Early Experience with a New Concept of Angioplasty Nitinol-Constrained Balloon Catheter (Chocolate®) in Severely Claudicant Patients

Short-term efficacy of endovascular procedures for lower extremity thromboangiitis obliterans (Buerger's disease)

PURPOSE

Although thrombolysis obliterans (TAO) has been recognized for more than a century, there is no optimal treatment for this disease. The aim of this report was to compare the short-term efficacies of catheter-directed thrombolysis (CDT), percutaneous transluminal angioplasty (PTA) and CDT+PTA in treating TAO disease.

METHOD

Consecutive patients with TAO treated at Ganzhou People's Hospital between 2012 and 2022 were included in this retrospective study. According to the information provided in the medical records, endovascular procedures included CDT, PTA or CDT+PTA. One-year follow-up outcomes of the patients with TAO who underwent endovascular procedures were compared. The primary outcome was major adverse limb event (MALE) and the secondary outcomes were the technical success, complications, ABI at 1 week after surgery and minor amputation.

RESULTS

Sixty-nine patients with TAO were assessed for inclusion in our single-center study from 2012 to 2022 and received endovascular procedures. Among them, 22 patients underwent CDT, 21 patients underwent PTA, and 26 patients underwent PTA+CDT. The one-year follow-up revealed significant differences in the MALE-free survival rates among the three groups, particularly between the CDT group and the PTA+CDT group (the hazard ratio (HR) for MALE-free survival was 0.173, 95% CI [0.050-0.599], p = 0.006). The technical success rates of the three groups were 63.6%, 90.5%, and 92.3%, respectively. There were differences in the ABI at one week after surgery among the three groups.

CONCLUSIONS

Endovascular procedures are effective for TAO in the short term. The effectiveness of CDT alone is suboptimal; combining CDT with PTA achieves the most favorable endovascular treatment outcome; while the effectiveness of PTA falls in between these two procedures.

The Ability to Look Beyond: The Treatment of Peripheral Arterial Disease

This paper offers a practical overview of the contemporary management of patients with peripheral arterial disease presenting intermittent claudication (IC), including clinical and instrumental diagnosis, risk factors modification, medical management, and evidence-based revascularization indications and techniques. Decision making represents a crucial element in the management of the patient with IC; for this, we think a review of this type could be very useful, especially for non-vascular specialists.

Specialty Balloons for Vessel Preparation During Infrainguinal Endovascular Revascularization Procedures: A Review of Literature

Balloon angioplasty with/without utilizing drug eluting technology or stenting constitutes the treatment of choice for a significant percentage of patients with peripheral artery disease requiring an intervention. However, in cases of diffuse disease and plaque complexity, angioplasty may lead to dissection, recoil, and/or early restenosis, making vessel preparation a key component for successful and durable endovascular revascularization outcome. This review of literature aims to present contemporary data for several commercially available specialty balloons that have been designed to minimize the arterial wall stress of conventional balloon angioplasty and facilitate technical success, as well as long-term patency.

Impact of Chocolate percutaneous transluminal angioplasty balloon on vessel preparation in drug-coated balloon angioplasty for femoropopliteal lesion

Purpose

To compare the impact of Chocolate and conventional balloons on vessel preparation in percutaneous transluminal angioplasty.

Materials and methods

This single-center retrospective study included 111 endovascular therapy consecutive cases of femoropopliteal lesions using drug-coated balloon strategy with a 1:1 pre-dilation balloon diameter between February 2020 and August 2021, divided into the Chocolate percutaneous transluminal angioplasty (n = 48) and conventional (n = 63) groups. Before the availability of Chocolate balloons in Japan (December 2020), a standard semi-compliant or non-compliant balloon was used for vessel preparation. The primary endpoint was rate of severe dissection after pre-dilatation. Secondary endpoints were angiographic percent diameter stenosis, bailout stent rate, primary patency rate, and freedom from target-lesion-revascularization rate at six months.

Results

There was no significant difference in patient and lesion characteristics. The procedural characteristics comprised balloon length 90 ± 37 and 149 ± 95 mm (P = 0.004) and inflation pressure 11 ± 3 and 16 ± 7 atm (P < 0.001) in the Chocolate and conventional groups, respectively. Regarding primary endpoint, rates of severe dissection were 4.2% and 25% (P = 0.003); regarding secondary endpoints, percent diameter stenosis was 18 ± 15% and 20 ± 17% (P = 0.409), and the rate of bailout stenting was 2.1% and 15.9% (P = 0.016) in the Chocolate and conventional groups, respectively. The primary patency rates at six months were 89.1% and 85.2% (P = 0.670), and freedom from target-lesion-revascularization rate at six months was 100% and 92.8% (P = 0.691) in the Chocolate and conventional groups, respectively.

Conclusion

Chocolate percutaneous transluminal angioplasty balloons reduce the rate of severe dissection while maintaining a sufficient dilatation effect during drug-coated balloon vessel preparation.

State-of-the-Art Endovascular Therapies for the Femoropopliteal Segment: Are We There Yet?

