JETSTREAM Atherectomy: A Review of Technique, Tips, and Tricks in Treating the Femoropopliteal Lesions

Abstract

JETSTREAM (Bayer, Whippany, NJ) atherectomy is a highly effective rotational atherectomy device with active aspiration capacity approved in the United States to treat infrainguinal obstructive peripheral arterial disease. The technique in using the JETSTREAM is critical and relies on appropriate wire use, appropriate sizing, and speed in advancing the cutter as well as the use of fluoroscopic imaging and tactile and auditory senses. Using the right technique, the device appears to have a low rate of distal embolization and complications and results in high procedural success. We describe our own experience with the JETSTREAM device and the techniques used in our endovascular laboratory.

JETSTREAM atherectomy is a rotational cutter with active aspiration capacity approved in the United States to treat infrainguinal obstructive peripheral arterial disease. As more endovascular specialists move toward using atherectomy in treating the femoropopliteal vessels, learning how to use this device correctly is of paramount importance to achieve a safe procedure and optimal results. Although nitinol stenting has been shown to be superior to balloon angioplasty in reducing target lesion revascularization (TLR), these data have been mostly limited to short lesions, less than 10 cm in length^{1 2 3} and not in all published randomized trials.⁴ The advantages of stenting over angioplasty in longer lesions in reducing TLR are unclear and in two randomized trials TLR was similar between the two modalities despite an improvement in restenosis with stenting.^{5 6} However, these same long lesions are more likely to require stenting because of suboptimal results with balloon angioplasty alone. Long lesions, the presence of calcification, total occlusions, and the use of balloon angioplasty have been shown to predict the need for bail-out stenting.⁷

In small randomized trials both Silverhawk (Covidien, Plymouth, MN) atherectomy and orbital atherectomy (CSI, St Paul, MN) have been shown to reduce dissection rate, bail-out stenting, and need for stenting with a trend toward less TLR than balloon angioplasty in treating infrainguinal vessels.^{8 9} The use of atherectomy, therefore, is a logical tool to minimize stent use in longer femoropopliteal lesions, when these long lesions are more likely to show less of an advantage with stenting over balloon angioplasty in reducing TLR. Furthermore, stenting the femoropopliteal vessels continues to carry a high rate of recurrent restenosis particularly in longer lesions^{5 6} and treating in-stent restenosis has its own set of challenges. Stents may fracture and advanced fractures have been associated with in-stent restenosis and occlusions.¹⁰ Also, total in-stent occlusions are typically thrombotic restenotic in nature¹¹ and are challenging to treat acutely with a higher rate of distal embolization, acute reocclusion, and less than optimal results with balloon angioplasty alone.

In this manuscript we describe what we believe is an optimal technique in using the JETSTREAM device in treating the femoropopliteal lesions. So far we have performed over 80 cases of JETSTREAM atherectomy with a significant learning curve in how to choose wires, select the appropriate device size, when to use embolic filter protection device, and how to approach various lesion subsets. These tips and tricks have been adopted by the author but it is likely that others may have their different approach in using this device.

Mechanisms of Action of the JETSTREAM Atherectomy Device

Intravascular ultrasound data indicate that the JETSTREAM atherectomy device works by tissue excision with no dottering effect. Total vessel volume remains unchanged pre- and posttreatment, whereas there is a significant reduction in tissue volume and increase in minimal luminal area postatherectomy¹² (Fig. 1 A, B). Furthermore, the device is a rotational cutter and does not perform directional cutting. This is in contrast to the Turbohawk (Covidien, Plymouth, MN) cutter or the Tandem laser (Spectranetics, Colorado Springs, CO) in which the device can be directed to the bulk of the lesion leading to selective cutting or ablation, respectively. The choice of the size of the device is therefore important as it determines the amount of plaque excision that can be removed with both blades down (BD; min tip) and blades up (BU; max tip) mode. In addition to tissue cutting, the device has an aspiration port that is able to suction debris simultaneously during the cutting process. This has the potential of reducing distal embolization when used at the appropriate speed and proper technique. A high incidence of distal embolization has been noted with the older version of the device,¹³ the Pathway system, but considerable improvement has been made to the current device including a larger aspiration capacity and moving the aspiration port from distal to proximal of the cutter resulting in enhanced aspiration efficiency. The combination of rotational cutting and aspiration makes this device appealing to use by operators. Early data suggested that the rate of distal embolization is favorable with no adverse events reported in the first 60 patients enrolled in the JET registry despite 3.6% use of embolic filter protection.¹⁴ Finally, experience with the Pathway device also indicated a potential for low overall stenting rate and dissection¹⁵ with an overall acceptable TLR rates at 6 and 12 months of 15% and 26%, respectively.¹⁶ No randomized trials, however, exist to compare the JETSTREAM device to balloon angioplasty or other devices that currently exist on the market.

