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A correction to this paper has been published: 10.1007/s00270-021-02862-w

Percutaneous atherectomy was first introduced as an alternative to balloon angioplasty (BA) in 1986 to improve the results that could be achieved with BA [1]. The advantages of atherectomy were the creation of a smooth luminal surface with less local thrombosis and the reduction of elastic recoil because the lumen can widen without stretching the arterial wall. In percutaneous atherectomy the atheromatous intima usually occurs with or without the media. The notion that the “bad” atheroma would be removed is also an appealing feature of this technique. Atherectomy can be divided into extirpative atherectomy, which means cutting and/or shaving and removing the atherosclerotic material from the patient, and ablative atherectomy, where the atheroma is fragmented with a high-speed device. The Simpson atherectomy catheter is an example of extirpative atherectomy, and the Kensey catheter and the rotablator are examples of ablative devices. The term “directional” means that the catheter removes one sector or direction of the vessel-wall atheroma. Eleven studies of the Simpson atherectomy device were published between 1988 and 1993. Excluding 2 studies that did not publish technical success, a total of 908 patients were reported. The technical success rate was reported at approximately 90%, and complications, mainly peripheral embolisation, were reported to be between 3% and 21% (median 4%). Six-month follow-up was available in eight reports, and patency by different definitions varied between 80% and 99%. Twelve-month follow-up of 71% to 94% was reported in only five reports. Only one article reported 24-month follow-up of a lager group of patients. The 24-months patency has since decreased to 37% [2]. The previous papers is typical for older interventional radiology (IR) publications concentrating on the technique but with less focus on long-term outcome or real evidence for effectiveness. In 1995, Vroegindeweij et al. [3] published data from a prospective randomized trial comparing BA with atherectomy. This is an example of probably the earliest randomized controlled trial (RCT) concerning peripheral interventional techniques. Although the total series is small (n = 73 patients), the outcome is clear and significant. Atherectomy does not result in improved clinical and hemodynamic outcome. Furthermore, atherectomy of segmental atherosclerotic femoropopliteal disease does not result in a better patency rate than BA; in patients with lesions longer than 2 cm, atherectomy results are significantly worse. So, the myth was busted and that was the end of directional atherectomy, one could say. However, it is well known that IR is a profession of the future, so we should never look back. Yes, directional atherectomy publications died out during the next 2 decades; then in approximately 2005, a well-orchestrated new directional atherectomy offensive began. The system was presented as “new” and promising. There was an early registry and enthusiastic presentations at many angioclubs, and IR meetings were held by small groups of physicians [4]. Again, directional atherectomy was booming once again. This time not only medical journals were involved, there was also a publication in the Wall Street Journal in August 2005: Physicians Testing SilverHawk Catheter Also Own Stock Options was the title of the warning article. Twelve doctors supplied information about the catheter’s effectiveness to a registry that the company used to evaluate the SilverHawk (EV3, USA)—its only product—and to promote it to other doctors. The article concluded with the warning that the results were anecdotal. By now (2008), new reports have shown that directional atherectomy, also performed with the “new” device, has no additional value to BA but moreover carries a high risk for peripheral embolization, which was not noted in the original registry [5–7]. Is the myth now finally busted? Some myths must be busted twice. However, in IR you never know.

Recently a few authors have reported experience regarding the safety and efficacy of planned combined subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) in patients with critical limb ischemia (CLI) presenting long occlusions involving the popliteal trifurcation. Spinosa et al. described the use of this technique in 20 limbs (21 cases), with a limb salvage rate of 90% at 6 months. The authors concluded that the SAFARI technique can be useful for completing subintimal recanalization when there is failure to reenter the distal true lumen from an antegrade approach or when there is limited distal target artery available for reentry. Also, according to these authors the SAFARI technique improves technical success in the performance of subintimal recanalization, and limb salvage rates are comparable to those with antegrade subintimal recanalization [1]. Gandini et al reported the use of this novel technique in four out of 104 patients with CLI. In their paper those authors concluded that the SAFARI technique should be adopted as a ‘‘standard procedure’’ in CLI cases showing long occlusions involving the trifurcation and presenting risk of amputation [2]. While we agree with Spinosa et al. that the SAFARI technique should be adopted in the presence of failure to reenter the distal true lumen from an antegrade approach, we do not think that this technique should always be used as first choice in the presence of long occlusion involving the trifurcation. Indeed, the SAFARI technique is indubitably an attractive option but, in view of the limited number of cases reported in the literature, should not yet be regarded as a standard procedure. According to the literature [3–5], intraluminal or subintimal recanalization of long occlusions involving the popliteal trifurcation is normally achieved by the transfemoral approach. In the last 2 years more than 1000 diabetic patients with CLI have been successfully treated endovascularly at our two centers (Multimedica IRCCS, Milan, and Multimedica Santa Maria Hospital, Castellanza, Va.). In this large cohort of subjects the use of the SAFARI technique was deemed necessary in four cases only (one posterior tibial and three anterior tibial artery approaches) and, importantly, after unsuccessful repeated attempts at distal revascularization. To the present authors, direct puncture of the distal third of a calf artery is not free of serious complications, leading in certain instances to flowlimiting dissection (due to introducer sheath advancement or due to the puncture itself) as well as thrombosis of the accessed artery (mainly at the end of the intervention during manual compression of the puncture site). Also, as reported by Gandini et al., the ‘‘presence of ulcers at the entry zone is an important limitation to the performance of this type of approach.’’ Finally, this type of procedure is time-consuming, which is a main limitation in such critically ill patients (heart and renal comorbidities are often associated). In conclusion, at this moment in time the use of the SAFARI technique should not be regarded as the first option for the treatment of diabetic patients with CLI. In expert hands, however, it may be considered in selected cases, after unsuccessful attempts at revascularization from the femoral artery. Most importantly, when this novel approach is deemed necessary, surgical exposure rather T. Lupattelli (&) Department of Radiology and Interventional Radiology, Via milanese 300, Sesto San Giovanni, Milan 20099, Italy e-mail: tommasolupattelli@hotmail.com

Success of percutaneous transluminal angioplasty (PTA) in disorders other than atherosclerosis has been reported in recent papers. It has been stated, however, that the unique histopathology characteristic of Takayasu's arteritis may prevent a successful dilatation of the stenotic segments. In a recent case, however, PTA was successful in the treatment of bilateral renal artery stenosis secondary to Takayasu's arteritis. Although more time is needed to evaluate the long-term results of this nonsurgical treatment, it is evident that the stenotic lesions in Takayasu's disease are amenable to balloon dilatation. PTA should be attempted in such cases, and surgery should only be performed in case of failure.

Technical success in percutaneous transluminal coronary angioplasty (PTCA) is a function of patient selection, operator experience, and the capabilities of the angioplasty equipment employed. When unsuccessful PTCA occurs, it is the result of one of several factors: (1) a failure to cross the stenosis; (2) a failure to dilate the stenosis; (3) an ischemic complication; or (4) a late recurrence of the anginal syndrome. In this paper, we discuss the relative frequency of these types of failure, and the ways in which improvements in technique and/or equipment may be employed to improve the chance of a successful procedure.