Cilostazol suppression of arterial intimal hyperplasia is associated with decreased expression of sialyl Lewis X homing receptors on mononuclear cells and E-selectin in endothelial cells

Cilostazol after endovascular therapy for femoropopliteal peripheral arterial disease: A systematic review and meta-analysis

BACKGROUND

Endovascular therapy (ET) outcomes for femoropopliteal peripheral arterial disease (FP-PAD) remain suboptimal. Cilostazol therapy may improve patency rates and decrease major adverse limb events after ET for FP-PAD. Our goal was to analyze published studies evaluating the use of cilostazol after ET for FP-PAD.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL for randomized and observational studies (OSs) evaluating cilostazol therapy after ET for FP-PAD. We only included OSs adjusting for confounding variables. We analyzed observational and randomized studies separately and explored heterogeneity by estimating an I2 statistic. A fixed-effects model was chosen if the I2 statistic was low. If the two-sided probability of observing the difference between groups under a true null hypothesis was <5%, we considered this difference statistically significant.

RESULTS

We screened 2171 studies and included 26 papers in our analysis (5 randomized controlled trials and 21 OSs). All randomized studies were open label. In randomized studies, the odds of restenosis were lower in patients treated with cilostazol (pooled odds ratio, 0.28; 95% confidence interval [CI], 0.18-0.43; P < .01; I2 = 0%). The odds of target lesion revascularization (TLR) were also lower in patients treated with cilostazol (pooled odds ratio, 0.35; 95% CI, 0.22-0.65; P < .01; I2 = 0%). In OSs, we also identified associations between peri-interventional treatment with cilostazol and lower rates of restenosis (pooled hazard ratio [pHR], 0.57; 95% CI, 0.51-0.65; P < .01; I2 = 34%), TLR (pHR, 0.53; 95% CI, 0.36-0.79; P < .01; I2 = 0%), and amputation (pHR, 0.54; 95% CI, 0.32-0.90; P = .02; I2 = 30%).

CONCLUSIONS

In randomized open-label studies, peri-interventional treatment with cilostazol after ET for FP-PAD decreased the odds of restenosis and TLR (Level 1A). Similarly, in OSs that adjusted for confounding, peri-interventional cilostazol therapy was associated with lower rates of restenosis, TLR, and amputation (Level 2A).

The effect of cilostazol on the platelet-derived growth factor-beta/beta isoform reduction on venous hyperplasia in an experimental balloon-induced injury model

BACKGROUND

Intimal hyperplasia is the response to endothelial injury. Platelet-derived growth factor is released early and favors the formation of intimal hyperplasia. Although multiple treatments, from open surgery to endovascular techniques, have been used they remain controversial. There is currently interest in developing pharmacological strategies to address this pathology. Local vascular inflammation induced by vessel barotrauma generates intimal hyperplasia due to mechanical stress over the venous endothelium. Cilostazol is a selective phosphodiesterase type 3 (PDE3) selective inhibitor with a regulatory effect over intimal hyperplasia. The objective was to investigate cilostazol's role in inhibiting smooth muscle cell proliferation due to changes in the expression and release of PDGF-BB isoform and the effect on developing IH using an experimental model of vascular barotrauma (balloon-induced injury model).

METHODS

We included 12 New Zealand rabbits. The balloon-induced injury model (BIIM) and experimental group cilostazol (20 mg/kg/day) included 6 rabbits each. Contralateral veins from 6 rabbits used in BIIM model has been taken as control group. We measured and compared the expression of PDGF-BB and the development of IH. A pathologist board chooses a PDGFRα antibody to localized its expression by immunohistochemistry analysis. Subsequently, using an automated immunohistochemical staining machine, the PDGFR expression was evaluated using a Zeiss Primo Star 4 light microscope.

