Comparison of treatment strategies for femoro-popliteal disease: A network meta-analysis

A registry-based study of paclitaxel drug-coated balloon angioplasty for the treatment of in-stent restenosis of the femoral-popliteal artery

OBJECTIVE

The aim of this study was to report the results of a prospective, single-arm, registry-based study assessing the safety and performance of a paclitaxel drug-coated balloon (DCB) for the treatment of superficial femoral artery (SFA) or popliteal artery in-stent restenosis (ISR) in a United States population.

METHODS

We conducted a prospective, non-randomized, multi-center, single-arm, post-market registry of the IN.PACT Admiral DCB for the treatment of ISR lesions in the SFA or popliteal artery at 43 sites within the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) Registry from December 2016 to January 2020. Clinical outcomes were assessed at 12, 24, and 36 months. The primary endpoint was target lesion revascularization at 12 months. Secondary endpoints included technical success, target vessel revascularization, major limb amputation, and all-cause mortality. Results are presented as survival probabilities based on Kaplan-Meier survival estimates.

RESULTS

Patients (N = 300) were 58% male, with a mean age of 68 ± 10 years. Diabetes was present in 56%, 80% presented with claudication, and 20% with rest pain. Lesions included ISR of the SFA in 68%, SFA-popliteal in 26%, and popliteal arteries in 7%. The mean lesion length was 17.8 ± 11.8 cm. Lesions were categorized as occlusions in 43% (mean occluded length, 16 ± 10 cm). TASC type was A (17%), B (29%), C (38%), and D (15%). Technical success was 99%. Re-stenting was performed in 5% and thrombolysis in 0.6% of patients. Kaplan-Meier estimates for freedom from target lesion revascularization were 90%, 72%, and 62% at 12, 24, and 36 months. Freedom from target vessel revascularization was 88%, 68%, and 59% and freedom from major target limb amputation was 99.6%, 98.9%, and 98.9%, respectively, at 12, 24, and 36 months. Survival was 95%, 89%, and 85% at 12, 24, and 36 months.

CONCLUSIONS

This post-market registry-based study shows promising results in treating femoral-popliteal ISR with paclitaxel DCB in comparison to the results of plain balloon angioplasty reported in the literature. These results demonstrate the ability of the SVS VQI to conduct post-market evaluation of peripheral devices in partnership with industry and federal regulators.

Pathology of Critical Limb Ischemia; Comparison of Plaque Characteristics Between Anterior and Posterior Tibial Arteries

AIMS

Though the number of patients with peripheral arterial disease (PAD) and critical limb ischemia (CLI) is increasing, few histopathological studies of PAD, particularly that involving below-the-knee arteries, has been reported. We analyzed the pathology of anterior tibial artery (ATA) and posterior tibial artery (PTA) specimens obtained from patients who underwent lower extremity amputation due to CLIMethods: Dissected ATAs and PTAs were subjected to ex-vivo soft X-ray radiography, followed by pathological examination using 860 histological sections. This protocol was approved by the Ethics Review Board of Nihon University Itabashi Hospital (RK-190910-01) and Kyorin University Hospital (R02-179).

RESULTS

The calcified area distribution was significantly larger in PTAs than in ATAs on soft X-ray radiographic images (ATAs, 48.3% ±19.2 versus PTAs, 61.6% ±23.9; p＜0.001). Eccentric plaque with necrotic core and macrophage infiltration were more prominent in ATAs than in PTAs (eccentric plaque: ATAs, 63.7% versus PTAs, 49.1%; p＜0.0001, macrophage: ATAs, 0.29% [0.095 - 1.1%] versus PTAs, 0.12% [0.029 - 0.36%]; p＜0.001), histopathologically. Thromboembolic lesions were more frequently identified in PTAs than in ATAs (ATAs, 11.1% versus PTAs 15.8%; p＜0.05). Moreover, post-balloon injury pathology differed between ATAs and PTAs.

