A review of the coronary applications of the drug coated balloon

Kissing Balloon-Stent Technique for Simple Bifurcation Lesions

Background: Coronary bifurcation lesions are commonly encountered during coronary angiography. The management of bifurcation lesions remains challenging, with various bifurcation techniques being available and outcomes varying depending on the Medina classification and operator experience. Methods: We present a short case series and the outcomes of a new bifurcation technique for the management of simple Medina '0,0,1' and '0,0,1' bifurcation lesions using the kissing balloon-stent technique (kissing BS). Results: We retrospectively identified 8 patients who underwent bifurcation stenting using the kissing Balloon-Stent technique, along with their clinical and angiographic follow-up outcomes. We also describe the benefits and limitations of the technique, delineate the potential mechanisms of target lesion failure, and outline appropriate patient selection. Conclusions: Kissing Balloon-Stent technique is a simple single stent technique that is safe and feasible in select patients with Medina '0,0,1' and '0,0,1' bifurcation lesions.

How to perform a successful drug-coated balloon angioplasty? Tips and tricks

Drug-coated balloons (DCB) offer an excellent alternative to stents as the antiproliferative drugs are delivered via balloons and hence there is no permanent implant of metal or polymer. This rationale applies perfectly in in-stent restenosis (ISR) as we want to avoid another layer of metal in a previously failed stent. However, their use has also been extended to de novo lesions especially in patients and lesion subsets where stents are not ideal. There is an increased desire toward expanding this further and studies are now being done which are testing DCB in large-caliber vessels. As the use of DCB is escalating, we felt the importance of writing this article whereby we aim to provide important tips and tricks when using DCB especially for the operators who are in the early phase or have the desire of embarking this technology. From our experience, the DCB-angioplasty substantially differs on several aspects from DES-angioplasty. We have provided several case bases examples including algorithm when using DCB in ISR and de novo lesions.

The evolution and revolution of drug coated balloons in coronary angioplasty: An up-to-date review of literature data

European Society of Cardiology (ESC) guidelines gave class I A indication for use of DCB in in-stent restenosis. However, no indication exists for the usage of DCB in de novo lesions. Although the current generation DES offer excellent results, as we embark more complex lesions such as calcified lesion and chronic total occlusion, restenosis and stent thrombosis are higher and tend to increase within the years. There is increasing desire to leave nothing behind to abolish the risk of restenosis and stent thrombosis and hence the absorbable scaffolds were introduced, but with disappointing results. In addition, they take several years to be absorbed. Drug coated balloons offer an alternative to stents with no permanent implant of metal or polymer. They are already in use in in Europe and Asia and they have been approved for the first time in the United States for clinical trials specifically for restenotic lesions. There is emerging data in de novo lesions which have shown that DCB are noninferior and in some studies maybe even superior to current generation DES especially in small vessels. In this article, we provide a comprehensive review of the literature on this expanding technology focussing on the evidence in both re-stenotic and de novo lesions.

Triglyceride-glucose index on risk of adverse events after drug-coated balloon angioplasty

BACKGROUND

The pathogenetic mechanism of atherosclerotic cardiovascular diseases is associated with insulin resistance (IR), which serves as a metabolic risk factor. As a novel indication for IR, triglyceride-glucose (TyG) index may predict cardiovascular disease outcomes.

METHODS

In current study, a cohort of 157 individuals with newly developed de novo lesions who received DCB angioplasty between January 2017 and May 2021 were included. The midterm follow-up clinical results consisted of the presence of vessel-oriented composite endpoint (VOCE). The baseline TyG index was divided into three groups by tertiles. This study compared various clinical characteristics and parameters among different groups during DCB angioplasty. A multivariate Cox regression model was built to investigate the potential predictors.

RESULTS

Higher TyG index indicated an increased risk of VOCE according to the adjusted model (HR = 4.0, 95%Cl: 1.0-15.4, P = 0.047). A non-linear correlation was uncovered between the index and VOCE from the smooth curve. Based on Kaplan-Meier curve, individuals in the highest TyG index group were more likely to develop VOCE (P < 0.05 for log-rank).

CONCLUSIONS

The incidence of VOCE was shown to be independently and positively correlated with an elevated TyG index in individuals with de novo coronary lesions who received DCB angioplasty.

