Selection and Characteristics
The initial search retrieved 273 studies in PubMed, 584
studies in Embase, and 154 studies in Cochrane Library.
After removal of duplicate studies and review of the ab-
stracts and full text, 5 articles (22–26) met the inclusion
criteria. Figure 1 presents a flowchart of study identification
and selection. PCB angioplasty served as control in 3 of 5
studies, including 1 RCT (26). Study characteristics are
shown in Table 1.
Patient Selection and Characteristics
This meta-analysis included 189 patients receiving DAART.
Of treatments, 98% were conducted with a distal protection
device (SpiderFX embolic protection device; Medtronic);
the proportion of severe calcification was 53% (100 of 189).
In 3 control studies (24–26), the proportion of severe
calcification was 24% (26 of 110) in the DAART group and
17% (10 of 111) in the PCB group, and no distal protection
device was used in the PCB group. Other characteristics are
listed in Table 2.
1588 ▪ DAART for Femoropopliteal Artery Disease Zhen et al ▪ JVIR

Figure 1. Flowchart of study identification and selection.

Table 1. Characteristics of Studies Included in Meta-Analysis

Reference Design Quality N PCB DA Device Distal

Protection (%)
Cioppa et al, 2012 (22) PC Moderate 30 IN.PACT Admiral TurboHawk 100
Cioppa et al, 2017 (23) PC Moderate 30 IN.PACT Admiral TurboHawk 100
Zeller et al, 2017 (26) RCT High 121 Cotavance TurboHawk 95
SilverHawk
Stavroulakis et al, 2017 (25) RC Moderate 72 IN.PACT Admiral/Pacific TurboHawk 100
FREEWAY SilverHawk
LUTONIX Pantheris
Passeo Lux HawkOne
Stavroulakis et al, 2018 (24) RC Moderate 47 IN.PACT Admiral TurboHawk 100
Passeo Lux Pantheris
HawkOne

Note–IN.PACT Admiral (Medtronic); Cotavance (Bayer AG, Berlin, Germany); IN.PACT Pacific (Medtronic); FREEWAY (Eurocor Tech
GmbH, Bonn, Germany); LUTONIX balloon (Bard Peripheral Vascular, Inc, Tempe, Arizona); Passeo Lux (Biotronik AG, Bülach,
Switzerland); TurboHawk (Medtronic); SilverHawk (Medtronic); Pantheris (Avinger Inc); HawkOne (Medtronic).
DA ¼ directional atherectomy; PC ¼ prospective cohort; PCB ¼ paclitaxel-coated balloon; RC ¼ retrospective cohort; RCT ¼
randomized controlled trial.

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 Volume 30 ▪ Number 10 ▪ October ▪ 2019
Table 2. Baseline Demographics and Lesion Characteristics of Patients Included in Meta-Analysis

Reference Men Age, y Smoking Hypertension Hyperlipidemia Diabetes Severe Occlusion Lesion Location
Mellitus Calcification Length (mm)
Cioppa et al,
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2012 (22)
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DAART n ¼ 30 23 (75%) 68 ± 10 27 (90%) 18 (60%) 21 (70%) 18 (60%) 30 (100%)† 4 (13%) 115 ± 35 Proximal SFA:5 (16%); mid
SFA: 15 (50%); distal SFA:7
(24%); popliteal artery: 3
(10%)
Cioppa et al,
2017 (23)
DAART n ¼ 30 25 (84%) 78 (55–84)* 24 (80%) 18 (60%) 21 (70%) 18 (60%) 26 (87%)† 6 (20%) 41 (21–49)* CFA
Zeller et al,
2017 (26)
DAART n ¼ 48 31 (65%) 70.1 ± 9.7 24 (50%) 42 (88%) 34 (71%) 13 (27%) 12 (25%)‡ 12 (25.0%) 112.3 ± 40.3 Proximal SFA: 2 (4.2%); mid
SFA: 28 (58.3%); distal SFA
and popliteal: 18 (37.5%)
NR DAART 14 (74%) 69.7 ± 8.9 7 (37%) 16 (84%) 14 (74%) 5 (26%) 18 (95%)‡ 5 (26.3%) 118.7 ± 56.2 Proximal SFA: 2 (10.5%); mid
n ¼ 19 SFA: 12 (63.2%); distal SFA
and popliteal: 5 (26.3%)
PCB n ¼ 54 37 (69%) 69.0 ± 8.2 34 (63%) 44 (82%) 37 (69%) 19 (35%) 10 (19%)‡ 18 (33.3%) 96.6 ± 40.9 Proximal SFA: 2 (3.7%); mid
SFA: 30 (55.6%); distal SFA
and popliteal: 22 (40.7%)
Stavroulakis et al,
2017 (25)
DAART n ¼ 41 29 (71%) 68 ± 9 17 (42%) 38 (93%) 28 (68%) 13 (32%) 7 (17%)† 11 (36%) 47 ± 24 P1: 19 (63%); P2: 21 (68%);
P3: 4 (13%)
PCB n ¼ 31 9 (29%) 72 ± 9 12 (39%) 30 (97%) 20 (65%) 8 (26%) 4 (13%)† 18 (44%) 42 ± 24 P1: 16 (39%); P2: 30 (73%);
P3: 7 (17%)
Stavroulakis et al,
2018 (24)
DAART n ¼ 21 10 (48%) 73 ± 9 NA 19 (91%) 14 (67%) 8 (38%) 7 (33%)† 4 (19%) 39 ± 14 Deep femoral artery disease:
8 (31%); SFA disease: 10
(39%); patent SFA: 16 (62%)
PCB n ¼ 26 16 (62%) 69 ± 9 NA 26 (100%) 19 (73%) 11 (42%) 5 (19%)† 0 34 ± 16 Deep femoral artery: 2 (10%);
SFA: 9 (43%); patent SFA:18
(86%)