CONCLUSIONS

Histological features differed strikingly between ATAs and PTAs obtained from CLI patients. Clarifying the pathological features of CLI would contribute to establishing therapeutic strategies for PAD, particularly disease involving below-the knee-arteries.

Drug-Coated Balloon versus Drug-Eluting Stent: The Debate of Leave Nothing Behind

Endovascular techniques for peripheral artery disease have changed significantly in the past 10 years with advances in technology and data. Treatment of superficial femoral disease is complex secondary to the length, degree of calcification, high rate of chronic total occlusion, and areas of flexion within this vessel. Use of drug-coated devices has increased the interventionalist's toolbox with the objective to improve freedom from target lesion revascularization and primary patency. There remains debate as to which devices may reach these goals while also limiting overall morbidity and mortality. This article aims to highlight recent advances in the literature regarding the use of drug-coated devices.

Use of stents with medication coating for the treatment of occlusive-stenotic lesions of the superficial femoral artery

Objective ‒ to analyze the results of endovascular revascularization of the femoropopliteal segment with drug-eluting stents. Materials and methods. Endovascular intervention was performed in 23 patients with stenotic lesions of the superficial femoral artery (SFA). Paclitaxel-eluting stents were used. There were 10 men (43.5 %), 13 women (56.5 %). The mean age of the patients was (66.0 ± 3.5) years. There were 16 (69.6 %) patients with diabetes mellitus type 2 and diabetic angiopathy, and 7 (23.4 %) patients had obliterating atherosclerosis of the arteries of the lower limbs. Critical ischemia of the lower extremities was diagnosed in 18 (56.5 %) cases, intermittent claudication ‒ in 5 (21.7 %). Isolated lesions of the femoral-popliteal segment were noted in 3 (13.4 %) patients, lesions of the iliac and femoral-popliteal segments ‒ in 4 (17.4 %), lesions of the femoral-popliteal and ankle segments ‒ in 16 (69.6 %). Results. Twenty (86.6 %) scheduled procedures for stenting of the SFA were technically successful. Among postoperative complications, 3 (13.04 %) patients had puncture site hematomas that did not require surgical evacuation. In 6 (26.1 %) patients, signs of reperfusion syndrome were observed, which were treated with conservative treatment. During follow-up period (3 months), there were no cases of reocclusion or clinically significant restenosis at the stented level. In 1 (5.0 %) case, a hemodynamically significant stenosis of the SFA was observed outside the implanted stent. The patient successfully underwent angioplasty of SFA stenosis. There were no «major» amputations during follow-up period. «Small» ankle amputations were performed in 7 (35.0 %) patients with diabetic gangrene, where endovascular revascularization of the femoro-popliteal and ankle segments was the stage of surgical treatment. Conclusions. Implantation of drug-eluting stents is an effective method of endovascular revascularization in patients with SFA lesions. To compare the results of implantation of drug-eluting stents with other methods of revascularization of the lesions of the femoro-popliteal segment, it is necessary to accumulate more data and increase the duration of the follow-up period.

DRUG-ELUTING STENTS IN THE TREATMENT OF PATIENTS WITH OCCLUSIVE-STENOTIC LESIONS OF THE SUPERFICIAL FEMORAL ARTER

OBJECTIVE

The aim: To analyze the results of endovascular revascularization of the femoropopliteal segment using drug-eluting stents.

PATIENTS AND METHODS

Materials and methods: Endovascular intervention was performed in 23 patients with occlusive-stenotic lesions of the superficial femoral artery (SFA). Paclitaxel-eluting stents were used. There were 16 (69.6%) patients with diabetes mellitus type 2 and diabetic angiopathy, and 7 (30.4%) patients had obliterating atherosclerosis of the arteries of the lower limbs. Critical ischemia of the lower extremities was diagnosed in 18 (78.3%) cases, and intermittent claudication - in 5 (21.7%).

