Real-World Results of Supera Stent Implantation for Popliteal Artery Atherosclerotic Lesions: 3-Year Outcome

A Bibliometric Analysis on Adherence to Reporting Standards for Endovascular Treatment of Chronic Lower Extremity Peripheral Artery Disease

OBJECTIVE

The treatment of chronic limb threatening ischemia (CLTI) involves a broad spectrum of therapies including many new and emerging techniques. To standardize results of studies examining this pathology and to allow critical analysis and comparison between studies, the Society for Vascular Surgery recommended reporting standard guidelines for the endovascular management of CLTI in 2016. Research studies that do not adhere to complete reporting standards are often more ambiguous in impact and external validity, leading to bias and misinformation that has potentially damaging effects on clinical decision making. We thus sought to examine adherence to, and factors associated with non-compliance with these recommended guidelines.

METHODS

A literature database search was conducted to include all clinical trials, randomized controlled trials, and retrospective comparative studies written in English examining the endovascular treatment of PAD/CLTI from January 2020 to August 2022. Systematic reviews, case reports and meta-analysis were excluded. The manuscripts were reviewed for adherence with the SVS guidelines (overall and by guideline subcategories based on demographics, treatment methods and outcomes), and factors associated with this adherence were determined. This data was used to calculate descriptive and comparative statistics.

RESULTS

54 manuscripts were identified from this timeframe. On average, articles reviewed reported on 42.0% of the SVS reporting standards (range 25.0-65.2%, Fig 1) with 74.1% of articles (n=40) not adhering to at least 50.0% of the standards. Manuscripts most completely followed guidelines regarding "Patient Factors" and were least likely to demonstrate adherence to description of CLTI and study complications. Within the guideline subcategories, complete adherence to guidelines was not demonstrated in any manuscript in stent trials, disease outcome measures, technical outcome measures, patient factors and critical limb ischemia description, and complete adherence rates within the other subcategories was low (range 5.6-18.6%). Studies conducted within the United States and those with industry sponsorship were more likely to adhere to >50% of the reporting standards (p<0.05). Journal impact factor, year of publication, and number of authors had no correlation to the percent adherence to guidelines in specific categories or adherence overall.

CONCLUSIONS

Adherence to reporting standard guidelines for endovascular treatment of lower extremity PAD specifically outlined by the SVS is suboptimal regardless of the quality of the journal the research is published in. Increasing adherence to reporting standards to provide a framework for comparison of studies across techniques used should be prioritized by authors, journal editors, and vascular societies.

Clinical Outcomes After Drug-Coated Balloon Treatment in Popliteal Artery Disease: K-POP Registry 12-Month Results

BACKGROUND AND OBJECTIVES

The popliteal artery is generally regarded as a "no-stent zone". Limited data are available on the outcomes of drug-coated balloons (DCBs) for popliteal artery disease. This study aimed to evaluate the 12-month clinical outcomes among patients who received DCB treatment for atherosclerotic popliteal artery disease.

METHODS

This prospective, multicenter registry study enrolled 100 patients from 7 Korean endovascular centers who underwent endovascular therapy using IN.PACT DCB (Medtronic) for symptomatic atherosclerotic popliteal artery disease. The primary endpoint was 12-month clinical primary patency and the secondary endpoint was clinically driven target lesion revascularization (TLR)-free rate.

RESULTS

The mean age of the study cohort was 65.7±10.8 years, and 77% of enrolled patients were men. The mean lesion length was 93.7±53.7 mm, and total occlusions were present in 45% of patients. Technical success was achieved in all patients. Combined atherectomy was performed in 17% and provisional stenting was required in 11%. Out of the enrolled patients, 91 patients completed the 12-month follow-up. Clinical primary patency and TLR-free survival rates at 12 months were 76.0% and 87.2%, respectively. A multivariate Cox regression analysis identified female and longer lesion length as the significant independent predictors of loss of patency.

CONCLUSIONS

DCB treatment yielded favorable 12-month clinical primary patency and TLR-free survival outcomes in patients with popliteal artery disease.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02698345.

Navigating complexity: The Supera's triumph in femoropopliteal lesions

INTRODUCTION

The femoropopliteal sector endovascular treatment is particularly challenging due to its high tortuosity and torsional forces. Better results are still needed to ensure the long-term patency of stenting in this area. The Supera stent appears to change this paradigm.