Fig. 1.

Intravascular ultrasound before (A) and after (B) JETSTREAM atherectomy in fibrofatty and calcified plaque. A larger minimal luminal area can be seen with significant tissue and calcium removal.

Wire Selection

The peripheral wire I use predominantly with the JETSTREAM is the Spartacore (Abbott Vascular, Santa Clara, CA) wire. It is a 0.014″ wire with good steerability and a soft shapeable tip (300-cm in length). It has a high-support stainless steel shaft and a microglide coating that reduces friction. It is imperative to avoid using soft coronary wires such as the Choice PT (Boston Scientific, Natick, MA) and Whisper (Abbott Vascular, Santa Clara, CA) wires as these would not provide adequate support. We also avoid the use of the GRAND SLAM (Abbott Vascular, Santa Clara, CA) hydrophobic wire as we had instances where we could not “rex” back the device over the wire and had to pull both wire and device together.

When embolic filter protection is needed as in long lesions, total occlusions, calcified vessels, and thrombotic lesions, I use the long (315 cm) BareWire in conjunction with the Nav-6 filter (Abbott Vascular, Santa Clara, CA). We avoid using the SpiderFX filter (Covidien, Plymouth, MN) because we had a similar experience to the GRAND SLAM wire in which the device could not be rexed back and the Spider filter and device had to be pulled out together as a single unit. Other operators have used the JETWIRE (Bayer, Whippany, NJ), a PTFE coating 0.014″ 300-cm wire that is indicated for coronary and peripheral use. It should also be noted that filter use with the JETSTREAM device is off-label and we restrict its use to lesions of high embolic potential. It should also be noted that the Nav-6 filter has an advanced design for enhanced capture efficiency (100-µm debris). This may create slow flow in the distal bed following atherectomy (intervention) which typically returns to normal after filter removal. Another advantage of the Nav-6 filter is that the wire and filter are not attached to one another allowing the wire to be placed far from the filter into the tibial arteries if needed. This also allows the filter to remain in place in the popliteal or distal superficial femoral artery even if the wire moves.

Irrespective of where a filter or nonfilter wire is used, the wire has to be intraluminal. In case of a stenosed but not totally occluded vessel, it is generally obvious where the wire location is. However, if a chronic total occlusion (CTO) is wired, the operator will usually be able to tell with reasonable certainty if there is a subintimal crossing. If this is not readily obvious to the operator, intravascular ultrasound (IVUS) can be done. If there remains any doubt that the wire is not intraluminal, it is best not to pursue atherectomy. It is likely that with BD on the device, an operator can go through a subintimal space with less chances of perforation. However, when blades are up, the risk of perforation is likely to increase. As a rule, when treating a CTO with the JETSTREAM, if significant resistance and/or severe revolutions per minute (RPM) drop is encountered, it is best not to forcefully advance the device. We typically abort the procedure and move to dilation and stenting as needed.

Distal positioning of the wire is important. The wire is generally positioned in a small tibial or peroneal vessel or in an angulated tibial such as the anterior tibialis. This allows more stability to the wire and the JETSTREAM cutter during rotational cutting. It is important to avoid wedging the wire at the end of a small branch or placing it far into the tibial vessel. This allows room for the wire to move with the device as this can still happen (this is one reason we avoid the Spider Filter because it may move forward with the wire).

