Episode # 3 • 17 Jan 2025
Understanding Laser Atherectomy in Calcified Peripheral Artery Disease
Half or more of the femoropopliteal lesions Dr. Nicolas Shammas treats are moderately to severely calcified, the kind that turn a routine case into recoil, dissection, and a stent no one planned to place. On this episode of the BackTable Podcast, Dr. Neil Jain welcomes back Dr. Shammas, an interventional cardiologist in Davenport, Iowa, and president and research director of the Midwest Cardiovascular Research Foundation, to talk about laser atherectomy in heavily calcified peripheral artery disease (PAD). Dr. Shammas explains his workup with duplex, CT angiography, and intravascular ultrasound (IVUS), how decades of vessel prep trials shaped his device choices, and how a 355 nm laser with a very short pulse delivers enough power to cross calcium while limiting thermal injury beyond the catheter tip.
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Timestamps
00:00 - Introduction
05:12 - Who Has Severely Calcified Femoropopliteal Disease?
06:38 - Preprocedural Workup and Contrast Sparing
08:40 - Access, IVUS, and the Evolution of Vessel Prep
13:12 - How a 355 nm Laser Acts on Calcium
16:32 - Safety: Embolization, Perforation, and Filters
19:10 - Technique Tips: Speed, Sizing, and Opening Pressure
21:51 - Comparing Laser Atherectomy and IVL in Calcified Femoropopliteal Disease
28:58 - Why Residual Narrowing Matters for Patency
30:34 - Study Limitations and the Need for Randomized Trials
33:15 - Combining Laser Atherectomy and IVL
39:36 - Treatment Sequence and Choosing a Device by Vessel Size
41:53 - Final Takeaways
Resources
- Shammas NW, et al. Shockwave Lithoplasty versus 355-nm Laser for Vessel Preparation in Calcified Femoropopliteal Arterial Disease: A Single-Center Comparative Study. Int J Angiol. 2026
- Shammas NW, et al. Predictors of Patency Following Infrainguinal Arterial Interventions Under Intravascular Ultrasound Guidance: Analysis from the iDissection Studies. Vasc Health Risk Manag. 2025
- AMBITION BTK: Auryon Atherectomy System With Standard Balloon Angioplasty Versus Standard Balloon Angioplasty Alone. ClinicalTrials.gov NCT06777901
- BackTable VI Episode 563: Techniques for Effective Vessel Prep with Dr. Jay Mathews and Dr. Michael Siah
- BackTable VI Episode 408: Laser BTK Study Insights: Navigating Complex Lesions with Dr. Nicolas Shammas
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More about this episode
Dr. Shammas then shares the technique lessons that matter most for new operators, from passing the catheter at no more than a millimeter per second to sizing with IVUS and finding the balloon's opening pressure, and why he now rarely uses an embolic filter. The two discuss his recent core lab adjudicated, single-center comparison of laser atherectomy and intravascular lithotripsy (IVL) for calcified femoropopliteal disease, why residual narrowing matters for patency, and why only randomized, long-term trials can settle the question. They close on combining laser and IVL, which should come first, and which vessels suit each device.
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