METHODS

This single-center retrospective cohort study aims to evaluate the efficacy and safety of femoropopliteal stenting with Supera in a real-world population. Seventy-nine patients were treated between January 2015 and December 2020, and the results are reported with a median follow-up of 28 months.

RESULTS

Indications for revascularization were chronic limb-threatening ischemia with tissue loss (73.6%) or ischemic rest pain (17.7%) and claudication (7.6%). Thirty-six patients (45.6%) were classified as GLASS stage III according to the Global Limb Anatomic Staging System, with 65.8% and 30.4% in grades 3 and 4 of femoropopliteal and infrapopliteal sectors, respectively. The 36-month primary, primary-assisted, and secondary patency rates were 68.6%, 72.0%, and 79.0%, respectively, with an amputation-free survival rate of 86.6%. There was no significant difference between primary patency rates in GLASS stages I-II compared with GLASS stage III (36-month primary patency rates of 72% vs 63% respectively, p = 0.342) nor in amputation-free survival (88% vs 84%, p = 0.877). After adjusting for potential confounders, only the stent conformation significantly affected the primary patency rates, with a higher hazard of reintervention for the elongated (HR = 3.179; p = 0.36; CI 1.081-9.347) and the compressed (HR = 3.014; p = 0.42; CI 1.039-8.746) forms.

CONCLUSIONS

The 36-month patency of the Supera stents in our real-world cohort was similar to other reported series. The GLASS stage did not interfere with the stent patency, proving it is a good choice even in the most adverse anatomy patients. Only the non-nominal stent conformation affected the primary patency rates in our patients.

Biomimetic Stents for Infrainguinal Peripheral Arterial Disease: Systematic Review and Meta-Analysis

OBJECTIVE

Biomimetic stents are peripheral infrainguinal self expanding stents that mimic the anatomy of the vasculature and artery movement. They are indicated for use in infrainguinal arteries. This research aimed to synthesise all current evidence on the use of biomimetic stents as adjuncts for endovascular treatment of infrainguinal peripheral arterial disease (PAD), helping to guide clinical decision making.

DATA SOURCES

MEDLINE, Embase, CINAHL and Cochrane databases.

REVIEW METHODS

Random effects meta-analysis following PRISMA guidelines (PROSPERO registration CRD42022385256). Study quality was assessed using the Joanna Briggs Institute critical appraisal tools checklist, and certainty assessment through the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Endpoints included primary patency, target lesion revascularisation, stent fracture, secondary patency, and Death at one year.

RESULTS

In total, 37 studies were included in the meta-analysis (33 cohort studies, two case series, and two randomised controlled trials [RCTs]), representing 4 480 participants. Of these, 34 studies included data on the Supera (81.5% of participants) and three studies reported data on the BioMimics 3D (18.5% of participants) stents. The pooled primary patency rate of 33 studies at one year follow up was 81.4% (95% confidence interval [CI] 78.7 - 83.9%), and the pooled target lesion revascularisation rate of 18 studies at one year was 12.2% (95% CI 9.6 - 15.0%). The certainty of evidence outcome rating as qualified by GRADE was very low for both. Only one study reported a positive stent fracture rate at one year follow up of 0.4% with a certainty of evidence outcome of low.

CONCLUSION

Using biomimetic stents for infrainguinal PAD may be associated with acceptable one year primary patency and target lesion revascularisation rates, with a near negligible one year stent fracture rate. Their use should be considered in those presenting with infrainguinal PAD undergoing endovascular revascularisation. A RCT is necessary to determine their clinical and cost effectiveness.

Endovascular treatment with interwoven nitinol stent for common femoral artery lesions: 2-year outcomes of a single center experience

OBJECTIVE

The study aimed was to report 2-year outcomes of endovascular treatment with interwoven nitinol (Supera™) stent for common femoral artery (CFA) lesions.

METHODS

We reviewed the clinical data of 20 patients who presented with CFA stenosis or occlusion and underwent balloon angioplasty followed by Supera™ stenting in CFA between February 2016 and January 2022. The outcomes were evaluated in these patients in terms of technical success, post-intervention complications, reintervention, and cumulative patency (1 year, and 2 years).

