Clinical outcomes of balloon angioplasty alone versus nitinol stent implantation in patients with small femoropopliteal artery disease: Observations from the Retrospective Multicenter Analysis for Femoropopliteal Stenting (REAL-FP)

Cilostazol effectiveness in reducing drug-coated stent restenosis in the superficial femoral artery: The ZERO study

Purpose

Drug-eluting stents (DESs) play an important role in endovascular therapy (EVT) for femoropopliteal (FP) lesions. Cilostazol improves patency after bare-metal nitinol stent (BNS) implantation for femoropopliteal lesions. This study aimed to establish whether cilostazol is effective in improving the patency of DESs and determine whether BNS or DESs with or without cilostazol are more effective in improving the 12-month patency after EVT for FP lesions.

Materials and methods

In this prospective, open-label, multicenter study, 85 patients with symptomatic peripheral artery disease due to de novo FP lesions were enrolled and treated with DESs with cilostazol from eight cardiovascular centers between April 2018 and May 2019. They were compared with 255 patients from the DEBATE SFA study, in which patients were randomly assigned to the BNS, BNS with cilostazol, or DES groups. The primary endpoint was the 12-month patency rate using duplex ultrasound (peak systolic velocity ratio < 2.5). This study was approved by the ethics committee of each hospital.

Results

The 12-month patency rates for the BNS, BNS with cilostazol, DES, and DES with cilostazol groups were 77.6%, 93.1%, 82.8%, and 94.2%, respectively (p = 0.007). The 12-month patency rate was higher in the DES with cilostazol group than in the DES group (p = 0.044). In small vessels, the DES with cilostazol group had a higher patency rate than the DES group (100.0% vs. 83.4%, p = 0.023).

Conclusions

DES with cilostazol showed better patency than DES alone. Cilostazol improved patency after EVT with DES in FP lesions and small vessels.

Clinical trial registration

University Hospital Medical Information Network Clinical Trials Registry (no. UMIN 000032473).

Bailout stenting in femoropopliteal arterial segment

Background: Disabling peripheral arterial disease (PAD) of femoropopliteal segment is usually treated with percutaneous balloon dilatation, and when this is not successful, stent is placed. Long-term patency of stent is often compromised due to in-stent restenosis (ISR). We aimed to identify factors associated with bailout stenting, and to recognise risk factors for ISR in procedures without paclitaxel application. Patients and methods: We analysed 592 consecutive successful femoropopliteal interventions performed in patients with either disabling intermittent claudication or chronic critical limb ischemia (CLI). In patients with stent implantation, clinical and ultrasound (US) examination were performed one year after the intervention to establish the presence of ISR, defined as >50% stenosis on US imaging. Results: Bailout stenting was required in 133 (22.5%) procedures. Patients with stent placement were younger (70±10 vs 72±11 years, p=0.007) and less often presented with CLI (29.3% vs 40.5%, p=0.019). They more often reported smoking (63.2% vs 49.2%, p=0.005), less often had diabetes mellitus (35.3% vs 47.5%, p=0.013) and arterial hypertension (82.0% vs 90.8%; p=0.004). Stenting was also dependent on lesion complexity (TASC II C>B>A; p<0.001). Subgroup analysis of 110 procedures with bare metal stent (BMS) placement performed in 107 patients revealed ISR in 46.4% of stents, in half of cases it was symptomatic. Neither clinical nor lesion characteristics proved to differ between the group of procedures with ISR and group of procedures without ISR. Conclusions: Factors associated with bailout stenting were age, diabetes mellitus, arterial hypertension, smoking, clinical picture of PAD and complexity of treated lesions. We did not find any risk factors influencing development of ISR in BMS.

Relationship Between Lipoprotein(a) and Angiographic Severity of Femoropopliteal Lesions

AIM

High levels of lipoprotein(a) [Lp(a)] are a risk factor for peripheral artery disease (PAD). However, the relationship between Lp(a) levels and the severity of femoropopliteal lesions in patients with PAD has not been systematically studied. This study aimed to assess the impact of Lp(a) levels on angiographic severity of femoropopliteal lesions in patients with PAD.

METHODS

We retrospectively analyzed a single-center database including 108 patients who underwent endovascular therapy for de novo femoropopliteal lesions and measured the Lp(a) levels before therapy between June 2016 and September 2019. Patients were divided into low Lp(a) [Lp(a) ＜30 mg/dL; 77 patients] and high Lp(a) [Lp(a) ≥ 30 mg/dL; 31 patients] groups. Trans-Atlantic Inter-Society Consensus (TASC) II classification, calcification [referring to the peripheral arterial calcium scoring system (PACSS) classification], and lesion length were compared between the groups.