CFA ¼ common femoral artery; DAART ¼ directional atherectomy with antirestenotic therapy; NA ¼ not available; NR ¼ nonrandomized; PCB ¼ paclitaxel-coated balloon; P1 ¼ from
intercondylar fossa to proximal edge of patella; P2 ¼ between proximal part of patella and center of knee joint space; P3 ¼ between knee joint space and origin of anterior tibial artery;
SFA ¼ superficial femoral artery.
*Median (interquartile range).
†
Severe calcification was defined as calcifications at both sides of the lumen > 1 cm in length.
‡
Severe calcification was defined as fluoroscopic dense circumferential calcification extending > 5 continuous cm.

1589
1590 ▪ DAART for Femoropopliteal Artery Disease
Figure 2. Pooled analysis of technical success, bailout stent placement, primary patency (PP) and TLR at 12 months.
Meta-Analysis
Three studies met the criteria of technical success (24–26).
In the remaining 2 studies, owing to technical success being
defined as < 30% residual stenosis after DAART, the results
were recalculated according to the raw data (22,23). The
pooled technical success and bailout stent placement rates of
DAART were 90.4% (95% CI 86.3%–94.6%) and 4.8%
(95% CI 0.7%–8.9%), respectively. The incidences of distal
embolization and arterial perforation were 3.2% (6 of 189)
and 2.6% (5 of 189) in DAART. The pooled primary
patency and TLR at 12 months were 85.3% (95% CI
79.6%–91.1%) and 5.5% (95% CI 1.9%–9.1%) (Fig 2).
The clinical outcomes were compared between the
DAART and PCB groups from 3 studies. No significant
differences were observed between the 2 groups in the rates
of technical success (relative risk [RR] 1.111, 95% CI
0.896–1.377, P ¼ .337), bailout stent placement (RR 0.400,
95% CI 0.120–1.332, P ¼ .135), primary patency (RR
1.136, 95% CI 0.841–1.535, P ¼ .405), and TLR at 12
months (RR 0.722, 95% CI 0.291–1.789, P ¼ .482). All-
cause patient death at 12 months after DAART was 5% (9
of 189) (Fig 3).
Heterogeneity, Sensitivity Analysis, and
Publication Bias
The heterogeneity of the endpoints is shown in Figures 2 and 3.
The estimates were robust in sensitivity analysis. Egger test
was used to assess the publication bias of the endpoints.
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Zhen et al ▪ JVIR
Significant publication bias was identified in bailout stent
placement and primary patency at 12 months (P < .05).
DISCUSSION
This meta-analysis included the best available evidence and
provided valuable information on the therapeutic efficacy
and safety of DAART for FPAD. DAART was associated
with a trend toward lower bailout stent placement rate,
higher primary patency, and decreased TLR at 12 months.
However, this trend was not statistically significant. The
“leave nothing behind” strategies have gained support
among interventionalists. However, mechanical scaffolding
is often required owing to elastic recoil and flow-limiting
dissections in complex femoropopliteal lesions. DA might
be a treatment option that can reduce the use of bailout stent
placement and improve the rate of technical success by
debulking the fibrocalcific portion of the plaque. In the
current meta-analysis, the proportion of patients with severe
calcified lesions was 53% (100 of 189), and the rate of
bailout stent placement was only 4.8% with a technical
success of 90.4%.
It is important to provide good vessel preparation before
PCB angioplasty. Calcium not only limits the effect of both
angioplasty and stent deployment but also impedes the de-
livery and absorption of antiproliferative drugs (27). Fanelli
et al (28) reported that severe calcification was a significant
risk factor for loss of patency after PCB. The role of PCB
angioplasty during the process is to preserve the good result
Volume 30 ▪ Number 10 ▪ October ▪ 2019
Figure 3. Comparison between DAART and PCB group in technical success, bailout stent placement, primary patency (PP) and TLR at