RESULTS

The study included 20 patients (22 lesions) who presented with isolated CFA lesions (3), iliac lesions involving CFA (6), superficial femoral artery (SFA) lesions involving CFA (8), and extensive lesions from the iliac artery to SFA (5). There were 16 men (80%) with a mean age of 69.7 years (range, 34-83). Hypertension, smoking, and diabetes were found in 15 (75%), 7 (35%), and 7 patients (35%), respectively. Clinical presentations were Rutherford stage 5 (9, 45%), Rutherford stage 4 (5, 25%), Rutherford stage 6 (4, 20%), and Rutherford stage 3 (2, 10%). Technical success was achieved in all patients (100%). The procedures for treatment were isolated CFA Supera™ stenting (1, 4.5%), CFA plus DFA Supera™ stenting (jailed SFA) (2, 9.1%), CFA plus SFA Supera™ stenting (jailed DFA) (8, 36.4%), CFA Supera™ stenting plus bare iliac stenting (Astron) (6, 27.3%), CFA plus SFA Supera™ stenting (jailed DFA) plus bare iliac stenting (Astron) (5, 22.7%), and additional DFA angioplasty (7, 31.8%). The rate of in-hospital mortality and morbidity were 0% and 10%, respectively. Distal embolization after pre-dilatation occurred in 1 patient, and cerebral infarction occurred 12 h after the procedure in 1 patient. The mean follow-up time was 23 months (range, 2-64). During the follow-up period, in-stent occlusion occurred in 2 patients at 9 and 46 months. Re-intervention was performed in 1 patient due to recurrent symptom of claudication. The cumulative primary patency at 1 year and 2 years were 93.3% and 93.3%, respectively.

CONCLUSION

Endovascular treatment with interwoven nitinol (Supera™) stent for CFA lesions was associated with acceptable outcomes at 2 years.

Repeated thrombus occlusion in superficial femoral artery at the gap between two stents: a case report

Background

In recent years, endovascular treatment has emerged as a preferred option for treating long lesions in the superficial femoral artery (SFA), including those classified as Trans-Atlantic Inter-Society Consensus IIC and D. This approach may involve the use of multiple stents to ensure adequate coverage of the entire lesion, as maintaining primary patency is a key consideration in the treatment strategy.

Case summary

An 82-year-old woman underwent endovascular treatment with two stents for a chronic total occlusion lesion in the left SFA. Six months later, she was admitted to our hospital with acute limb ischaemia (ALI). Angiography revealed significant thrombus within the stents and a gap between the stents, while intravascular ultrasounds showed neointimal hyperplasia at the gap. Initially, the patient was treated with a cutting balloon for the gap, but experienced another episode of ALI the following day. Subsequently, a stent was placed to cover the gap, resulting in the resolution of ALI without further recurrence.

Discussion

Superficial femoral arteries expose the stent to high stresses due to the unique external forces. When multiple stents are implanted, there must be sufficient overlap. If a stent gap occurs, stent deployment is unavoidable due to the neointimal hyperplasia as well as the coronary stent gap. Further research and clinical expertise are needed to optimize stent placement strategies and minimize stent-related complications in SFA lesions.

High-Risk Characteristics for Clinical Failure after Isolated Femoropopliteal Peripheral Vascular Interventions

BACKGROUND

Recent studies suggesting increased late mortality with paclitaxel-coated devices (PCDs) in femoropopliteal peripheral vascular interventions (PVIs) prompted the US Food and Drug Administration to recommend limiting the use of PCDs to "patients at particularly high risk for restenosis". This study's aim is to characterize patients at high risk for restenosis and develop a risk score to guide clinicians in selecting patients for treatment with PCDs.

METHODS

Patients who underwent isolated femoropopliteal PVI for claudication or rest pain from 2016-2019 in the Vascular Quality Initiative were included. Patients who received intervention with a PCD, hybrid procedures, died within 1 year, or had missing follow-up data were excluded. The primary end point was clinical failure at 1 year defined as > 50% restenosis, loss of patency, reintervention, or major amputation. Data were split randomly into 2/3 for development and 1/3 for validation. A parsimonious multivariable hierarchical logistic regression for clinical failure was developed and a risk score was created using beta-coefficients. The risk score was applied to the validation dataset and tested for goodness-of-fit and discrimination.