Understudied factors in drug-coated balloon design and evaluation: A biophysical perspective

Drug-coated balloon (DCB) percutaneous interventional therapy allows for durable reopening of the narrowed lumen via physical tissue expansion and local anti-restenosis drug delivery, providing an alternative to traditional uncoated balloons or a permanent indwelling implant such as a conventional metallic drug-eluting stent. While DCB-based treatment of peripheral arterial disease (PAD) has been incorporated into clinical guidelines, DCB use has been recently curtailed due to reports that showed evidence of increased mortality risk in patients treated with paclitaxel (PTX)-coated balloons. Given the United States Food and Drug Administration's 2019 consequent warning regarding PTX-eluting DCBs and the subsequent marked reduction in clinical DCB use, there is now a critical need to better understand the compositional and mechanical factors underlying DCB efficacy and safety. Most work to date on DCB refinement has focused on designing both the enabling balloon catheter and alternate coatings composed of various drugs and excipients, followed by device evaluation in preclinical and clinical studies. We contend that improvement in DCB performance will require a better understanding of the biophysical factors operative during and following balloon deployment, and moreover that the elaboration and demonstrated control of these factors are needed to address current concerns with DCB use. This article provides a perspective on the biophysical interactions that govern DCB performance and offers new design strategies for the development of next-generation DCB devices.

Using drug-coated balloons for symptomatic vertebral artery origin stenosis: A systematic review and meta-Analysis

BACKGROUND

Endovascular stenting has emerged as an effective treatment for patients with symptomatic vertebral artery origin stenosis (VAOS), but the incidence of severe restenosis is concerning. Angioplasty alone with a drug-coated balloon (DCB) is a potential treatment for VAOS. The purpose of this systematic review and meta-analysis was to assess the utility of DCB angioplasty for VAOS.

METHODS

A systematic search of the Medline (PubMed), Embase, CNKI, and Cochrane databases for studies on the treatment of VAOS by DCB angioplasty published in English and Chinese before June 15, 2022 was conducted. Data were extracted using standardized methods. The incidence rates of restenosis, technical success, and perioperative complication in the follow-up period were pooled using Freeman-Tukey double arcsine transformation with random or fixed-effect models. Tests for heterogeneity and publication bias were performed.

RESULTS

A total of seven studies containing 159 patients were included in this review and meta-analysis. The pre-treatment stenosis rate of the vertebral artery in the DCB group ranged from 70.0 % to 86.3 %, and the median follow-up time ranged from 6.0 to 14.1 months. The pooled restenosis incidence was 11.9 % (95 % CI: 3.4 %-23.4 %; I² = 59 %, p = 0.02) during the follow-up period. The pooled technical success rate was 96.6 % (95 % CI: 91.4 %-99.7 %; I² = 37 %, p = 0.14). The overall perioperative complication rate was 2.9 % (95 % CI: 0.3 %-6.9 %; I² = 0 %, p = 0.64). According to the funnel diagram and Egger's test, there was no evidence of publication bias.

CONCLUSION

It is suggested in this review and meta-analysis that angioplasty with DCB may be a potential treatment for VAOS. However, randomized studies including a large representative sample of VAOS patients are needed to validate our findings.

Analysis of the incidence and influencing factors associated with binary restenosis of target lesions after drug-coated balloon angioplasty for patients with in-stent restenosis

BACKGROUND

Drug-coated balloon (DCB) is a novel and effective device for coronary artery disease patients with in-stent restenosis (ISR). However, the incidence and possible influencing factors associated with binary restenosis have not yet been adequately assessed.

METHODS

The data are extracted from a prospective, multicenter, randomized controlled trial. A total of 211 patients with ISR were enrolled at 13 centers from August 2017 to October 2018 and treated with DCB. At the 9-month coronary angiographic follow-up, patients were divided into restenosis and non-restenosis groups, and demographic data, lesion features, and laboratory tests were retrospectively reviewed. Furthermore, logistic regression analysis was used to identify possible influencing factors.