RESULTS

The measurement obtained in the intimal layer was: 126.12 μm2 in the CG, 232 μm2 in the BIIM group, and 178 μm2 in the EG. A statistically significant difference was observed. Baseline serum concentrations of PDGF-BB in the BIIM group were 0.22 pg/mL. At 12 h 0.42 pg/mL, and 0.17 pg/mL at seven days. In the experimental group, the basal levels were 0.33 pg/mL. With the use of cilostazol, a lower peak was obtained at 12 h (0.08 pg/mL). This difference was statistically significant.

CONCLUSIONS

Cilostazol induced a significant reduction of IH caused by barotrauma in the venous endothelium, which correlates with decrease in the PDGF-BB in serum. This could be attributed to the pharmacologic effect on PDGFR expression.

A Systematic Review and Meta-Analysis of Efficacy and Safety of Cilostazol Prescription in Patients With Femoropopliteal Peripheral Artery Disease After Endovascular Therapy

PURPOSE

The purpose of this study is to assess the efficacy and safety of cilostazol prescription in patients with femoropopliteal peripheral artery disease (PAD) after endovascular therapy (EVT).

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis of all studies reporting the outcomes of cilostazol after femoropopliteal EVT of PAD up to September 2022. Clinical outcomes of interest included primary patency, in-stent restenosis (ISR), vessel re-occlusion, freedom from target lesion revascularization (TLR), repeat revascularization, all-cause mortality, amputation, major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs), and bleeding complication.

RESULTS

A total of 4 randomized controlled trials (RCTs) and 8 observational studies containing a total of 4898 patients met the inclusion criteria and were included in this systematic review and meta-analysis. We found that the use of cilostazol was associated with higher primary patency after femoropopliteal artery EVT (odds ratio [OR]=1.67, 95% confidence interval [CI]=1.50-1.87, p<0.001, I2=33.2%), a lower risk of ISR (OR=0.43, 95% CI=0.29-0.63, p<0.001, I2=37.6%), repeat revascularization (OR=0.43, 95% CI=0.24-0.76, p<0.005, I2=27.4%), and vessel re-occlusion (OR=0.59, 95% CI=0.38-0.93, p<0.05, I2=0%). There was an increase in freedom from TLR rate (OR=2.19, 95% CI=1.58-3.05, p<0.001, I2=0%), as well as a reduction in the occurrence of MALEs (OR=0.50, 95% CI=0.29-0.85, p<0.05, I2=0%). However, there was no significant difference in amputation, MACEs, all-cause mortality, and major bleeding complications. Subgroup analysis showed that cilostazol treatment in patients with femoropopliteal drug-eluting stents (DES) implantation remained associated with higher primary patency and a lower risk of ISR.

CONCLUSIONS

After EVT of femoropopliteal artery lesions, additional oral cilostazol enhances primary patency, reduces the occurrences of ISR and vessel re-occlusion, diminishes the risks associated with MALEs, lowers the need for repeat revascularization, and increases freedom from TLR rates. However, it does not impact amputation, MACEs, all-cause mortality, or major bleeding complications. These findings suggest cilostazol as a potentially safe and effective adjunct therapy in patients with femoropopliteal PAD after EVT.

CLINICAL IMPACT

After undergoing endovascular therapy (EVT) for femoropopliteal artery lesions, the addition of cilostazol to antiplatelet therapy can significantly improve primary patency, reducing the incidence of in-stent restenosis, repeat revascularization, vessel re-occlusion, and major adverse limb events while increasing freedom from target lesion revascularization rate. The simultaneous use of drug-eluting stents in the femoropopliteal artery lesions, combined with cilostazol, potentially results in a synergistic anti-stenotic effect. This therapeutic approach does not appear to be associated with an increased risk of major bleeding events or all-cause mortality. These findings provide additional evidence supporting the treatment of anti-stenosis in patients with femoropopliteal artery lesions after EVT.

Peripheral Vascular Disease

Peripheral artery disease is most often caused by atherosclerosis. Arterial insufficiency from atherosclerotic blockages in the limbs can impair walking distance and put patients with severe disease at risk of limb loss. Management of the disease centers around early diagnosis, supervised exercise therapy and lifestyle modification, optimizing medical care (with the goal of reducing fatal cardiac and cerebrovascular events), and revascularization.