RESULTS

Results: Twenty (86.6 %) scheduled procedures for stenting of the SFA were technically successful. During follow-up period (3 months), there were no cases of reocclusion or clinically significant restenosis at the stented level. There were no "major" amputations during follow -up period. "Small" ankle amputations were performed in 7 (35%) patients with diabetic gangrene.

CONCLUSION

Conclusions: Implantation of drug-eluting stents is an effective method of endovascular revascularization in patients with SFA lesions. To compare the results of implantation of drug-eluting stents with other methods of revascularization of the lesions of the femoro-popliteal segment, it is necessary to accumulate more data and increase the duration of the follow-up period.

Peripheral Artery Disease Intervention: Drug-Coated Balloon vs Drug-Eluting Stent, A Long-Term Comparison

Objectives. The aim of the study is to evaluate current trends and long-term durability of both drug-eluting stents (DES) and drug-coated balloons (DCB) in the treatment of peripheral artery disease (PAD). Background. PAD affects more than 200 million people worldwide. Endovascular treatment of critical PAD has advanced in recent years. DES and DCB have demonstrated superiority compared to balloon angioplasty or bare metal stenting. The current literature lacks any long-term, direct comparison. Methods. A retrospective analysis was completed on patients who had femoral-popliteal interventions from June 2014 to June 2018 with either DCB or DES. Patient medical data and lesion characteristics were retrieved using the Vascular Quality Initiative database. Outcomes were analyzed through December 2019. Primary endpoint of time to clinical event-driven target lesion reintervention (TLR) and secondary endpoint of all-cause mortality were examined. Results. Four hundred eighty-three patients with a total of 563 interventions met the inclusion criteria. Three hundred fifty-nine DCB and 204 DES were performed. Of the DCBs, 132 required bailout stenting at the time of procedure. The mean time for TLR in the DES group was 1,277 days (SD 546), compared to 904 days (SD 330.1) for DCB. For patients requiring TLR, DES remained patent significantly longer (373 days longer on average) ( $p$ < 0.001). For all-cause mortality there was no significant difference at 50 months between DCB and DES ( $p$ = 0.06). Conclusions. In patients who required TLR, DES had a significantly longer length of time to reintervention vs DCB (average 373 days), although no difference in mortality was observed.

Changes in national endovascular management of femoropopliteal artery disease: an analysis of the 2011-2019 Medicare data

PURPOSE

Current evidence supports endovascular approaches (including balloon angioplasty, atherectomy, and stenting) for management of femoropopliteal peripheral artery disease (PAD); this study sought to describe national trends in utilization of each intervention.

METHODS

The Medicare Physician/Supplier Procedure Summary dataset containing 100% of part B claims were interrogated for years 2011-2019. Current procedural terminology codes specific for femoropopliteal angioplasty, stenting, and atherectomy were used to create summary statistics for utilization by year, place of service (hospital inpatient, hospital outpatient, and office-based lab), and provider specialty (cardiology, radiology, and surgery).

RESULTS

Atherectomy use increased from 34,732 procedures (33%) in 2011 to 75,435 (53%) in 2019 and became the dominant treatment strategy for femoropopliteal PAD. Relative utilization of stenting (36,793/35% to 28,899/20%) and angioplasty only (34,398/32% to 38,228/27%) decreased concomitantly from 2011 to 2019. Atherectomy use by 2019 was two-fold higher in office-based labs compared with the outpatient hospital setting (44,767 and 20,901, respectively). Treatment strategy varied by provider specialty in 2011 when cardiologists used atherectomy most frequently (17,925/43%), while radiologists used angioplasty alone (5,928/6%) and surgeons stented (18,009/37%) most frequently. By 2019 all specialties utilized atherectomy most frequently (29,564/59% for cardiology, 10,912/58% for radiology, and 33,649/47% for surgery).

