Clinical Impacts and Procedural Risks of Rotational Atherectomy for Heavily Calcified Femoropopliteal Lesions

BACKGROUND: Whether atherectomy-assisted drug-coated balloon (DCB) therapy provides durable benefit in severely calcified femoropopliteal (FP) lesions remains uncertain. OBJECTIVES: In this study, we wanted to compare clinical outcomes of rotational atherectomy plus DCB vs DCB alone in severely calcified FP lesions. METHODS: In this multicenter retrospective study, 582 de novo FP lesions with Peripheral Arterial Calcium Scoring System grades 3 to 4 were evaluated. After propensity score matching, 153 lesion pairs treated with DCB alone or rotational atherectomy plus DCB were analyzed. The primary endpoint was 2-year primary patency. Hierarchical Cox models adjusted for baseline, procedural, and acute angiographic factors. RESULTS: The median follow-up duration was 439 days (IQR: 232-760). Rotational atherectomy use resulted in significantly lower postprocedural residual stenosis (16.7% [95% CI: 14.9-18.4] vs 20.3% [95% CI: 17.8-22.9]; P = 0.019) and fewer lesions with residual stenosis >30% (9/153 lesions, 5.9% [95% CI: 3.1-10.8] vs 22/153 lesions, 14.4% [95% CI: 9.7-20.8]; P = 0.012). One-year primary patency was higher in the rotational atherectomy group (86.2% [95% CI: 80.0-92.3] vs 75.1% [95% CI: 67.8-82.4]; P = 0.01), but this difference attenuated at 2 years (64.4% [95% CI: 52.4-76.4] vs 57.1% [95% CI: 47.1-65.9]; P = 0.07). In hierarchical Cox models, rotational atherectomy use remained independently associated with improved patency after adjusting for acute angiographic results (HR: 0.56; 95% CI: 0.31-1.00; P = 0.05). Procedural complications were markedly higher with rotational atherectomy, driven by distal embolization. CONCLUSIONS: Although rotational atherectomy improves acute luminal results, the early patency benefit is not durable and is offset by increased procedural risk, supporting selective rather than routine use.