The Role of Cilostazol, a Phosphodiesterase-3 Inhibitor, in the Development of Atherosclerosis and Vascular Biology: A Review with Meta-Analysis

Atherosclerotic cardiovascular disease (ASCVD) stands as the leading global cause of mortality. Addressing this vital and pervasive condition requires a multifaceted approach, in which antiplatelet intervention plays a pivotal role, together with antihypertensive, antidiabetic, and lipid-lowering therapies. Among the antiplatelet agents available currently, cilostazol, a phosphodiesterase-3 inhibitor, offers a spectrum of pharmacological effects. These encompass vasodilation, the impediment of platelet activation and aggregation, thrombosis inhibition, limb blood flow augmentation, lipid profile enhancement through triglyceride reduction and high-density lipoprotein cholesterol elevation, and the suppression of vascular smooth muscle cell proliferation. However, the role of cilostazol has not been clearly documented in many guidelines for ASCVD. We comprehensively reviewed the cardiovascular effects of cilostazol within randomized clinical trials that compared it to control or active agents and involved individuals with previous coronary artery disease or stroke, as well as those with no previous history of such conditions. Our approach demonstrated that the administration of cilostazol effectively reduced adverse cardiovascular events, although there was less evidence regarding its impact on myocardial infarction. Most studies have consistently reported its favorable effects in reducing intermittent claudication and enhancing ambulatory capacity in patients with peripheral arterial disease. Furthermore, cilostazol has shown promise in mitigating restenosis following coronary stent implantation in patients with acute coronary syndrome. While research from more diverse regions is still needed, our findings shed light on the broader implications of cilostazol in the context of atherosclerosis and vascular biology, particularly for individuals at high risk of ASCVD.

Cilostazol: a Review of Basic Mechanisms and Clinical Uses

Primarily used in the treatment of intermittent claudication, cilostazol is a 2-oxyquinolone derivative that works through the inhibition of phosphodiesterase III and related increases in cyclic adenosine monophosphate (cAMP) levels. However, cilostazol has been implicated in a number of other basic pathways including the inhibition of adenosine reuptake, the inhibition of multidrug resistance protein 4, among others. It has been observed to exhibit antiplatelet, antiproliferative, vasodilatory, and ischemic-reperfusion protective properties. As such, cilostazol has been investigated for clinical use in a variety of settings including intermittent claudication, as an adjunctive for reduction of restenosis after coronary and peripheral endovascular interventions, and in the prevention of secondary stroke, although its widespread implementation for indications other than intermittent claudication has been limited by relatively modest effect sizes and lack of studies in western populations. In this review, we highlight the pleiotropic effects of cilostazol and the evidence for its clinical use.

Characteristics and outcomes of stent occlusion after iliocaval stenting

OBJECTIVE

With increasing use of iliocaval stenting, complications have become more noticeable. Stent occlusion is one such outcome that has not been studied in detail. Characteristics of stent occlusion in addition to outcomes after recanalization are presented.

METHODS

An analysis of 3468 initial iliocaval stents placed during an 18-year period from 1997 to 2015 was performed. A total of 102 stent occlusions were identified, amounting to a 3% stent occlusion rate. Characteristics evaluated included onset after stent placement, techniques used for restoring patency, and their outcome. Kaplan-Meier analysis was used to assess stent patency. Regression analysis was used to evaluate risk factors for stent occlusion.

RESULTS

Stent occlusions occurred at a median of 5.8 months after placement. The occluded stent could be reopened after a wide range of intervals, the longest being 14 years. The majority (69%) of occlusions were chronic (>30 days) and the remainder (31%) were acute; 77% of the occlusions occurred in post-thrombotic limbs. The most common technique used to recanalize the acutely occluded stent was pharmacomechanical thrombectomy, whereas wire recanalization with balloon angioplasty was the technique most used for chronic occlusions. Of the 102 occluded stents, patency was achieved in 75 of 88 (84%) attempts. After successful recanalization, the median primary patency was 7 ± 1.9 months, median primary assisted patency was 7.5 ± 3.5 months, and median secondary patency was 25 ± 8.3 months. Clinically, there was improvement in the visual analog scale pain scores from a median of 3.5 to 1 (P < .01), in the median grade of swelling from 2 to 1 (P < .01), and in the mean Venous Clinical Severity Score from 6.4 to 3.8 (P < .01) after recanalization. A 40% ulcer healing rate was noted after recanalization during a median follow-up period of 17 months. There were no significant adverse events or mortality. Regression analysis revealed stent placement for native vein occlusion as the only statistically significant predictor of stent occlusion.