CONCLUSION

National approach to endovascular management of femoropopliteal PAD has changed since 2011, towards an implant-free strategy including a multi-fold increase in atherectomy use. Discordant rates of atherectomy between the ambulatory hospital and office-based settings highlight the need for comparative effectiveness studies to guide management.

An indirect comparison by Bayesian network meta-analysis of drug-coated devices versus saphenous vein graft bypass in femoropopliteal arterial occlusive disease

OBJECTIVE

To compare the efficacy and safety between drug-coated devices (DCDs) and bypass surgery with saphenous vein graft (BSV) in femoropopliteal arterial occlusive disease.

METHODS

A Bayesian network meta-analysis and indirect comparison were performed. Randomized controlled trials of BSV, bypass surgery with prosthetic graft, bare metal stents, endoluminal bypass (covered stent), percutaneous transluminal angioplasty, and DCDs treating femoropopliteal arterial occlusive disease were collected. The primary end point was target lesion revascularization/target vessel revascularization, and secondary end points were all-cause mortality, limb salvage, and early complications (PROSPERO registry number: CRD42019136530).

RESULTS

Forty-two trials and 6867 patients were included. The comparison of DCDs and BSV revealed no significant difference in the 1-year target lesion revascularization/target vessel revascularization (DCDs vs BSV: odds ratio [OR], 0.60; 95% credible interval [CrI], 0.16-2.39). Total early complications from BSV were significantly higher than those from DCDs (DCDs vs BSV: OR, 0.14; 95% CrI, 0.05-0.45), and the main complications of BSV were not death related. There was also no significant difference in systemic early complications (DCDs vs BSV: OR, 0.19; 95% CrI, 0.00-7.82) and 1-year amputation rate (DCDs vs BSV: OR, 2.81; 95% CrI, 0.16-89.53). The 30-day (DCDs vs BSV: OR, 0.38; 95% CrI, 0.00-110.46), 1-year (DCDs vs BSV: OR, 0.96; 95% CrI, 0.24-3.29), 2-year (DCDs vs BSV: OR, 1.60; 95% CrI, 0.64-4.95), and 5-year all-cause mortality rates (DCDs vs BSV: OR, 2.05; 95% CrI, 0.92-4.39) showed no significant differences between DCDs and BSV, although there was a noticeable tendency toward significant results of a higher 5-year mortality rate.

CONCLUSIONS

There is no significant difference between DCDs and BSV in short-term efficacy or short- and long-term mortality. Despite traditional BSV remaining the gold standard, DCDs provide a reasonable alternative therapy. In addition, the DCDs have a lower short-term morbidity associated with the procedure at the cost of the possible risk of higher long-term mortality. Clinical trials with more validity are required for a direct comparison between BSV and DCDs.

Paclitaxel exposure: Long-term safety and effectiveness of a drug-coated balloon for claudication in pooled randomized trials

BACKGROUND

Paclitaxel drug-coated balloons (DCB) prevent recurrent claudication after angioplasty, yet data from randomized trials with incomplete follow-up have raised uncertainty regarding long-term mortality.

OBJECTIVES

To evaluate the effect of paclitaxel exposure on the long-term safety and efficacy of angioplasty of femoropopliteal artery lesions in the combined IN.PACT randomized trials.

METHODS

The IN.PACT randomized trials (SFA, N = 331 and Japan, N = 100) each compared the DCB with standard percutaneous transluminal angioplasty (PTA) for claudication, and consented patients for 5 and 3 years, respectively. To address long-term safety, sites were requested to obtain vital status follow-up. In the pooled, updated data set, we examined the association between randomized treatment and mortality by cumulative incidence and hazard ratio (HR), and freedom from clinically driven target lesion revascularization (CD-TLR). Multivariable Cox regression with adjustment for baseline characteristics was used to evaluate the dose effect. Causes of death were adjudicated by a blinded clinical events committee that included oncologists with paclitaxel expertise.

