What Is Atherectomy? A Modern Approach to Clearing Arterial Plaque

For decades, the primary tool for opening a blocked artery was a balloon. The concept was simple: insert a catheter, inflate a balloon, and push the plaque against the artery wall. This procedure, known as balloon angioplasty, saved countless limbs and lives. But what happens when the plaque is too hard, too dense, or too widespread to simply be pushed aside? What if the blockage is more like rock than soft butter?

This is a common challenge in treating Peripheral Arterial Disease (PAD), especially in patients with long-standing disease, diabetes, or kidney issues. Their arterial plaque can become heavily calcified, making it resistant to balloon pressure. Pushing against this hard plaque can damage the artery or lead to rapid re-narrowing.

Enter atherectomy, a groundbreaking advancement in endovascular medicine. Instead of just compressing the plaque, atherectomy physically removes it. Think of it as the “Roto-Rooter” for your arteries. This minimally invasive technique allows vascular surgeons to drill, shave, or vaporize blockages, creating a clean, wide-open channel for blood to flow freely.

At Fox Vein and Vascular, we are at the forefront of using the atherectomy procedure to treat complex arterial disease. In this comprehensive guide, we will explore what atherectomy is, how it works, who it is for, and why it has become an indispensable tool in our mission of amputation prevention.

Defining Atherectomy: More Than Just Pushing Plaque

Atherectomy is a minimally invasive endovascular procedure designed to remove atherosclerosis (plaque) from a blood vessel. Unlike balloon angioplasty, which compresses plaque, or stenting, which scaffolds it open, atherectomy debulks the artery by physically eliminating the blockage.

The procedure involves inserting a specialized catheter into the artery, typically through a small puncture in the groin or foot. This catheter is equipped with a unique tip—a tiny blade, burr, or laser—that is guided to the site of the blockage using advanced imaging. Once in position, the device is activated to meticulously remove the plaque buildup from the vessel wall.

How It Works: A Look Inside the Artery

Imagine a pipe clogged with hardened mineral deposits. You could try to force a balloon through it, but you might crack the pipe or leave a very narrow channel. A better approach would be to use a tool to grind away the deposits, restoring the pipe to its original diameter. This is precisely what an atherectomy does.

By removing the plaque, atherectomy:

• Restores a wider, more natural arterial channel.
• Improves vessel flexibility.
• Reduces the need for high-pressure balloon inflations that can tear the artery.
• May lower the rate of re-blockage (restenosis) compared to angioplasty alone.

Types of Atherectomy Devices

There isn’t a single “atherectomy” device. A Manhattan vascular surgeon like Dr. David Fox chooses the right tool for the job based on the location of the blockage, the type of plaque (soft vs. calcified), and the size of the artery.

1. Rotational Atherectomy

This device uses a high-speed rotating burr, often diamond-coated, on the tip of a catheter. As the burr spins, it grinds the hardened plaque into microscopic particles that are small enough to be safely carried away by the bloodstream and filtered out by the body. It is highly effective for breaking through extremely hard, calcified blockages.

2. Directional Atherectomy

This device features a catheter with a small cutting blade on one side and a collection chamber on the other. Using imaging, the surgeon orients the blade directly toward the plaque. The blade then shaves off the plaque, which is captured in the catheter’s nose cone and removed from the body when the device is withdrawn. This allows for precise, targeted plaque removal, especially in areas where plaque is unevenly distributed.

3. Orbital Atherectomy

Similar to rotational atherectomy, this device uses a spinning, diamond-coated crown. However, the crown orbits as it spins, creating a wider channel by sanding away plaque. The centrifugal force allows the device to treat larger vessels and ablate plaque in a 360-degree fashion. It is particularly effective for long stretches of calcified disease.

4. Laser Atherectomy

This advanced technique uses a catheter that emits pulses of ultraviolet light. The laser energy vaporizes the plaque, water, and other matter into tiny gas bubbles, effectively dissolving the blockage. Laser atherectomy is versatile and can be used to treat soft plaque, calcified lesions, and even old, clotted bypass grafts.