RESULTS

All patients successfully underwent treatment, and 166 patients with 190 lesions took part in angiography follow-ups at 9 months. Of these, 41 patients with 44 target lesions developed restenosis following treatment, and the incidence of ISR was 24.7%. There were significant differences in the average length of target lesions and the number of multivessel lesions and fasting plasma glucose (FBG) between the two groups (p < 0.05). Demographic data, cardiac risk factors, left ventricular ejection fractions (LVEF), blood routine tests, biochemical tests, and other features of devices and lesions showed no difference. Logistic regression analyses showed that FBG > 6.1 mmol/L (OR: 7.185 95% CI: 2.939-17.567 P < 0.001) and length of lesion (OR:1.046 95% CI: 1.001-1.093 P = 0.046) were associated risk factors.

CONCLUSIONS

The longer length of lesions, more target lesions and FBG > 6.1 mmol/L per individual may be characteristics of patients showing ISR following treatment. Studies with larger sample size, and more complete follow-up data are needed in the future to expend on these findings.

TRIAL REGISTRATION

No.: NCT04213378, first posted date (30/12/2019).

Progress in drug-delivery systems in cardiovascular applications: stents, balloons and nanoencapsulation

Drug-delivery systems in cardiovascular applications regularly include the use of drug-eluting stents and drug-coated balloons to ensure sufficient drug transfer and efficacy in the treatment of cardiovascular diseases. In addition to the delivery of antiproliferative drugs, the use of growth factors, genetic materials, hormones and signaling molecules has led to the development of different nanoencapsulation techniques for targeted drug delivery. The review will cover drug delivery and coating mechanisms in current drug-eluting stents and drug-coated balloons, novel innovations in drug-eluting stent technologies and drug encapsulation in nanocarriers for delivery in vascular diseases. Newer technologies and advances in nanoencapsulation techniques, such as the use of liposomes, nanogels and layer-by-layer coating to deliver therapeutics in the cardiovascular space, will be highlighted.

Rationale and design of a randomized study comparing the agent drug coated balloon to plain old balloon angioplasty in patients with In-stent restenosis

BACKGROUND

Drug-coated balloon (DCB) technology was developed as an alternative treatment for obstructive coronary artery disease (CAD) and in-stent restenosis (ISR). Management of coronary ISR is clinically challenging and frequently encountered in practice. The Agent DCB uses an inactive excipient to effectively deliver a targeted, therapeutic dose of paclitaxel to the vessel wall.

STUDY DESIGN

AGENT IDE is a prospective, multicenter, randomized controlled trial to evaluate superiority of the Agent DCB to balloon angioplasty in treating patients with ISR. A total of 480 patients with ISR of a previously treated lesion length <26 mm and reference vessel diameter >2.0 mm to ≤4.0 mm will be initially randomized. Subjects presenting with recent myocardial infarction (MI), complex lesions, or thrombus in the target vessel will be excluded. An adaptive group sequential design with one formal interim analysis for sample size re-estimation will be conducted, and the sample size may be increased to a maximum of 600 subjects. The primary endpoint is the rate of 12-month target lesion failure (TLF; composite of any ischemia-driven revascularization of the target lesion (TLR), target vessel related MI, or cardiac death) and will be tested for superiority in the test arm against the control. Functional status and general health-related quality of life will be measured by changes in the EQ-5D scores. Subjects will be followed for 5 years following the index procedure.

CONCLUSION

This study will prospectively evaluate the safety and efficacy of Agent DCB in patients treated for coronary ISR.

Drug-Coated Balloons for the Treatment of Symptomatic Intracranial High-Grade Stenosis: A Review of the Current Rationale

Symptomatic intracranial atherosclerotic disease (sICAD) remains a challenging disorder in the neurovascular field. Despite best medical treatment, the recurrence rate for stroke remains high in patients with intracranial high-grade stenosis (>70–99%). Furthermore, two large randomized trials (SAMMPRIS and VISSIT) failed to prove the efficacy of percutaneous transluminal angioplasty and stenting in patients with sICAD. Drug-coated balloon percutaneous transluminal angioplasty (DCB-PTA) represents an alternative treatment modality with therapeutic benefits for interventional cardiology. However, there are very few articles in the existing literature that relate to the use of DCB-PTA in sICAD patients. Here, we aimed to review the rationale underlying the use of DCB-PTA in sICAD patients and summarize recent developments in the neurovascular field.

