Infrapopliteal Atherectomy for the Treatment of Critical Limb Ischemia – A Systematic Review

To identify and synthesize the evidence in patients with critical limb ischemia treated with infrapopliteal (IP) atherectomy. The following databases and search interfaces were searched: Embase (via Embase.com), Medline (via PubMed), and the Cochrane Central Register of Controlled Trials. Additional references were identified via bibliographies of included studies. Studies had to be randomized controlled trials (RCTs) or quasi-experimental studies (non-randomized studies and prospective or retrospective pre–posttest studies), assessing the impact of atherectomy to treat IP lesions and English language articles. Two authors independently assessed the studies for inclusion criteria, extracted the data and conducted the quality evaluation of the included studies based on the Cochrane Risk of Bias (RoB) critical appraisal tools. A total of 13 studies were included in the review, of which 3 were RCTs, 7 retrospective, and 3 prospective pre–posttest studies. A total number of 2840 patients participated in the identified studies, of whom all were adults. Primary patency rates at 12 months ranged from 45% to 84%, and secondary patency rates at 12 months ranged from 74% to 92%. Generally, a low rate of adverse events was observed after atherectomy. When comparing atherectomy with angioplasty, there was no statistically significant difference seen in the majority of outcomes assessed. The findings of this systematic review of studies assessing IP atherectomy in patients with critical limb ischemia suggest that atherectomy may be able to provide acceptable primary and secondary patency rates in the mid-term, as well as being a generally safe procedure. However, the comparative effectiveness with angioplasty is still unclear. Large-scale prospective, randomized studies with low RoB and long-term follow-up are essential to inform clinical practice in the real-world setting.