Abstract 4363693: Cutting Through Calcification: A Comparison of Laser and Orbital Atherectomy Using Pedal Access in Peripheral Artery Disease

Background: Atherectomy is widely used in treating peripheral artery disease (PAD), especially for heavily calcified femoropopliteal and tibial lesions. However, procedural risks remain notable, with reported dissection rates of 3–15%, perforation 0.5–2.0%, embolization 1–6%, and access-site complications like hematoma or pseudoaneurysm in 2–4%. Outcomes can vary by device type and access strategy. This study compared the safety and procedural outcomes of laser atherectomy (LA) versus orbital atherectomy (OA), all performed via pedal access, in patients with calcified PAD at a single center between 2021 and 2024. Methods: We conducted a retrospective cohort study of 259 patients with Rutherford class 3–4 PAD who underwent intervention with LA (n=61) or OA (n=198). One patient treated with both modalities was excluded. Primary endpoints were technical success, defined as residual stenosis <30% without in-lab complications, and periprocedural events (arterial occlusion, dissection, perforation, pseudoaneurysm). Secondary endpoints included one-year amputation, mortality, ED visits within one week, and procedure time. Results: Technical success was 100% in LA and 99.5% in OA (p<0.01), confirming high effectiveness for both. Periprocedural complications occurred in 4.9% of LA and 6.1% of OA cases. In LA, occlusion occurred in 1.6% and dissection in 3.3%. In OA, dissection and pseudoaneurysm each occurred in 1.0%; no perforations were observed. At one year, amputation occurred in 3.3% (LA) vs. 0.5% (OA), and mortality was 1.6% vs. 4.5%, respectively. ED visits within one week were 0% (LA) vs. 2.5% (OA). Mean procedure time was slightly shorter with OA (61 ± 25 min) vs. LA (66 ± 35 min). Logistic regression showed no significant difference in adjusted complication rates (OR 0.83, 95% CI: 0.27–2.53, p=0.75). Pedal access was used in all patients and associated with minimal access-site complications: one access-site dissection (1.6%) and no hematoma, pseudoaneurysm, retroperitoneal bleeding, or bleeding requiring intervention. Access via anterior tibial, posterior tibial, or peroneal arteries was successfully obtained under ultrasound guidance in all cases. Conclusion: In this single-center cohort of patients with calcified PAD, both LA and OA achieved high technical success and low complication rates. Device selection may be guided by lesion and procedural factors. Pedal access was safe and effective, supporting its role in atherectomy-based interventions.