Contemporary Management of Isolated Ostial Side Branch Disease: An Evidence-based Approach to Medina 001 Bifurcations

The optimal management of bifurcation lesions has received significant interest in recent years and remains a matter of debate among the interventional cardiology community. Bifurcation lesions are encountered in approximately 21% of percutaneous coronary intervention procedures and are associated with an increased risk of major adverse cardiac events. The Medina classification has been developed in an attempt to standardise the terminology when describing bifurcation lesions. The focus of this article is on the management of the Medina 0,0,1 lesion (‘Medina 001’), an uncommon lesion encountered in <5% of all bifurcations. Technical considerations, management options and interventional techniques relating to the Medina 001 lesion are discussed. In addition, current published data supporting the various proposed interventional treatment strategies are examined in an attempt to delineate an evidence-based approach to this uncommon lesion.

Drug-Coated Balloon Treatment in Symptomatic Intracranial High Grade Stenosis : A Retrospective Study of 33 Patients

PURPOSE

Endovascular therapy (EVT) represents an alternative treatment modality for symptomatic intracranial high-grade atherosclerotic stenosis (sICAS); however, periprocedural complication rates as well as midterm restenosis rates represent relevant limitations of EVT. Drug-coated balloon percutaneous transluminal angioplasty (DCB-PTA) may overcome some of these shortcomings. The aim of this study was to assess feasibility and safety as well as the stroke recurrence rate in 33 patients.

METHODS

A retrospective, monocentric cohort study of sICAS patients treated with DCB-PTA. Outcome measures were the periprocedural intracranial complication rate, the recurrent stroke rate and mortality during follow-up.

RESULTS

This cohort study included 33 patients with 35 sICAS treated with DCB-PTA. The median age was 72 years (interquartile range, IQR 66-77 years); median clinical and mean radiological follow-up time was 9 months (IQR 3-22 months). Median preprocedural degree of stenosis (WASID) was 80% (IQR 73-80%) and median postprocedural residual stenosis degree (WASID) was 50% (IQR 33-60%). Intracranial periprocedural complications occurred in 2 (6%) patients. The overall restenosis rate was 15% (n = 5). In four patients a symptomatic ischemic re-event occurred within 7 months after the initial treatment. None of the patients died.

CONCLUSION

This DCB-PTA cohort study showed a relatively low intracranial complication rate of 6% with a symptomatic recurrence rate of 12%. Larger trials are needed to validate these promising observations.

Synthesis of novel carbohydrate based pyridinium ionic liquids and cytotoxicity of ionic liquids for mammalian cells

The large pool of naturally occurring carbohydrates with their diversity in chirality and structure led to the idea of a systematic investigation of carbohydrate based ILs. To this end, we investigated the influence of different ether groups, mainly methyl or ethyl ether, on the secondary OH groups as well as different configurations on physical properties such as melting point, thermostability and especially the influence on cell toxicity. For this investigation we chose α- and β-methyl-, β-allyl- and β-phenyl d-glucopyranose as well as four 1-deoxy-pentoses. In order to be able to classify the results, more ionic liquids with different structural motives were examined for cytotoxicity. Here, we present data that confirm the biocompatibility of such ILs consisting of naturally occurring molecules or their derivatives. The synthesized carbohydrate based ILs were tested for their suitability as additives in coatings for medical applications such as drug-eluting balloons.

Device profile of different paclitaxel-coated balloons: Neuro Elutax SV, Elutax '3' Neuro and SeQuent Please NEO for the treatment of symptomatic intracranial high-grade stenosis: overview of their feasibility and safety

Introduction: Intracranial atherosclerotic disease (ICAD) is highly prevalent and probably the most common cause of stroke worldwide. Despite best medical treatment (BMT), the rate of recurrent stroke in symptomatic ICAD patients is elevated, especially in those with high-grade stenosis. Thus, alternative treatment options are needed. So far, endovascular ICAD treatment has been considered a second-line therapy. However, recent progress in the endovascular acute stroke treatment challenges this issue. Drug-coated balloon (DCB) - percutaneous transluminal angioplasty (PTA) represents a promising alternative to BMT alone.Areas covered: In this review, current clinical studies on paclitaxel-coated DCB-PTA in symptomatic high-grade ICAD patients will be presented and discussed. Furthermore, technical profile of the different paclitaxel-coated DCB, which has been used for intracranial use (Neuro Elutax SV, Elutax '3' Neuro, and SeQuent Please NEO) are being presented.Expert opinion: Despite limited data and its experimental (off-line) use, DCB-PTA has been demonstrated to be feasible and safe in selected ICAD patients with symptomatic high-grade stenosis. DCB-PTA offers several advantages compared to alternative endovascular therapy option as well as BMT alone. Consequently, DCP-PTA might be a promising candidate for the future armamentarium in ICAD treatment.

