Cutting Balloon Angioplasty (CBA) Versus Conventional Balloon Angioplasty (PTA) in the Pre-Dilatation of Carotid Artery Stenosis: Our Preliminary Experience

Selective-versus-Standard Poststent Dilation for Carotid Artery Disease: A Systematic Review and Meta-Analysis

BACKROUND

The safety and efficacy of standard poststent angioplasty in patients undergoing carotid artery stent placement have not been well-established.

PURPOSE

We conducted a systematic review of the literature to evaluate the safety and efficacy of carotid artery stent placement and analyzed outcomes of standard-versus-selective poststent angioplasty.

DATA SOURCES

A systematic search of MEDLINE, EMBASE, Scopus, and the Web of Science was performed for studies published between January 2000 and January 2015.

STUDY SELECTION

We included studies with >30 patients describing standard or selective poststent angioplasty during carotid artery stent placement.

DATA ANALYSIS

A random-effects meta-analysis was used to pool the following outcomes: periprocedural stroke/TIA, procedure-related neurologic/cardiovascular morbidity/mortality, bradycardia/hypotension, long-term stroke at last follow-up, long-term primary patency, and technical success.

DATA SYNTHESIS

We included 87 studies with 19,684 patients with 20,378 carotid artery stenoses. There was no difference in clinical (P = .49) or angiographic outcomes (P = .93) in carotid artery stent placement treatment with selective or standard poststent balloon angioplasty. Both selective and standard poststent angioplasty groups had a very high technical success of >98% and a low procedure-related mortality of 0.9%. There were no significant differences between both groups in the incidence of restenosis (P = .93) or procedure-related complications (P = .37).

LIMITATIONS

No comparison to a patient group without poststent dilation could be performed.

CONCLUSIONS

Our meta-analysis demonstrated no significant difference in angiographic and clinical outcomes among series that performed standard poststent angioplasty and those that performed poststent angioplasty in only select patients.

Cutting-balloon angioplasty of resistant ureteral stenosis as bridge to stent insertion

Ureteral stenting is a routine, minimally invasive procedure performed for relief of benign or malignant obstruction. In case of ureteral stenosis, to allow a correct insertion of the stent, a predilatation of the ureter stenosis with a conventional balloon catheter can be necessary. In exceptional cases, it can be difficult to advance an 7-8 Fr JJ-catheter over a tight resistant ureter stenosis following unsuccessful high-pressure balloon dilatation. In the present report, we describe two cases of resistant ureter stenosis successfully dilated by a cutting-balloon following the failure of high-pressure balloon dilatation, allowing a correct and uncomplicated antegrade stent insertion.

How to avoid complications associated with carotid angioplasty and stenting

Carotid angioplasty and stenting (CAS) has been proposed as an alternative to surgery and is now performed more frequently and is well accepted, at least for high surgical risk patients. However, complications and particularly embolic strokes, even with a meticulous technique, can occur at any step of the procedure. Silent embolism is detected after CAS and may be a problem that needs to be discussed. To avoid and reduce these complications associated with CAS, it is important to have good indications dependent upon on good patient and lesions selection, as well as correct technique. New parameters have been proposed, particularly for asymptomatic lesions. The authors consider that embolic protection devices (EPDs) are mandatory for CAS, and new techniques will be presented. The choice of the EPD depends on the clinical status of the patient, the lesion morphology and characteristics, and the anatomy of the artery. All stents are not equivalent and so a good choice of the stent is necessary to avoid and reduce the complications associated with CAS, and experienced operators are also needed. With all these considerations, CAS can now be performed with acceptable outcomes and in certain population the results are comparable or superior to surgery. The results of ongoing randomized trials are awaited.

Cutting balloon angioplasty in percutaneous carotid interventions

PURPOSE

To report a prospective feasibility study of cutting balloon angioplasty (CBA) applied in the predilation phase of carotid artery stenting (CAS) in highly calcified lesions.

METHODS

From January 2003 to February 2007, 178 consecutive patients (109 men; mean age 73.1+/-7.3 years) with highly calcified carotid lesions underwent CAS with CBA applied as a pre-specified strategy in the predilation phase of the procedure. All steps in the procedure were performed under cerebral filter protection. The cutting balloon ranged in diameter from 3 to 4 mm and was inflated at nominal pressures in the target lesion. Pre-CBA dilation with a low-profile coronary balloon was performed only when the cutting balloon was not able to cross the lesion. Selection of the filters and stents was at the operator's discretion. Primary endpoints were the all stroke and death rates at 30 days and 6 months. Secondary endpoints included cutting balloon success (positioning and full balloon inflation), CAS technical success (residual angiographic stenosis <30%), CAS procedural success (technical success and no complications), and in-hospital major complications.

RESULTS

Cutting balloon success was achieved in all 178 patients. In 32 (18.0%), pre-CBA dilation was necessary due to inability to cross the lesion with the cutting balloon initially. CAS technical success was achieved in all patients. One (0.6%) patient suffered transient neurological intolerance due to flow cessation from massive debris in the distal filter; this event was completely resolved after the filter was removed (CAS procedural success 99.4%). One patient suffered a major stroke at day 15 (0.6% 30-day all stroke and death rate). At the 6-month follow-up, 174 (97.7%) patients were evaluated; 1 patient died from myocardial infarction at day 35, and 2 patients died from non-neurological or cardiac causes at days 103 and 158. The cumulative all stroke and death rate was 2.2%.

CONCLUSION

These data suggest that CBA performed during the predilation phase of CAS in highly calcified lesion is a safe and useful method to prepare this lesion subset for stenting.

Cutting balloon versus conventional balloon angioplasty in short femoropopliteal arterial stenoses

PURPOSE

To compare midterm results of cutting balloon angioplasty (CBA) to conventional percutaneous transluminal angioplasty (PTA) for the treatment of short femoropopliteal arterial stenosis.

METHODS

Between February 2004 and June 2006, 84 consecutive patients (49 men; mean age 68.5 years, range 53-89) with a total of 142 focal (<3 cm), calcified femoropopliteal occlusive lesions underwent endovascular treatment via an antegrade approach: 40 patients (67 lesions) were treated with PTA and 44 patients (75 lesions) underwent CBA. Follow-up consisted of clinical examination and color duplex ultrasonography at intervals to 2 years.

RESULTS

All treatments were technically successfully, without any major complication. In 4 (6%) of 67 lesions treated with PTA, a self-expanding stent was implanted due to a flow-limiting dissection; no patient treated with CBA had recoil, dissection, or arterial tears requiring stent placement. In the PTA group, primary and secondary patency rates, respectively, were 91.0% and 95.5% at 6 months, 83.1% and 92.4% at 12 months, and 66.6% and 76.5% at 2 years. In the CBA patients, the primary and secondary patency rates, respectively, were 93.2% and 95.9% at 6 months, 90.4% (p<0.001 versus PTA at same interval) and 94.5% at 12 months, and 79.7% (p<0.001) and 85.6% (p<0.001) at 2 years.

CONCLUSION

CBA seems to be a valuable tool in the endovascular treatment of short femoropopliteal stenotic lesions, achieving better patency at midterm compared to conventional PTA.