12 months.
obtained on the day of intervention by delaying restenosis
owing to neointimal hyperplasia (29,30). By removing
plaque including calcium, DA might lead to better pene-
tration of the antiproliferative drug in the arterial wall, thus
improving drug uptake and minimizing excessive neointima
hyperplasia. The theoretical concept has been examined in
animal models using orbital atherectomy (31). Moreover,
PCB angioplasty can diminish the local inflammatory
response with consequent platelet activation owing to me-
chanical plaque excision by DA. Therefore, DAART can be
theoretically helpful to obtain a better long-term outcome
(32). However, in the current meta-analysis, compared with
PCB angioplasty, DAART did not show statistically sig-
nificant advantages in terms of the primary patency and TLR
at 12 months. RCTs with more patients are needed to verify
the above-reported results in the future research. In addition,
there is still no standard classification of calcification de-
gree, and the relationship between calcification and lumen
patency needs to be further investigated.
Previous studies have shown that atherectomy could in-
crease the incidence of distal embolization during endo-
vascular therapy in lower extremity arterial disease (33,34).
Semaan et al (35) reported that without a distal embolic
protection device, a greater rate of thromboembolic events
occurred in the atherectomy group compared with the an-
gioplasty group (22% vs 0%, P < .01). In this meta-analysis,
the incidence of distal embolization in the treatment of
DAART was 3.2% with 98% using a distal embolic pro-
tection device. At the present time, there is no consensus on
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1591
the use of a distal protection device, which still depends on
the discretion of the physician (8).
In this meta-analysis, the rate of perforation in DAART
was 2.6%. Although most of the time an arterial perforation
can be successfully treated by prolonged POBA or stent
graft placement, concerns have been raised regarding the
potential risk of adventitial injury after DA and DAART
(8,36). At the present time, the most commonly used DA
devices are operated based on fluoroscopy and angiography,
increasing the risk of vessel wall injury. A novel DA device
(Pantheris; Avinger Inc, Redwood City, California) will be
theoretically safer by using optical coherence tomography
providing real-time imaging during the process (11). How-
ever, there are no reports comparing postoperative outcomes
of different DA devices.
In the current meta-analysis, all-cause death after DAART
at 12 months was 5% (9 of 189), which also needs attention.
The meta-analysis recently published by Katsanos et al (37)
showed that there was increased risk of death following
application of paclitaxel-coated balloons and stents in the
FPAD. The actual causes of these deaths still need further
investigation with longer-term follow-up.
The current meta-analysis has some limitations. First,
there were only 5 available studies regarding treatment of
FPAD using DAART, and the sample size was small. Sec-
ond, studies included in the current meta-analysis involved 4
different DA devices and 5 different PCBs, and further
comparisons were not conducted. Third, significant publi-
cation bias was identified in bailout stent placement and
1592 ▪ DAART for Femoropopliteal Artery Disease
primary patency at 12 months. One possible reason is the
small sample size. Finally, subgroup analysis or meta-
regression was not performed of many factors that may
have impacted effectiveness, such as lesion length, calcifi-
cation severity, location, and occlusion.
CONCLUSIONS
This meta-analysis showed that DAART did not demon-
strate statistically significant advantages in terms of bailout
stent placement, technical success, primary patency, and
TLR at 12 months compared with PCB angioplasty alone.