RESULTS

The prevalence of TASC II class D (13% vs 38%, P＜0.01) and severe calcification (PACSS 4) (6% vs 23%, P=0.02) was significantly higher and the lesion length longer (123±88 mm vs 175±102 mm, P＜0.01) in the high Lp(a) group than in the low Lp(a) group. In multivariate analysis, Lp(a) ≥ 30 was an independent predictor for the prevalence of TASC II class D (HR=3.67, 95% CI 1.27-10.6, P=0.02) and PACSS 4 (HR=4.97, 95% CI 1.27-19.4, P=0.02).

CONCLUSION

The prevalence of TASC II class D and severe calcification of femoropopliteal lesions was higher in patients with high Lp(a) than those with low Lp(a).

Drug-Eluting Versus Bare-Metal Stent Implantation With or Without Cilostazol in the Treatment of the Superficial Femoral Artery

BACKGROUND

New-generation bare-metal nitinol (BNS) and drug-eluting stents have improved long-term outcomes in patients undergoing endovascular therapy for femoropopliteal lesions. Furthermore, cilostazol reduces in-stent restenosis (ISR) after first-generation BNS implantation for femoropopliteal lesions.

METHODS AND RESULTS

We studied 255 patients with femoropopliteal lesions treated at 25 cardiovascular centers. Patients were randomly assigned to the BNS group (Misago stent implantation without cilostazol), BNS with cilostazol group (Misago stent implantation with cilostazol), or drug-eluting stents group (Zilver PTX stent implantation without cilostazol). Primary end point was 1-year restenosis noted using duplex ultrasound (peak systolic velocity ratio, >2.0). Secondary end point was major adverse limb events (limb-related death, target lesion revascularization, major amputation, and major bleeding). During the 1-year follow-up, 12 patients (4.7%) died and 237 (92.9%) had relevant ultrasound findings. The 1-year ISR rate did not differ significantly among the BNS, BNS with cilostazol, and drug-eluting stents groups (28.4% versus 12.2% versus 21.0%; P=0.052). Although the 1-year ISR rate was significantly lower in the BNS with cilostazol group than in the BNS group, it was similar to that in the drug-eluting stents group ( P=0.16). Major adverse limb event was significantly higher in the BNS group (16.9% versus 6.5% versus 6.3%; P=0.034); however, target lesion revascularization and major bleeding were similar (9.7% versus 5.1% versus 3.6%; P=0.25, 4.8% versus 1.2% versus 2.4%; P=0.37, respectively).

CONCLUSIONS

Misago stent implantation with cilostazol showed a comparable 1-year ISR rate with Zilver PTX. Cilostazol reduced the 1-year ISR rate after endovascular therapy when used with new-generation BNS.

CLINICAL TRIAL REGISTRATION

URL: http://www.umin.ac.jp/ctr/ . Unique identifier: UMIN 000010071.

Comparison of Balloon Angioplasty and Stent Implantation for Femoropopliteal Disease According to Patient and Lesion Subgroup

Background: Little is known about the superiority of balloon angioplasty vs. stent implantation for femoropopliteal (FP) lesions according to subgroup.

Methods and Results: This study involved 1,018 de novo (balloon angioplasty, n=462; stent implantation, n=556) and 114 in-stent restenosis (ISR) FP lesions (balloon angioplasty, n=69; stent implantation, n=45) treated with endovascular therapy. For de novo FP lesions, the 3-year primary patency rate was significantly better with stent implantation than with balloon angioplasty (61% vs. 69%, log-rank P=0.001), but it was similar for ISR FP lesions (40% vs. 43%, log-rank P=0.83). For de novo FP lesions, stent implantation was favorable in all subgroups except for female sex (hazard ratio [HR], 0.92; 95% CI: 0.65–1.31, P=0.66), critical limb ischemia (CLI; HR, 0.70; 95% CI: 0.46–1.06, P=0.10), calcified lesion (HR, 0.81; 95% CI: 0.46–1.39, P=0.44), and poor tibial run-off (HR, 0.86; 95% CI: 0.59–1.25, P=0.42) subgroups. No difference was found between the 2 treatment strategies for ISR FP lesions in the majority of subgroups. Stent implantation, however, was favorable in totally occluded ISR FP lesions (HR, 0.45; 95% CI: 0.21–1.01, P=0.05).

Conclusions: The primary patency rate in de novo FP lesions for the 2 treatment strategies was similar in the female, calcified lesion, CLI, and poor tibial run-off subgroups. Stent implantation was superior to balloon angioplasty for totally occluded ISR FP lesions.