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Who Is a Candidate for an Atherectomy Procedure?

Atherectomy is not necessary for every case of PAD. Simple balloon angioplasty or stenting for PAD is often sufficient for soft, focal blockages. However, atherectomy becomes a vital tool for patients with more complex disease.

Ideal candidates often include:

• Patients with Calcified Arteries: This is the primary indication. Calcium makes arteries rock-hard and resistant to balloon inflation. Atherectomy is essential for breaking through this “armor.” Diabetics and patients with chronic kidney disease are especially prone to calcification.
• Patients with Long, Diffuse Blockages: When an entire segment of an artery is narrowed, simply placing a long stent may not be ideal. Atherectomy can “clean out” the entire segment, often reducing the need for extensive stenting.
• Patients with Blockages at Branch Points: Placing a stent across the opening of a smaller, branching artery can block it off (a phenomenon called “jailing”). Atherectomy allows for precise plaque removal without compromising side branches.
• Patients with In-Stent Restenosis: Sometimes, a previously placed stent can re-narrow with new tissue growth. Atherectomy, particularly laser atherectomy, can be used to clean out the blocked stent.
• Patients with Critical Limb Ischemia (CLI): In cases of ischemic rest pain, leg ulcers, or gangrene, maximizing blood flow is critical for limb salvage. Atherectomy helps achieve the widest possible arterial opening to promote wound healing and prevent amputation.

Atherectomy vs. Other PAD Treatments: A Comparison

To understand the value of atherectomy, it is helpful to compare it to other common Peripheral Artery Disease treatments.

Atherectomy vs. Balloon Angioplasty

• Angioplasty: Pushes plaque to the side. It’s like compacting trash.
• Atherectomy: Physically removes plaque. It’s like taking the trash out.
• Advantage of Atherectomy: For hard, calcified plaque, atherectomy is superior. It creates a cleaner channel and reduces the risk of “barotrauma” (artery damage from high-pressure balloon inflation). Often, atherectomy is followed by a low-pressure balloon inflation to smooth the vessel wall, a combination known as “atherectomy-assisted angioplasty.”

Atherectomy vs. Stenting

• Stenting: Places a metal scaffold to hold the artery open. It is a passive solution.
• Atherectomy: Actively removes the disease.
• Advantage of Atherectomy: Atherectomy can reduce the need for stents. While stents are life-saving, they are permanent implants and can sometimes fracture or re-clot. In flexible areas like behind the knee, avoiding a stent is often preferred. By removing the plaque first, a stent may not be needed, or a smaller stent can be used. This is a “leave nothing behind” philosophy.

Atherectomy vs. Bypass Surgery

• Bypass Surgery: A major open operation where a surgeon creates a new route around the blockage using a vein from your leg or a synthetic tube. It requires a hospital stay, general anesthesia, and a long recovery.
• Atherectomy: A minimally invasive procedure done through a needle puncture. It is typically an outpatient procedure with a quick recovery.
• Advantage of Atherectomy: Atherectomy offers a much less invasive alternative for many patients who would have previously required bypass surgery. It avoids large incisions, surgical risks, and long recovery times, making it an excellent option for older or sicker patients.

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The Atherectomy Procedure: What to Expect

The idea of a device grinding away plaque inside your artery can sound intimidating, but the reality is a controlled, minimally invasive procedure.

Before the Procedure

You will have a full evaluation at our vascular lab Manhattan, including an Ankle-Brachial Index (ABI) and Duplex Ultrasound to map your blockages. Dr. Fox will discuss the best strategy with you. You may be instructed to stop certain medications, like blood thinners, and not to eat or drink for several hours before the procedure.