Cutter Size Selection

There are two cutter designs with the JETSTREAM device. The JETSTREAM XC (or eXpandable Cutter Catheters) and the JETSTREAM SC (or Single Cutter Catheters) (Fig. 2) The eXpandable Cutter, as the name implies, can be used BD and BU with single insertion and is for femoropopliteal vessels. The XC or eXpandable Cutter Catheters come in two sizes: 2.1 mm/3.0 mm (135-cm in length) is best suited for vessel size larger than 3.0 BD and 4.0 to 5.0 mm BU; and the 2.4 mm/3.4 mm (120-cm in length) is typically used for vessels 4.0 to 4.9 mm BD and 5.0 mm or larger BU. Also, the SC or Single Cutter Catheters come in two sizes: 1.6 mm (145-cm in length) best suited for vessel size 2.0 to 2.5 mm and the 1.85 mm (145-cm shaft length) typically used for vessel sizes 2.6 to 3.0 mm. The single cutters have only a front end cutter with no BU feature and typically are used for proximal and mid-tibial and peroneal vessels.

Fig. 2.

JETSTREAM catheter tips.

Cutter Advancement

Prior to initiating the JETSTREAM cutter, it is important to have in 1-L saline flush bag 1 mg of nitroglycerin and 5 mg of verapamil (if no contraindication). This will avoid vessel spasm around the catheter and avoid potential dissection particularly when blades are up. The cutter should be advanced very slowly and always with the BD first. As a rule, we advance 2 mm forward and 1 mm backward to allow maximum aspiration efficiency and minimize the risk of distal embolization. It is common to notice a change in the rotational speed via auditory and tactile feeling once the lesion is reached. Do not push too hard against the lesion to avoid stalling the cutter within the lesion (speed and stalling can also be anticipated by the sound of the cutter). We advise placing the device over the lesion with a very gentle push against it avoiding forceful pushing. If we detect that stalling is about to occur, we pull back the device by ∼1 mm until it regains its speed and we readvance slowly back toward the lesion. Keeping the speed of the cutter at or near maximum speed is preferred. An optimal speed in advancing the cutter should not exceed more than 1 mm per second.

If the lesion is short (< 5 cm), we typically treat the lesion with BD then follow with BU. On the other hand, if lesion is long (> 5 cm) or CTO, we treat the lesion with BD except the distal cap (if CTO) or just proximal to the most severe distal segment (if not a CTO). We repeat the initial treatment with BU. Following this, the distal cap or most severe distal segment of the vessel is then treated with BD followed by BU.

We believe that the distal cap or severe distal segment of the lesion acts like a filter. Debris are captured distally and then later aspirated before they have a chance to embolize. This technique is particularly important in CTO, mixed thrombotic-fibrotic plaques, calcified disease, long disease, and TASC D lesions where potential for distal embolization is high.

If the operator is certain that the wire is positioned intraluminal but the vessel is highly calcified, it is expected that some resistance will be encountered when the device is being advanced. Again, a very slow advancement as described above is advised. It is important, however, to never push against a high resistance if the device cannot be advanced. This resistance is likely to be related to a significant spiral dissection.

Removing the Device

The device is retracted through the treatment area by “rexing” it until wire loop is back to its initial size (Fig. 3). While rexing the device, always watch the distal end of the wire. Following this, remove the wire loop from the Wire Guard, and while rexing, pin wire and then pull out device (pin/pull technique). Once device enters the sheath, stop rexing and continue pulling the device through the sheath with the pin/pull technique until the device exits the sheath.

Fig. 3.

JETSTREAM handle with correct loop positioning within the Wire Guard.

Summary

JETSTREAM atherectomy is a highly effective rotational atherectomy device that cuts and aspirates fibrofatty plaque, calcium, and thrombus (Fig. 4). We have noted a high procedural acute success rate, lower stenting rate, and lower rate of distal embolization with this device (Fig. 5). The technique in using the JETSTREAM is critical and relies on appropriate wire use, appropriate sizing, and speed of advancing the cutter as well as the use of fluoroscopic imaging and tactile and auditory senses. Data from ongoing trials will help us add robustness to the existing data on acute and long-term results.

Fig. 4.

JETSTREAM removes fibrofatty plaque and thrombus from within the lesion.

Fig. 5.

Superficial femoral artery before (A) and after (B) treatment with JETSTREAM atherectomy.