The Role of Orbital Atherectomy in the Endovascular Approach to Upper Extremity Critical Limb Ischemia
Travis J. Vowels, MD, Manuel R. Rojo, MD, Jean Bismuth, MD, Linda Le, MD.
Houston Methodist Hospital, Houston, TX, USA.
OBJECTIVES: Critical limb ischemia (CLI) of the upper extremity is an infrequent but morbid problem encountered primarily in patients with diabetes mellitus and end stage renal disease. The forearm arteries are frequently involved and diffuse disease is typically present which makes treatment challenging. Available literature is limited to case reports and small case series. We evaluate the role of orbital atherectomy in the treatment of patients with upper extremity CLI.
METHODS: We retrospectively reviewed all patients with CLI undergoing treatment of the forearm arteries at our institution from May 2016 to August 2018. Patients were separated into 2 cohorts including those undergoing a combination of balloon angioplasty and atherectomy with the DIAMONDBACK360 Coronary Orbital Atherectomy System (Cardiovascular Systems, Inc), and those undergoing balloon angioplasty alone. We collected demographic and outcome data and reviewed all arteriograms. We compared the two groups using Fisher’s exact test, unpaired t-test, and Kaplan-Meier analysis where appropriate.
RESULTS: A total of 21 limbs in 20 patients were treated for upper extremity CLI with forearm vessel involvement. Eight patients underwent atherectomy plus balloon angioplasty and 13 were treated with angioplasty alone (Table). Demographics were similar between the two groups. Patients undergoing atherectomy were more likely to have severe diffuse angiographic disease involving >5 cm of the artery (100% vs 38%, p=.01) and require ligation of the ipsilateral dialysis access for resolution of dialysis associated steal symptoms (80% vs 13%, p=.03) compared to those receiving angioplasty alone. Overall freedom from combined major and minor amputation at 1 year was not significantly different between the two groups (83% vs 75%, p=.66). Freedom from reintervention, excluding access ligation or revision, at 1 year was also similar between the two groups (75% vs 92%, p=.75). There was no difference in the incidence of complete wound healing (75% vs 43%, p=.55).
CONCLUSIONS: Orbital atherectomy is a reasonable option for patients with upper extremity CLI and severe diffuse disease of the forearm arteries where angioplasty alone would be expected to yield poor results. Further prospective studies are needed to fully evaluate this underutilized treatment of upper extremity CLI. 
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