RESULTS

The rate of long-term vital status ascertainment increased from 81% to 97% for DCB and from 85% to 97% for PTA in the IN.PACT SFA trial. The cumulative incidence of mortality was 14.7% DCB versus 12.0% PTA at 5 years, HR 1.39, log-rank p = .286. Paclitaxel dose (mg) was not an independent predictor of mortality (HR 1.02, p = .381), but was an independent predictor of reduced risk of CD-TLR (HR 0.79; p < .001). Causes of death did not differ by treatment arm.

CONCLUSIONS

In pooled randomized trial data with updated vital status ascertainment, paclitaxel was associated with improved efficacy but was not associated with increased mortality.

Reewarm™ PTX drug-coated balloon in the treatment of femoropopliteal artery disease: A multi-center, randomized controlled trial in China

BACKGROUND

Drug-coated balloons (DCB) have demonstrated satisfactory clinical results in the treatment of femoropopliteal artery diseases.

OBJECTIVE

To evaluate the efficacy and safety of the Reewarm™ PTX DCB in the treatment of femoropopliteal artery lesions compared with plain balloon.

METHODS

This was a multi-center, parallel-group, randomized controlled trial in patients with femoropopliteal artery lesions in China,. The participants were randomized 1:1 to percutaneous transluminal angioplasty with Reewarm™ PTX DCB or with standard plain balloon (PTA group) after pre-dilatation with a residual stenosis less than 70%. The primary endpoint was late lumen loss (LLL) at 6 months in the intent-to-treat set. The secondary endpoints included the target lesion revascularization (TLR) and major advance events(MAE)rate at 12 months.

RESULTS

Between July 2014 and April 2017, a total of 200 patients were enrolled. The mean age of the subjects was 67.8 ± 9.2 years in the DCB group (n = 100) and 69.4 ± 10.3 years in the PTA group (n = 100). The LLL at 6 months in the DCB group was significantly lower than in the PTA group (0.5 ± 0.8 mm vs. 1.5 ± 1.2 mm, P < 0.001). The TLR rate in the DCB group was lower than in the PTA group at 12 months (15.0% vs. 29.0%, P < 0.05). The occurrence of MAE⁴ in the DCB group by 12 months was lower than in the PTA group (23.0% vs. 38.0%, P < 0.05).

CONCLUSION

Reewarm-PTX drug-coated balloon is associated with better efficacy and safety than the plain balloon for femoropopliteal lesion.

Facilitated Intravascular Ultrasound-Guided Balloon-Assisted Re-Entry Technique for Complex Lower-Extremity Chronic Total Occlusions: The FIBRE Technique

PURPOSE

To examine the efficacy and safety of the facilitated intravascular ultrasound (IVUS)-guided balloon assisted-re-entry (FIBRE) technique in the treatment of complex, chronic total occlusion (CTO) peripheral arterial lesions.

METHODS

A retrospective analysis of 150 patients undergoing peripheral intervention for lower extremity CTO was performed from 2014 to 2017 at two institutions. From the selected population, 10 patients with complex CTOs were identified using the FIBRE technique. Procedural success, 30 day and 6 month patency rates, ankle brachial index improvement, and complications were analyzed.

RESULTS

Ten out of 150 patients had the FIBRE technique utilized to attempt revascularization of a complex CTO of a femoropopliteal artery. Technical success was achieved in all 10 patients (100%). There were no intra-operative or peri-procedural complications reported including vessel perforation, bleeding, distal embolization, infrapopliteal vessel compromise, or infection. Arterial studies were obtained at 30 days and 6 months to assess patency in 9/10 patients (90%), with 1 patient being lost to follow up. Of the 9 patients, all 9 (100%) had documented arterial patency at both 30 days and 6 months. All patients reported improvement in symptoms. There were also no reports of re-intervention, amputation, or death at 6-month follow up.

CONCLUSIONS

The FIBRE technique is a safe and feasible strategy with excellent technical success in experienced hands for revascularization of complex lower extremity CTO when conventional modalities fail.