Angioplasty Using Drug-Coated Balloons in Ostial Vertebral Artery Stenosis

BACKGROUND

Ostial vertebral artery stenosis (OVAS) is a relevant cause of acute ischemic posterior circulation stroke. Percutaneous trans-luminal angioplasty (PTA) might offer a promising treatment modality, but restenosis rate is high. So far, little is known about recanalization using drug-coated balloons (DCB) in OVAS. We aimed to show feasibility and safety of DCB-PTA in OVAS.

METHODS

Retrospective, monocenter case series of 12 patients with ostial vertebral artery stenosis (≥50%) treated with PTA using a drug-coated balloon.

RESULTS

Median age was 69.5 years (IQR 57-78.5) with a female rate of 41%. Patients were treated either with a SeQuent Please NEO or Neuro Elutax SV DEB. Median preinterventional stenosis degree was 75% (IQR 70-85) with a median lesion length of 4.5 mm (IQR 4-7.5). Median postinterventional stenosis degree was 40% (IQR 27-50). All treated vessels remained patent. No major complications such as dissection, vessel perforation, hemorrhage, or ischemic events occurred. Moreover, we did not detect any restenosis during a median follow-up period of 6.1 months. The clinical outcome was excellent with median mRS scale of 0 (IQR 0-1).

CONCLUSIONS

PTA using drug-coated balloons is feasible and safe in patients with ostial vertebral artery stenosis.

Intrinsic coating morphology modulates acute drug transfer in drug-coated balloon therapy

The hallmark of drug-coated balloon (DCB) therapy for the treatment of peripheral vascular disease is that it allows for reopening of the narrowed lumen and local drug delivery without the need for a permanent indwelling metal implant such as a stent. Current DCB designs rely on transferring drugs such as paclitaxel to the arterial vessel using a variety of biocompatible excipients coated on the balloons. Inherent procedural challenges, along with limited understanding of the interactions between the coating and the artery, interactions between the coating and the balloon as well as site-specific differences, have led to DCB designs with poor drug delivery efficiency. Our study is focused on two clinically significant DCB excipients, urea and shellac, and uses uniaxial mechanical testing, scanning electron microscopy (SEM), and biophysical modeling based on classic Hertz theory to elucidate how coating microstructure governs the transmission of forces at the coating-artery interface. SEM revealed shellac-based coatings to contain spherical-shaped microstructural elements whereas urea-based coatings contained conical-shaped microstructural elements. Our model based on Hertz theory showed that the interactions between these intrinsic coating elements with the arterial wall were fundamentally different, even when the same external force was applied by the balloon on the arterial wall. Using two orthogonal cell-based assays, our study also found differential viability when endothelial cells were exposed to titrated concentrations of urea and shellac, further highlighting the need to maximize coating transfer efficiency in the context of DCB therapies. Our results underscore the significance of the excipient in DCB design and suggest that coating microstructure modulates acute drug transfer during device deployment.

Interventional cardiology: from balloons to stents … and back?

The treatment of coronary artery disease has seen rapid change following the invention of percutaneous coronary intervention (PCI). Since its introduction and widespread adoption for the treatment of coronary artery disease, efforts have been underway to minimise both the acute and long-term complications associated with the procedures, resulting in varying degrees of success over the years. These measures have taken many forms, from the adjunctive drug treatment regimen that patients receive before, during and after procedures to the actual mechanical intervention to the vessels themselves. The current gold standard in the interventional field is second-generation drug-eluting stents. However, with ongoing research into new technologies and trials underway in absorbable and non-stent treatments, it may soon be possible to achieve the goal of leaving no long-term physical implant behind in the artery. This could overcome issues with inflammation associated with permanent foreign body implants and prove less limiting for future treatment if needed.