CONCLUSIONS

Stent occlusion after iliocaval stenting is a rare occurrence. Recanalization of occluded stents can be performed with minimal morbidity even months to years after occlusion with good outcomes. Long-term patency of occluded stents that were recanalized is poor compared with patency of the initially placed stent.

Restenosis after Coronary and Peripheral Intervention: Efficacy and Clinical Impact of Cilostazol

Restenosis is one of the main complications in patients undergoing coronary or peripheral revascularization procedures and is the leading cause for their long-term failures. Cilostazol is the only pharmacotherapy that showed an adequate efficacy for preventing restenosis in randomized, controlled studies after coronary or peripheral revascularization procedures. The present review sums up the main clinical evidence supporting the use of cilostazol after revascularization interventions, focusing on all its benefits, warnings, and administration schedules.

Long-term clinical efficacy and safety of adding cilostazol to dual antiplatelet therapy for patients undergoing PCI: a meta-analysis of randomized trials with adjusted indirect comparisons

OBJECTIVE

To assess the long-term clinical efficacy and safety of adding cilostazol to aspirin plus clopidogrel (triple antiplatelet therapy, TAT) in patients undergoing percutaneous coronary intervention (PCI) and explore its role in the era of new generation adenosine diphosphate (ADP)-receptor antagonists.

METHODS

PUBMED, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) comparing TAT versus dual antiplatelet therapy (DAT), followed by a manual search. Then, a meta-analysis of RCTs comparing TAT versus standard DAT in patients undergoing PCI was performed. Furthermore, indirect comparisons of TAT versus new generation ADP-receptor antagonist based DAT (prasugrel or ticagrelor based DAT) were undertaken, with standard DAT as a common comparator. The included end-points were major adverse cardiovascular event (MACE), target lesion revascularization (TLR), target vessel revascularization (TVR), death, myocardial infarction (MI), stent thrombosis, bleeding and other drug adverse events.

RESULTS

Twelve RCTs with a total of 31,789 patients were included. Compared with standard DAT (n = 2551), TAT (n = 2545) significantly reduced the incidence of MACE (OR: 0.56, 95% CI: 0.47-0.68, P < 0.00001), TLR (OR: 0.51, 95% CI: 0.34-0.75, P = 0.0006) and TVR (OR: 0.59, 95% CI: 0.46-0.75, P < 0.0001), and did not change significantly in death (OR: 0.68, 95% CI: 0.44-1.05, P = 0.08), MI (OR: 0.80, 95% CI: 0.45-1.44, P = 0.46), stent thrombosis (OR: 0.61, 95% CI: 0.27-1.36, P = 0.23), major bleeding (OR: 1.42, 95% CI: 0.52-3.85, P = 0.49) and overall bleeding (OR: 1.16, 95% CI: 0.79-1.69, P = 0.45). Compared with prasugrel (n = 6813) or ticagrelor based DAT (n = 6732), TAT (n = 2545) further reduced the incidence of MACE (OR: 0.80, 95% CI: 0.72-0.90, P = 0.0012; OR: 0.83, 95% CI: 0.75-0.92, P = 0.0003, respectively).

CONCLUSIONS

Compared with standard DAT, the long-term use of TAT in patients with PCI gives more benefits in reducing the incidence of MACE, TLR and TVR without increasing bleeding. Furthermore, it might be superior to prasugrel or ticagrelor based DAT in term of MACE, which needs to be confirmed by future studies with direct comparisons.