RESULTS

Among 4,856 treated patients, 718 (14.8%) experienced clinical failure within 1 year. Clinical failure was associated with age ≤ 50 years, female sex (48.1% vs. 39.5%), insulin-dependent diabetes (29.9% vs. 23.1%), creatinine > 2.0 mg/dL (9.9% vs. 5.7%), prior ipsilateral lower extremity revascularization (48.5% vs. 38.5%), prior ipsilateral minor amputation (5.3% vs. 1.7%), rest pain versus claudication (30.8% vs. 18.7%), occlusion length ≥ 20 cm (18.8% vs. 15.0%), and Trans-Atlantic Inter-Society Consensus II Classification C or D (40.4% vs. 28.0%), all P ≤ 0.01. Risk score development was performed using a multivariable regression. The model demonstrated good fit and discrimination (C-statistic 0.71 in development and 0.72 in validation dataset). Predicted clinical failure was 8.9% for standard-risk (45.9% of interventions), 15.5% for high-risk (44.2% of interventions), and 33.8% for very high-risk patients (9.8% of interventions).

CONCLUSIONS

A novel risk score was created with good discrimination for identifying patients at high risk for clinical failure at 1 year after femoropopliteal PVI for claudication and rest pain. Patients at high risk and very high risk for clinical failure may benefit from alternative strategies including PCDs.

Three-Year Real-World Outcomes of Interwoven Nitinol Supera Stent Implantation in Long and Complex Femoropopliteal Lesions

BACKGROUND

Peripheral artery disease (PAD) remains a major issue in modern societies and affects more than 200 million people around the world. Endovascular methods have been evaluated to be safe and effective in limb salvage. The Supera is able to withstand increased compression, biomechanical stress and to have higher radial force. The objective of this study is to evaluate performance, durability and 3-year patency of Supera stent implantation in severe femoropopliteal disease.

METHODS

A retrospective real-world analysis was performed with consideration of 77 patients that had a Supera stent implanted with femoropopliteal atherosclerotic disease at a single center. Among the 77 individuals, 92 Supera stents were implanted. Analysis of patients' demographics, lesions characteristics, reintervention rates and patency rates was performed.

RESULTS

The median follow-up was 33 months and ranged from 0 to 84 months. Chronic limb-threatening ischemia was observed among 43 patients. Mean lesion length was 152.8 ± 94.6 mm. Chronic total occlusions were observed in a majority of lesions. Overall, primary patency rates at 6, 12, 24 and 36 months were 85.0%, 73.6%, 59.2% and 53.2%, respectively.

CONCLUSIONS

The Supera stent is effective in the management of long and complex lesions. The results of patency rates were evaluated to be worse among lesions extending to the popliteal artery.

Drug coated balloon improves outcomes of sub-optimal Supera deployment in the intermediate term

Sub-Optimal deployment of Self expanding interwoven stents (Supera) has been shown to increase the rate of Clinically Driven Target Lesion Revascularization (CD-TLR). Meanwhile, drug coated balloons (DCB) have been shown to reduce CD-TLR in the femoral-popliteal segment in de- novo and restenotic lesions. However, the clinical effects of vessel preparation with DCB in nominal, compressed, and elongated Supera has not been widely studied. The purpose of this study is to assess the outcomes of clinically driven re-intervention, major amputations, and mortality in relation to the use of DCB as vessel preparation in different deployment conditions (nominal, compressed, elongated) of the Supera stent. Patient chart data was collected at a single center hospital between March 2015 and May 2020. All patients were adults (≥ 18 years old) and were treated with at least one (≥ 1) Supera stent. Deployment status was extrapolated from anonymized angiograms. The primary endpoint of this study was CD-TLR. Secondary endpoints included amputation and mortality rates associated with each deployment condition. A total of 670 limbs were treated and patients were followed for 36 months. Nominal stent deployment was observed in 337 limbs, followed by elongated condition (n = 176), then by compressed conditions (n = 159). CD-TLR was observed most frequently with elongated deployment. Drug coated balloons were used as vessel prep prior to stenting and showed a protective effect regardless of deployment status; O.R = 0.44 (CI 0.30-0.66, p < .05).