RCTs with more patients are needed to further characterize
the potential benefits of DAART.
ACKNOWLEDGMENTS
We thank all our colleagues and authors who cooperated
with us by preparing the full text of the papers.
REFERENCES
1. Hong MS, Beck AW, Nelson PR. Emerging national trends in the man-
agement and outcomes of lower extremity peripheral arterial disease.
Ann Vasc Surg 2011; 25:44–54.
2. Shammas NW. Current role of atherectomy for treatment of femo-
ropopliteal and infrapopliteal disease. Interv Cardiol Clin 2017; 6:235–249.
3. Karch LA, Mattos MA, Henretta JP, et al. Clinical failure after percuta-
neous transluminal angioplasty of the superficial femoral and popliteal
arteries. J Vasc Surg 2000; 31:880–887.
4. Cwikiel W. Restenosis after balloon angiology and/or stent insertion—
origin and prevention. Acta Radiol 2002; 43:442–454.
5. Katsanos K, Spiliopoulos S, Paraskevopoulos I, Diamantopoulos A,
Karnabatidis D. Systematic review and meta-analysis of randomized
controlled trials of paclitaxel-coated balloon angioplasty in the femo-
ropopliteal arteries: role of paclitaxel dose and bioavailability. J Endovasc
Ther 2016; 23:356–370.
6. Tepe G, Laird J, Schneider P, et al. Drug-coated balloon versus standard
percutaneous transluminal angioplasty for the treatment of superficial
femoral and popliteal peripheral artery disease: 12-month results from the
IN.PACT SFA randomized trial. Circulation 2015; 131:495–502.
7. Shammas NW, Coiner D, Shammas G, Jerin M. Predictors of provisional
stenting in patients undergoing lower extremity arterial interventions. Int J
Angiol 2011; 20:95–100.
8. McKinsey JF, Zeller T, Rocha-Singh KJ, Jaff MR, Garcia LA. Lower ex-
tremity revascularization using directional atherectomy: 12-month pro-
spective results of the DEFINITIVE LE study. JACC Cardiovasc Interv
2014; 7:923–933.
9. Diamantopoulos A, Katsanos K. Atherectomy of the femoropopliteal ar-
tery: a systematic review and meta-analysis of randomized controlled
trials. J Cardiovasc Surg (Torino) 2014; 55:655–665.
10. Shammas NW, Coiner D, Shammas GA, et al. Percutaneous lower-
extremity arterial interventions with primary balloon angioplasty versus
Silverhawk atherectomy and adjunctive balloon angioplasty: randomized
trial. J Vasc Interv Radiol 2011; 22:1223–1228.
11. Stavroulakis K, Bisdas T, Torsello G, et al. Optical coherence tomography
guided directional atherectomy with antirestenotic therapy for femo-
ropopliteal arterial disease. J Cardiovasc Surg (Torino) 2019; 60:191–197.
12. Akkus NI, Abdulbaki A, Jimenez E, Tandon N. Atherectomy devices:
technology update. Med Devices (Auckl) 2015; 8:1–10.
13. Garcia L, Lyden S. Atherectomy for infrainguinal peripheral artery disease.
J Endovasc Ther 2009; 16:105–115.
14. Tomey MI, Kini AS, Sharma SK. Current status of rotational atherectomy.
JACC Cardiovasc Interv 2014; 7:345–353.
15. Mureebe L, McKinsey J. Infrainguinal arterial intervention: is there a role
for an atherectomy device? Vascular 2006; 14:313–318.
Descargado para Anonymous User (n/a) en Castilla and Leon Health Council de ClinicalKey.es por Elsevier en noviembre 30, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Zhen et al ▪ JVIR
16. Stavroulakis K, Bisdas T, Torsello G, Stachmann A, Schwindt A. Com-
bined directional atherectomy and drug-eluting balloon angioplasty for
isolated popliteal artery lesions in patients with peripheral artery disease.
J Endovasc Ther 2015; 22:847–852.
17. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred
reporting items for systematic reviews and meta-analyses: the PRISMA
statement. BMJ 2009; 339:b2535.
18. Downs SH, Black N. The feasibility of creating a checklist for the
assessment of the methodological quality both of randomised and non-
randomised studies of health care interventions. J Epidemiol Commu-
nity Health 1998; 52:377–384.
19. Wang D, Mou ZY, Zhai JX, Zong HX, Zhao XD. Application of Stata soft-
