Mid-term results of orbital atherectomy in heavily calcified lesions above and below the knee

Summary: Background: Severe arterial calcification poses a major challenge to endovascular therapy (EVT) in peripheral artery disease (PAD). Orbital atherectomy (OAS) is used to modify plaque and enhance luminal gain, potentially improving EVT outcomes, but long-term evidence remains limited. Patients and methods: This retrospective single-center study assessed the mid-term outcomes of OAS in heavily calcified infrainguinal disease. We included symptomatic PAD patients (Rutherford 2–6) with ≥70% stenosis undergoing OAS for above- and below-the-knee (BTK) arterial lesions. Results: From 2018 to 2023, 78 patients underwent EVT for 83 infrainguinal lesions with OAS. Most were male (84.6%; 66/78) and had significant cardiovascular risk factors. Lesions were located in the femoropopliteal (FP) segment in 28.9% (24/83) and in BTK in 71.1% (59/83). Chronic limb threatening ischemia (CLTI) was significantly more frequent in BTK disease (13.0% [3/23] vs. 76.4% [42/55], p < .001). Mean lesion length was 101.8 ± 72.9 mm in FP and 133.0 ± 102.7 mm in BTK lesions, with chronic total occlusions in 25.0% (6/24) and 49.2% (29/59), respectively. One-year freedom from target lesion revascularization was 90.5% ± 6.5% for FP and 73.1% ± 7.7% for BTK lesions. One-year survival was 95.7% ± 4.3% in claudicants and 62.4% ± 7.8% CLTI patients (logrank p = .001). Major limb amputation occurred in .0% (0/22) of FP and 4.4% (2/45) of BTK cases at 30 days. Conclusions: OAS demonstrated feasibility in this highly selected cohort; however, its comparative efficacy remains uncertain.