Percutaneous Coronary Intervention in the Elderly: Are Drug-coated Balloons the Future?

Background:

Balloon angioplasty revolutionised percutaneous treatment for coronary ar-tery disease four decades ago, but vessel-threatening dissections, elastic recoil and restenosis were major drawbacks to an otherwise successful long-lasting intervention. Subsequent advances with bare metal stents and then drug eluting stents followed, aiming to mitigate the risks of acute vessel closure and restenosis. However, stent implantation often necessitates dual antiplatelet therapy for a pro-longed period of time, which in itself can lead to adverse outcomes, especially in the frail elderly pop-ulation at higher risk of bleeding. More recently, bioabsorbable stents have been implemented in clini-cal practice enabling earlier intimal coverage of the stent and apposition.

However, another addition to the armamentarium of percutaneous coronary intervention is the use of drug-coated balloons without the need for deploying any coronary stents or scaffolds. Drug-coated balloons are semi-compliant balloons coated with an antiproliferative agent that is rapidly released on contact with the vessel intima exerting an anti-restenotic effect. The absence of a metallic scaffold means that the need for antiplatelet therapy can potentially be negated in the longer term if required. In this article, we will review the history of percutaneous coronary intervention and the available evi-dence for the appropriate use of drug-coated balloons especially in the elderly population.

Conclusion:

We will conclude this review by demonstrating the potential use of drug-coated balloon rather percutaneous stenting through case examples.

Comparison of drug-eluting balloon versus drug-eluting stent for treatment of coronary artery disease: a meta-analysis of randomized controlled trials

Background

Drug-eluting balloons (DEB) have significant value for treating coronary artery disease (CAD). However, the merits of using DEB versus drug-eluting stents (DES) to treat CAD remain controversial. Herein, we conducted a meta-analysis to compare the safety and efficacy of DEB and DES for treatment of CAD.

Methods

We searched MEDLINE, EMBASE, and CENTRAL databases for eligible trials comparing DEB with DES for treatment of CAD. The primary endpoint was major adverse cardiac events (MACE); the secondary endpoints included in-lesion late lumen loss (LLL), binary restenosis (BR), myocardial infarction (MI), target lesion revascularization (TLR) and mortality.

Results

Twenty-three trials with a total of 2712 patients were included. There were no significant differences in the primary endpoint of MACE between the DEB and DES groups (Risk Ratio (RR) 1.19; 95% confidence interval (CI) (0.87, 1.63); P = 0.27), or in the clinical outcomes of each of MACE’s components, including TLR, MI and mortality. However, efficacy was significantly different between the DEB and DES groups, especially when we compared DEB to second-generation DES: in-lesion LLL (Mean Difference (MD) 0.11; (0.01, 0.22); P = 0.03); binary restenosis (RR 1.46; (1.00, 2.13); P = 0.05).

Conclusions

DEB is equivalent to DES in terms of safety for managing CAD, and DEB may be considered as an alternative choice for treatment of CAD.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0771-y) contains supplementary material, which is available to authorized users.

Drug-coated balloons: "Do they still have a role in treating coronary artery disease?"

Small vessels with coronary artery disease (CAD) are at high risk of restenosis, despite the use of drug-eluting stents (DESs). Drug-coated balloon (DCB) therapy offers a viable alternative to DESs for the management of small vessel CAD. The literature regarding the use of DCBs in lieu of the newer generation DESs to treat small vessel CAD is controversial.

Treatment of de novo coronary artery bifurcation lesions with drug coated balloons: A reappraisal according to the available scientific data

The treatment of coronary artery bifurcation often represents a challenge for interventional cardiologist. Although several stenting techniques are available for the treatment of de novo coronary bifurcation lesions, over the last years, different studies have proposed and analysed the use of drug-coated balloon (DCB) in the treatment of coronary artery bifurcation lesions as an alternative treatment. To date, even considering those studies which have analysed a combined strategy (DCB+stenting) or a DCB-only approach, the evidences are scant and the results debatable. We review the available scientific data regarding the use of DCB in the treatment of naive coronary bifurcation lesions.