Endovascular retrieval of an elongated Supera stent

Stenting is used to achieve artery patency, and the Supera stent, a self-expanding interwoven nitinol stent, has produced good clinical outcomes. A 70-year-old woman with peripheral artery disease had experienced intermittent claudication (Fontaine stage IIb). Endovascular treatment was performed for a chronic total occlusion TransAtlantic InterSociety Consensus class II type B lesion. A Supera stent (Abbott Vascular, Santa Clara, CA) was used. However, it had become severely elongated to the proximal end in the superficial femoral artery and was removed using a balloon inserted from the side and trapped to the guide sheath with the distal end of the stent outside the sheath. After this bailout, an alternate stent could be placed through an antegrade approach to the contralateral common femoral artery.

Supera stent implantation for the treatment of isolated popliteal artery disease systematic review and evaluation of current endovascular strategies

&lt;b&gt;Introduction:&lt;/b&gt; The anatomical location of the popliteal artery is one of the greatest challenges for percutaneous interventions. The biomechanical attributes of the vessel lead to higher rates of restenosis, stent fracture, and occlusion. Some surgeons consider the popliteal artery as a no stenting zone. Many specialists favor percutaneous transluminal angioplasty to be the first line of endovascular treatment in the popliteal artery with bail-out stent implantation if the results are suboptimal. The Supera peripheral stent system is a novel stent that has been manufactured with a high degree of flexibility and supposedly might be appropriate for implantation in the popliteal artery. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Aim:&lt;/b&gt; Evaluation of the performance of Supera stent in isolated popliteal artery disease in comparison to other methods of treatment. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Methods:&lt;/b&gt; As many as 92 articles were found in the databases and after full-text review, 4 studies matched the inclusion criteria and were evaluated. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Results:&lt;/b&gt; Primary patency rates of Supera implantation in an isolated popliteal artery at 12 months ranged from 68% to 90%. In all four studies, no stent fractures were observed. Only one study provided longer follow-up than 12 months and evaluated the performance of the Supera stent 36 months after implantation. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusion:&lt;/b&gt; In conclusion, mentioned studies show promising and superior to other stent patency rates of the Supera stent regarding popliteal artery lesions. What is more, no stent fracture is promising regarding longer follow-up. However, more studies with longer follow-ups and direct comparison to other methods are required to fully evaluate Supera&apos;s performance in the popliteal artery.

Excimer laser ablation combined with drug-coated balloon versus drug-coated balloon in the treatment of de novo atherosclerotic lesions in lower extremities (ELABORATE): study protocol for a real-world clinical trial

Background

The efficacy and validity of excimer laser ablation (ELA) in the in-stent restenosis (ISR) has been confirmed. However, its application in de novo atherosclerotic lesions of lower extremity artery disease (LEAD) has not been clearly defined and its procedure has not been standardized.

Methods

ELABORATE is a prospective, multicenter, real-world study designed to evaluate the efficacy and safety between ELA combined with drug-coated balloon (DCB) and DCB alone in de novo atherosclerotic lesions of LEAD.

Discussion

ELABORATE is a prospective, multicenter, real-world study designed to assess the efficacy and safety between ELA combined with drug-coated balloon (DCB) and DCB alone in patients with de novo atherosclerotic lesions of LEAD. According to the real-world situation, eligible patients will be allocated to ELA + DCB group (group E) and DCB group (group C). Baseline and follow-up information (at 3, 6, and 12 months) will be collected. The primary efficacy point is primary patency at 12-months, and the secondary efficacy points include clinically driven target lesion reintervention (CD-TLR), change of Rutherford class, ankle-brachial index and ulcer healing rate. These indexes will be assessed and recorded at 3, 6, and 12-month follow-up. Also, safety evaluation, including major adverse event, all-cause mortality through 30-day follow-up, unplanned major amputation, bailout stent and distal embolization, will also be evaluated by an independent core laboratory. All the data will be collected and recorded by the electric data capture system. This study will be finished in 3 years and the 12-month results will be available in 2023. All the patients will be followed for 5 years.

Trial registration number Chinese Clinical Trial Registry (ChiCTR2100051263). Registered 17 September 2019. http://www.chictr.org.cn/listbycreater.aspx.