During the Procedure

1. Access and Sedation: The procedure is typically performed in our outpatient facility. You will be given a light sedative to help you relax, but you will not be under general anesthesia. The access site (usually the groin) will be numbed with a local anesthetic.
2. Catheter Insertion: Dr. Fox will make a tiny needle puncture to access the artery. A small tube called a sheath is inserted to provide a working channel.
3. Guidance to the Blockage: Using real-time X-ray imaging (fluoroscopy), a thin guidewire is carefully navigated through your arteries to and across the blockage.
4. Plaque Removal: The atherectomy catheter is advanced over the guidewire to the lesion. Dr. Fox activates the device, which begins to shave, grind, or vaporize the plaque. You will not feel this part of the procedure. You may hear the whirring of the device.
5. Finishing Touches: After the plaque is removed, Dr. Fox will perform an angiogram (injecting contrast dye) to see the newly opened channel. He may follow up with a low-pressure balloon angioplasty to smooth the vessel wall or place a stent if needed for structural support.
6. Closure: Once the treatment is complete, the catheters are removed. A closure device or manual pressure is used to seal the small puncture site in the artery.

After the Procedure

You will rest in a recovery area for a few hours for observation. Most patients go home the same day. You will need to take it easy for a day or two and avoid heavy lifting, but you can typically return to normal activities quickly. Many patients report immediate relief from symptoms like leg pain when walking (claudication) or ischemic rest pain.

The Benefits of Atherectomy

When used in the right patient, the atherectomy procedure offers significant advantages:

• Highly Effective for Calcified Plaque: It is the best tool for tackling the rock-hard blockages that balloons can’t treat.
• Minimally Invasive: It avoids the risks, pain, and long recovery of open surgery.
• Preserves Future Options: By cleaning out the native artery, it preserves the vessel for any potential future treatments, unlike a bypass which reroutes flow entirely.
• Reduces Stent Usage: A “leave nothing behind” approach avoids permanent implants in many cases.
• Improves Outcomes: By creating a wider and smoother channel, it may lead to better long-term patency (keeping the artery open) and a lower risk of re-intervention.
• Facilitates Limb Salvage: In patients with non-healing wounds, achieving maximum blood flow is essential. Atherectomy helps get that critical flow all the way to the foot to heal a leg wound or toe ulcer.

Why Choose Fox Vein and Vascular for Your PAD Treatment?

Treating complex Peripheral Arterial Disease requires more than just technology; it requires expertise and judgment.

• Expertise in Complex Disease: Dr. David Fox is a board-certified vascular surgeon in Manhattan with extensive experience in all forms of endovascular therapy, including the full range of atherectomy devices.
• Personalized Treatment: We don’t use a one-size-fits-all approach. We analyze your specific anatomy and plaque type to choose the best tool for you.
• Focus on Limb Preservation: Our primary goal is amputation prevention. We exhaust all minimally invasive options to restore flow and save limbs.
• Comprehensive Care: We manage everything from PAD diagnosis and risk factor modification to advanced interventions and follow-up, serving patients from the 5 Boroughs, Nassau, Suffolk, South Western Ct., and North East NJ.

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Conclusion: A Clearer Path Forward for PAD Patients

If you have been told your arteries are “too blocked” or “too calcified” for a standard procedure, atherectomy may be the answer you’ve been looking for. This modern approach to clearing plaque allows us to treat patients who previously had no option but major bypass surgery or, in the worst cases, amputation.

By physically removing the disease from the artery, atherectomy provides a clean slate, restoring robust blood flow and giving patients back their mobility and quality of life. Whether you suffer from limiting leg pain, night-time foot pain, or a non-healing wound, this technology could be the key to your recovery.

Don’t let blocked leg arteries dictate your life. Explore the most advanced, minimally invasive vascular procedures Manhattan has to offer.

Schedule your consultation with Dr. Fox today to learn if atherectomy is right for you.

Fox Vein and Vascular – Manhattan, NY
📍 1041 Third Avenue, New York, NY 10065
📞 (212) 362-3470
🌐 foxvein.com

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Note: This content is for informational purposes and does not constitute medical advice. Always consult a healthcare professional for diagnosis and treatment.