ware to test heterogeneity in meta-analysis method [in Chinese].
Zhonghua Liu Xing Bing Xue Za Zhi 2008; 29:726–729.
20. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsis-
tency in meta-analyses. Education and Debate 2003; 327:557.
21. Song F, Gilbody S. Bias in meta-analysis detected by a simple, graphical
test. Increase in studies of publication bias coincided with increasing use
of meta-analysis. BMJ 1998; 316:471.
22. Cioppa A, Stabile E, Popusoi G, et al. Combined treatment of heavy
calcified femoro-popliteal lesions using directional atherectomy and a
paclitaxel coated balloon: one-year single centre clinical results. Car-
diovasc Revasc Med 2012; 13:219–223.
23. Cioppa A, Stabile E, Salemme L, et al. Combined use of directional
atherectomy and drug-coated balloon for the endovascular treatment of
common femoral artery disease: immediate and one-year outcomes.
EuroIntervention 2017; 12:1789–1794.
24. Stavroulakis K, Schwindt A, Torsello G, et al. Directional atherectomy with
antirestenotic therapy vs drug-coated balloon angioplasty alone for com-
mon femoral artery atherosclerotic disease. J Endovasc Ther 2018; 25:
92–99.
25. Stavroulakis K, Schwindt A, Torsello G, et al. Directional atherectomy with
antirestenotic therapy vs drug-coated balloon angioplasty alone for iso-
lated popliteal artery lesions. J Endovasc Ther 2017; 24:181–188.
26. Zeller T, Langhoff R, Rocha-Singh KJ, et al. Directional atherectomy fol-
lowed by a paclitaxel-coated balloon to inhibit restenosis and maintain
vessel patency twelve-month results of the DEFINITIVE AR Study. Circ
Cardiovasc Interv 2017; 10:e004848.
27. Tzafriri AR, Garcia-Polite F, Zani B, et al. Calcified plaque modification
alters local drug delivery in the treatment of peripheral atherosclerosis.
J Control Release 2017; 264:203–210.
28. Fanelli F, Cannavale A, Gazzetti M, et al. Calcium burden assessment and
impact on drug-eluting balloons in peripheral arterial disease. Cardiovasc
Intervent Radiol 2014; 37:898–907.
29. Swinnen J, Zahid A, Burgess D. Paclitaxel drug-eluting balloons to
recurrent in-stent stenoses in autogenous dialysis fistulas: a retrospective
study. J Vasc Access 2015; 16:388–393.
30. Zheng J, Cui J, Meiyan Qing J, Irani Z. Safety and effectiveness of
combined scoring balloon and paclitaxel-coated balloon angioplasty for
stenosis in the hemodialysis access circuit. Diagn Interv Imaging 2019;
100:31–37.
31. Tellez A, Dattilo R, Mustapha J, et al. Biological effect of orbital athe-
rectomy and adjunctive paclitaxel-coated balloon therapy on vascular
healing and drug retention: early experimental insights into the familial
hypercholesterolaemic swine model of femoral artery stenosis. Euro-
Intervention 2014; 10:1002–1008.
32. Beschorner U, Zeller T. Combination of mechanical atherectomy and
drug-eluting balloons for femoropopliteal in-stent restenosis. J Cardiovasc
Surg (Torino) 2014; 55:347–349.
33. Cheema M, Wu P, Ghumman S, et al. Distal embolization during endovascular
therapy for lower extremity peripheral arterial disease: a systematic review and
meta-analysis. Catheter Cardiovasc Interv 2017; 89:S9–S10.
34. Ochoa Chaar CI, Shebl F, Sumpio B, et al. Distal embolization during lower
extremity endovascular interventions. J Vasc Surg 2017; 66:143–150.
35. Semaan E, Hamburg N, Nasr W, et al. Endovascular management of the
popliteal artery: comparison of atherectomy and angioplasty. Vasc
Endovasc Surg 2010; 44:25–31.
36. Cioppa A, Stabile E, Tesorio T. Commentary: Never forget your old toys
when you get new ones. J Endovasc Ther 2015; 22:853–854.
37. Katsanos K, Spiliopoulos S, Kitrou P, Krokidis M, Karnabatidis D. Risk of
death following application of paclitaxel-coated balloons and stents in the
femoropopliteal artery of the leg: a systematic review and meta-analysis
of randomized controlled trials. J Am Heart Assoc 2018; 7:e011245.