Midterm Results of the Supera Stent for the Treatment of Femoropopliteal Occlusive Disease

BACKGROUND

The Supera (Abbott Vascular, Santa Clara, CA) stent is an interwoven nitinol, shape-memory stent with high strength and flexibility characteristics which are purported to increase resistance to kinking and compression. The purpose of this study was to review single-center outcomes of the use of this stent in the femoropopliteal segment.

METHODS

We performed a single-center, retrospective analysis of patients who underwent Supera stent placement for femoropopliteal occlusive disease from 2016-2019. Data was collected on patient demographics and procedural details. Follow-up imaging data, including duplex imaging and ankle-brachial indices, and clinical data were abstracted from encounter notes.

RESULTS

Sixty-two patients with 72 unique Supera stent placements were identified. Mean age was 76 and 69% were male. 56% of patients had severe calcification and 11% had moderate calcification. 48% of lesions were Trans-Atlantic Inter-Society Consensus Document C or D lesions. Primary patency rates at 12, 24, and 36 months were 85%, 82%, and 75%, respectively. Primary patency was not affected significantly by lesion length, degree of calcification, number of outflow vessels, concomitant interventions, or stent size.

CONCLUSIONS

These results demonstrate sustained primary patency with the Supera stent over a 3-year interval in treatment of patients with femoropopliteal occlusive disease, including in the setting of severely calcified vessels.

The Effect of Aggressive Wire Recanalization in Calcified Atheroma and Dilatation (ARCADIA) Technique in Eccentric Calcified Lesion of No-stenting Zone

PURPOSE

The endovascular approach for eccentric calcified lesions of the no-stenting zone is challenging. This study aimed to investigate the effect of a novel technique for these lesions.

METHODS

We performed EVT for severe and eccentric calcified lesions using the technique, which is presented previously and named aggressive wire recanalization in calcified atheroma and dilatation (ARCADIA). In brief, a guidewire is passed to the residual lumen firstly. Next, another guidewire is advanced into and cross through the calcified plaque and returned to the distal original lumen with intravascular ultrasound (IVUS) guided. The calcified plaque is dilated by using a scoring-balloon or non-compliant balloon.

RESULTS

Consecutive 14 peripheral artery disease patients with isolated and eccentric calcification in a no-stenting zone were treated using ARCADIA technique between January 2018 and March 2020. In IVUS data, lumen cross-section area was significantly increased from 5.2 ± 2.0 mm² to 18.1 ± 6.9 mm² (p < 0.01), lumen area was expanded roundly evaluating as symmetry index from 0.45 ± 0.09 to 0.81 ± 0.12 (p < 0.01). There were no distal embolization and perforation after ARCADIA technique. One-year target lesion revascularization occurred in only 2 cases. The primary patency of 1 year was 85.7%.

CONCLUSION

ARCADIA technique is safe and appropriate, and can be 1 option to treat for eccentric calcified lesions of the no-stenting zone as an optimal wire crossing method.

Mid-term results and predictors of restenosis in patients undergoing endovascular therapy for isolated popliteal artery steno-occlusive disease

Background and aim

There is only a limited number of major publications on the outcome of interventions for isolated popliteal artery stenosis. The purpose of this study was to report our results on mid-term patency and predictors of restenosis.

Patients and methods

This single-center retrospective study included 61 symptomatic patients (males, N = 33; median age, 65.1 years [IQR, 60.7–71.9 years]; Rutherford grade 4–6, N = 14) with at least two patent crural arteries, whose atherosclerotic stenoses/occlusions were treated with percutaneous transluminal angioplasty (PTA) or stenting (using self-expanding bare-metal Astron Pulsar stents) between 2011 and 2018.

Results

Twenty-six patients had PTA, while 35 underwent stenting. The median follow-up was 29 months (IQR, 10–47 months). The primary patency rates were not significantly different (P = 0.629) between PTA and stenting groups. Restenosis developed in nine patients (34.6%) in the PTA group, and in 12 (34.3%) in the stenting group. Restenotic lesions required re-intervention in nine cases (100%) in the PTA group, and in eight (66.7%) in the stenting group. Restenosis developed significantly less frequently (P = 0.010) in patients with a popliteal/P1 stent; the primary patency rates were also significantly better (P = 0.018) in patients with a popliteal/P1 stent when compared to popliteal/P2 plus multi-segment stents. Cox regression analysis identified lesion location as a predictor of in-stent restenosis (HR, 2.5; 95% CI, 1.2–5.5; P = 0.019).

