CX at ISET: Debulking below the knee is debated


In a spirited debate at the ISET, in Hollywood, FL, speakers made their case for or against the use of atherectomy. The debate “Debulking Below the Knee Has No Value” was presented in collaboration with the CX Symposium. Known as “Great Debate,” the session followed CX’s format of well-intentioned, good-natured debate on a controversial and important subject.

“It’s the medical equivalent of the gong show,” joked moderator Stephen Greenhalgh, who explained that at the London meeting a handbell is wrung when the time allotted to a given speaker runs out. Greenhalgh is the organiser of the CX Symposium and introduced the ISET’s session.

Drs Gary Ansel and Stephen Ramee spoke in favor of the proposition that such a procedure constitutes a waste of time. In separate presentations, Ansel and Ramee cited study results that they believe made clear atherectomy’s inferiority to angioplasty and even surgery. And they questioned other studies that appeared to rely on too few patients or were otherwise suspicious. They argued strongly that atherectomy causes unnecessary complications.

“The hindenberg was a great idea, but putting helium in it didn’t work too well,” Ansel said. “It crashed and burned. That’s what happens when we get too complicated.”

Ramee added that the most experienced physicians know that excisional and orbital atherectomy constitute failed strategies. “We’ve lived through the debulking era,” he said of himself and others who have witnessed two decades of studies that, he believes, clearly show atherectomy does not result in improved clinical and hemodynamic outcome.

Ramee criticised manufacturers that are today promoting atherectomy devices without benefit of randomised trials, and he frowned upon the high price tags associated with the devices.

Speaking against the proposition that atherectomy has no value was Dr Rajesh Dave, who argued that atherectomy has a definite place in certain types of cases. He cited the LACI study, which at six months showed only a 16% re-intervention rate and only a 7% amputation rate.

Dave shared a slide of one of his recent cases that he believed proved the efficacy of the aniogplasty/atherectomy combination in below-the-knee vessels. “You can’t argue with this result,” he told the audience.

Dave concluded by stating that atherectomy remains useful as an adjunct to angioplasty and that it improves acute results with percutaneous transluminal angioplasty with less stents. He added that in the future atherectomy used in conjunction with the placing of drug-eluting stents may prove to have an essential role in maintaining uniform drug dispersion in extensively diseased small below-the-knee vessels. He also believes that, over time, the entry of additional devices into the market will help drive down costs.

Dr Gunnar Tepe, in an unwitting mix-up for which no one has claimed blame, prepared points that backed up arguments in favor of the proposition that atherectomy is no good, rather than supporting the other side, and so left Dave alone in his corner. Despite this lopsidedness, however, not everyone was swayed to the position that debulking below the knee has no value. A poll of the audience revealed that 65% believed it is worthless, but 35% believed it has merit.

On 5 April, ISET will present a complex-case review session at the 2009 CX Symposium. Several physicians comprise a panel to discuss unusual or difficult cases that offer an important learning opportunity for the audience.