Novel, vessel anatomy adjusting drug-coated balloon-Preclinical evaluation in peripheral porcine arteries

BACKGROUND

The diameter of balloons or stents is selected according to the estimated reference vessel diameter and do not adapt to the vessel anatomy. The aim of the present preclinical studies was to investigate a novel, vessel anatomy adjusting hypercompliant drug-coated balloon catheter (HCDCB).

METHODS

Hypercompliant balloon membranes were coated in a constricted state with high drug density. Drug adherence was investigated in vitro, transfer to the porcine peripheral arteries and longitudinal distribution in vivo. In young domestic swine, neointimal proliferation was induced by vessel overstretch and continuous irritation by permanent stents. Uncoated hypercompliant balloons (HCB), and standard uncoated balloons and drug-coated balloons (DCB) served as controls. Efficacy was assessed by angiography, optical coherence tomography (OCT), and histomorphometry.

RESULTS

HCDCB lost 18.0 ± 3.9% of dose during in vitro simulated delivery to the lesion. Drug transfer to the vessel wall was 13.9 ± 6.4% and drug concentration was 1,044 ± 529 ng/mg tissue. Four weeks after treatment, the histomorphometric neointimal area was smaller with HCDCB versus uncoated HCB (2.39 ± 0.55 mm² vs. 3.26 ± 0.72 mm² , p = .038) and area stenosis (OCT) was less (11.6 ± 6.9% vs. 24.7 ± 9.7%, p = .022). No premature death occurred and no in-life clinical symptoms or treatment-associated thrombi were observed.

CONCLUSIONS

HCDCB were found to inhibit excessive neointimal proliferation. Balloon adaption to different vessel diameters and shapes may provide drug-delivery in irregular lumen and facilitate balloon selection.

Long-Term Clinical Effectiveness of a Drug-Coated Balloon for the Treatment of Femoropopliteal Lesions

Supplemental Digital Content is available in the text.

Background:

While randomized trials have demonstrated the superiority of drug-coated balloon (DCB) angioplasty versus standard percutaneous transluminal angioplasty (PTA) in patients with femoropopliteal peripheral artery disease, the long-term durability of DCB angioplasty remains uncertain.

Methods and Results:

IN.PACT SFA is a prospective, multicenter, randomized single-blinded trial (Randomized Trial of IN.PACT Admiral Paclitaxel-Coated Percutaneous Transluminal Angioplasty [PTA] Balloon Catheter vs Standard PTA for the Treatment of Atherosclerotic Lesions in the Superficial Femoral Artery [SFA] and/or Proximal Popliteal Artery [PPA]) that enrolled 331 subjects with symptomatic (Rutherford 2–4) femoropopliteal lesions. Subjects were randomly assigned 2:1 to the IN.PACT Admiral DCB or PTA. Assessments through 5 years included freedom from clinically driven target lesion revascularization, the primary safety end point, and major adverse events. Through 5 years, patients treated with the IN.PACT Admiral DCB demonstrated a sustained treatment effect with superior freedom from clinically driven target lesion revascularization when compared with PTA (Kaplan-Meier estimate of 74.5% versus 65.3%; log-rank P=0.020). The primary safety composite was achieved in 70.7% of subjects in the DCB and 59.6% in the PTA groups (P=0.068). The major adverse event rate was 42.9% for DCB and 48.1% for PTA (P=0.459). There were no device- or procedure-related deaths in either group as adjudicated by an independent and blinded Clinical Events Committee.

Conclusions:

The IN.PACT SFA randomized trial demonstrates that the IN.PACT Admiral DCB continues to perform better than PTA through 5 years with higher freedom from clinically driven target lesion revascularization. The sustained safety and effectiveness profile of this DCB supports its use as a preferred treatment choice compared with PTA for femoropopliteal lesions.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01175850 (IN.PACT SFA phase I) and NCT01566461 (IN.PACT SFA phase II).