Conclusion

Stenting was not superior when compared to PTA (if selective stenting was not considered as loss of patency). Follow-up should be more thorough in patients undergoing popliteal/P2 or multi-segment stenting.

Efficacy and one-year outcomes of Luminor® paclitaxel-coated drug-eluting balloon in the treatment of popliteal artery atherosclerosis lesions

PURPOSE

Reporting outcomes with a new generation paclitaxel eluting balloon (Luminor®; iVascular, Vascular, S.L.U., Barcelona, Spain) in the popliteal district. Endovascular treatment of popliteal artery atherosclerotic disease is still debated without definitive evidences.

METHODS

From January to June 2019, patients' data presenting popliteal artery atherosclerotic diseases and treated with the Luminor® (iVascular) drug eluting balloon (DEB) were prospectively collected. Critical limb ischemia (CLI) or severe claudication associated with popliteal artery stenosis >50% were the inclusion criteria. Measured outcomes were technical success, early and late results; including mortality, morbidity, symptoms recurrence, amputation, ankle-brachial index (ABI), survival, primary patency, secondary patency, freedom from restenosis. Median follow-up was 22.43 ± 4 (mean:21.58; IQR:20-24) months.

RESULTS

Of the 33 included patients, 28 (85%) were diagnosed with CLI, with a mean preoperative run-off score of 5.39 (r:0-10; SD:3) and a chronic popliteal occlusion in 21 (64%). Technical success was achieved in all cases. Perioperative mortality was observed in 1 (3%) patient and perioperative complications in 2 (6%). During the follow-up were reported 2 symptoms recurrence; a significant ABI increase (0.57; IQR:0.41-0.47 vs. 0.69; IQR:0.50-0.67; P < 0.01); 1 (3%) major and 2 (6%) minor amputations. Estimated 24 months survival, primary patency, secondary patency, and freedom from restenosis were 97%, 96.9%, 100%, and 93.8% respectively.

CONCLUSIONS

In this prospective study, the use of the Luminor® (iVascular) was safe and effective in addressing atherosclerotic popliteal artery lesions. Larger studies with longer term-outcomes are required to assess the durability of this device in the popliteal artery.

[General Treatment Strategy for Intervention in Lower Extremity Arterial Disease]

The prevalence of lower extremity disease is increasing with age. With recent technological advancements, endovascular treatment is being performed more frequently. The treatment goal of intermittent claudication is to improve walking and reduce claudication. To achieve these goals, anatomical durability and patency are important. In patients with critical limb ischemia, the lesions are diffuse and particularly severe in below-the-knee arteries. The treatment goal of critical limb ischemia is to promote wound healing and to prevent major amputation, which is evaluated by the limb salvage rate. Primary stenting using covered or bare metal stents is a widely accepted endovascular treatment. While drug-eluting technologies with or without atherectomy are widely used in the treatment of femoropopliteal disease, balloon angioplasty is the mainstay treatment for below-the-knee intervention. CT angiography provides a road map for planning endovascular treatment in patients without absolute contraindications.

Use of the Orbital Atherectomy System in Isolated, Chronic Atherosclerotic Lesions of the Popliteal Artery

The treatment of isolated calcified lesions involving the popliteal artery are demanding and they often require stent placement to achieve acceptable luminal gain. This study evaluates the safety and performance of the orbital atherectomy system (Cardiovascular Systems Inc.) and percutaneous transluminal angioplasty with a drug-coated balloon (PTA-DCB) for the treatment of chronic atherosclerotic lesions within the popliteal artery segment. From November 2018 to November 2019, a series of six patients with Rutherford classification stage III peripheral arterial disease with isolated, focal, calcified occlusions of the popliteal artery were treated with orbital atherectomy followed by PTA-DCB. No embolic protection devices were used. The technical success rate was 100%, the primary patency rate was 100% at 7.0 (±4.2) months of follow-up. The Rutherford classification improved in all patients from stage III to stage II and the mean ankle brachial pressure index after the procedure was 0.97 (±0.08), with a preoperative mean ankle brachial pressure index of 0.69 (±0.21). In one instance, spasm was noted in a distal arterial bed and it was successfully treated with local nitroglycerine. No distal embolisation, perforation or aneurysmal degeneration was observed. During follow-up there were no deaths, major amputations or revascularisation of target lesions. The use of orbital atherectomy system in combination with PTA-DCB was found to be safe and effective in modifying focal, chronic, calcified plaques in the popliteal artery segment in these six cases.