Peripheral arterial disease is an increasingly prevalent condition with significant associated morbidity, mortality, and health care expenditure. Endovascular interventions are appropriate for most patients with either ongoing symptoms of intermittent claudication despite lifestyle and medical optimization or chronic limb-threatening ischemia. The femoropopliteal segment is the most common arterial culprit responsible for claudication and the most commonly revascularized segment. Endovascular approaches to revascularization of the femoropopliteal segment are advancing with an evolving landscape of techniques for arterial access, device-based therapies, vessel preparation, and intraprocedural imaging. These advances have been marked by debate and controversy, notably related to the safety of paclitaxel-based devices and necessity of atherectomy. In this review, we provide a critical overview of the current evidence, practice patterns, emerging evidence, and technological advances for endovascular intervention of the femoropopliteal arterial segment.

Endovascular Materials and Their Behavior in Peripheral Vascular Surgery

Endovascular techniques have progressively become the first option for the treatment of stenosis and occlusions of both aorto-iliac and femoro-popliteal district. The development of new technologies and new materials has broadened the applicability of the endovascular techniques, allowing the treatment of each lesion with the most suitable material. A knowledge of the behavior of endovascular materials when treating peripheral arterial disease (PAD) is, therefore, crucial for optimization of the results. Here, we aim to review the most important technical features of the actually available endovascular materials for treating PAD.

Vessel Preparation Is Essential to Optimize Endovascular Therapy of Infrainguinal Lesions

Symptomatic peripheral arterial disease management involves medical treatment and interventional procedures. Intermittent claudication and critical limb threatened ischemia (CLTI) should be individually considered with specific outcomes and procedures. When intervention is required, an endovascular approach is usually the first-line option. Plain balloon angioplasty was previously used to dilate clinically significant femoropopliteal lesions with variable results. However, over recent years, the use of self-expanding nitinol stents has enabled treatment of long lesions, yielding significantly improved clinical results. Drug-eluting technology has also exhibited a capacity to limit in-stent restenosis and to drive target revascularization. Nevertheless, calcifications and elastic recoil of the arterial wall remain risk factors for early restenosis and failure. Therefore, vessel preparation using specific devices is required to modify vessel compliance and debulk obstructive calcification. In this short review, we provide an overview of the options for gaining lumen before stenting or dilation using drug-coated balloons.

Is vessel prep necessary before treating the superficial femoral artery?

The standard of care for treating symptomatic peripheral arterial disease has been percutaneous transluminal angioplasty with or without stenting over the last couple of years. This endovascular treatment of claudicants or patients with critical limb ischemia has increased in numbers and has even surpassed open surgery. Our daily practice has evolved to an endovascular-first approach, especially in the femoropopliteal region, being the most frequently treated vessel. However, neointimal hyperplasia and elastic recoil leading to target lesion restenosis or occlusion after initial successful treatment is not uncommon. In recent years, drug-eluting technologies on balloons or stents have been investigated as a potential solution for this problem with excellent results compared to plain-old balloon angioplasty. Nonetheless in the majority of those trials, the bailout stenting rate increased with lesion complexity, albeit it in long or heavily calcified lesions due to flow-limiting dissections, elastic recoil or the calcium barrier preventing adequate drug uptake. There is a need for vessel preparation in order to ameliorate drug delivery, especially in complex lesions. Multiple devices are available to prepare even the most challenging lesions for drug uptake or stenting, by achieving maximal luminal gain and by minimizing dissections. This review aims to give an overview of the most common modalities for vessel preparation in the superficial femoral artery beside plain old balloon angioplasty together with an overview of the current literature of each device in the superficial femoral artery.

Recanalization of bilateral axillaris/brachialis artery occlusion in a patient with Takayashu arteritis: First case report on using a novel drug-coated nitinol "chocolate" balloon catheter

When fibrosis develops in Takayasu arteritis (TA), endovascular treatment may become necessary. A 63-year-old woman with TA underwent PTA with a nitinol-structured (chocolate-like) drug-coated balloon (C-DEB PTA). She remained in remission for >1 year. The case may foster research into the use of C-DEB PTA in TA.

Unexpected Complication of a Nitinol-Constrained Balloon Angioplasty (Chocolate) in Rutherford Class 3 Patient Presenting Challenging Aorto-Iliac Anatomy

We report an unusual complication of Chocolate nitinol-constraining structure after right superficial femoral artery (SFA) angioplasty. The procedure was performed by vascular surgeons in an operating theater equipped by a portable fluoroscopy unit. Under local anesthesia, by a contralateral approach, a 7F introducer sheath was advanced through the proximal portion of the right common iliac artery. Owing to the severe aorto-iliac vessels calcification, it was not possible to place the introducer sheath into a more distal vessel, as planned. After external iliac artery (EIA) stenting (7 × 80 mm Eluvia), SFA obstruction was intraluminal crossed, and a 6 × 120 mm nitinol-constrained balloon (Chocolate; Medtronic) was advanced in place and inflated. Once the balloon came out, the nitinol-constraining structure was not attached to the balloon surface. Under fluoroscopy, the crashed nitinol mesh was identified at distal edge of previously positioned EIA stent. To prevent mesh migration, it was fixed by covering with a 7 × 40 mm stent. The procedure was then successfully completed, as planned. One-month, postoperative computed tomography angiography showed complete expansion of the stents and no significant residual stenosis (>30%) in EIA, and SFA. Chocolate's mesh was still evident between the stent and the iliac artery wall, in absence of further complications. A 3 months follow-up, patient was still completely asymptomatic for claudication.