Prediction Model for Freedom from TLR from a Multi-study Analysis of Long-Term Results with the Zilver PTX Drug-Eluting Peripheral Stent

Purpose

Develop a prediction model to determine the impact of patient and lesion factors on freedom from target lesion revascularization (ffTLR) for patients who are candidates for Zilver PTX drug-eluting stent (DES) treatment for femoropopliteal lesions.

Methods

Patient factors, lesion characteristics, and TLR results from five global studies were utilized for model development. Factors potentially associated with TLR (sex, age, diabetes, hypertension, hypercholesterolemia, renal disease, smoking status, Rutherford classification, lesion length, reference vessel diameter (RVD), popliteal involvement, total occlusion, calcification severity, prior interventions, and number of runoff vessels) were analyzed in a Cox proportional hazards model. Probability of ffTLR was generated for three example patient profiles via combinations of patient and lesion factors. TLR was defined as reintervention performed for ≥ 50% diameter stenosis after recurrent clinical symptoms.

Results

The model used records from 2227 patients. The median follow-up time was 23.9 months (range: 0.03–60.8). The Kaplan–Meier estimates for ffTLR were 90.5% through 1 year and 75.2% through 5 years. In a multivariate analysis, sex, age, Rutherford classification, lesion length, RVD, total occlusion, and prior interventions were significant factors. The example patient profiles have predicted 1-year ffTLRs of 97.4, 92.3, and 86.0% and 5-year predicted ffTLRs of 92.8, 79.5, and 64.8%. The prediction model is available as an interactive web-based tool (https://cooksfa.z13.web.core.windows.net).

Conclusions

This is the first prediction model that uses an extensive dataset to determine the impact of patient and lesion factors on ffTLR through 5 years and provides an interactive web-based tool for expected patient outcomes with the Zilver PTX DES.

Clinical Trial Registrations

Zilver PTX RCT unique identifier: NCT00120406; Zilver PTX single-arm study unique identifier: NCT01094678; Zilver PTX China study unique identifier: NCT02171962; Zilver PTX US post-approval study unique identifier: NCT01901289; Zilver PTX Japan post-market surveillance study unique identifier: NCT02254837.

Levels of Evidence

Zilver PTX RCT: Level 2, randomized controlled trial; Single-arm study: Level 4, large case series; China study: Level 4, case series; US post-approval study: Level 4, case series Japan PMS study: Level 4, large case series.

Electronic supplementary material

The online version of this article (10.1007/s00270-020-02648-6) contains supplementary material, which is available to authorized users.

[Recommended interventions for the treatment of peripheral artery disease : Keep the patients moving]

BACKGROUND

Peripheral artery disease (PAD) is often diagnosed in an advanced stage. Accordingly, revascularization is also performed late.

OBJECTIVES

In this paper, the authors describe the progression to critical limb ischemia and cardiovascular risk. Revascularization for secondary prevention is explained. Revascularization strategies according to lesion location and complexity of the stenosis or occlusion are discussed.

MATERIALS AND METHODS

The current guidelines and randomized controlled studies and meta-analyses are analyzed.

RESULTS

PAD is associated with a considerable level of suffering and a high cardiovascular risk. Up to 20% of patients with claudicants will progress to critical limb ischemia. Progression and risk of mortality increase during the course of the disease. Improvement of walking ability by revascularization is a major goal of secondary prevention. In the femoropopliteal segment, drug-coated balloon (DCB) angioplasty and bare-metal stent (BMS) implantation are the methods of choice. In long lesions, spot-stenting should be preferred. For treatment of in-stent restenosis, DCB have proven their effectiveness. In severely calcified or dissected lesions, BMS are well suited. Infrapopliteal lesions should be revascularized to provide in-line flow to the foot through the target arterial path. According to current evidence, DCB or drug-eluting stents are more effective than plain old balloon angioplasty or BMS.