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Thanigaimani S, Sun D, Ahmad U, Anning N, Tian K, Golledge J. Network Meta-analysis of Randomised Controlled Trials Comparing the Outcomes of Different Endovascular Revascularisation Treatments for Infra-inguinal Peripheral Arterial Disease Causing Chronic Limb Threatening Ischaemia. Eur J Vasc Endovasc Surg 2024; 68:246-254. [PMID: 38754723 DOI: 10.1016/j.ejvs.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 04/19/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE The aim of this study was to compare the efficacy of different endovascular revascularisation procedures for treating chronic limb threatening ischaemia (CLTI) using network meta-analysis (NMA). DATA SOURCES The databases PubMed and Cochrane Central Register for Controlled Trials were searched on 14 March 2023. REVIEW METHODS A NMA of randomised controlled trials (RCTs) reporting the efficacy of different endovascular revascularisation techniques for treating CLTI was performed according to PRISMA guidelines. The primary and secondary outcomes were major amputation and death, respectively. Random effects models were developed and the results were presented using surface under the cumulative ranking curve plots and forest plots. A p value of ≤ .050 was considered statistically significant. The Cochrane collaborative tool was used to assess risk of bias. RESULTS A total of 2 655 participants of whom 94.8% had CLTI were included. Eleven trials compared plain balloon angioplasty (PBA) vs. drug coated balloon (DCB) angioplasty (n = 1 771), five trials compared bare metal stent (BMS) vs. drug coated stent (DCS) (n = 466), three trials compared atherectomy vs. DCB (n = 194), two trials compared PBA vs. BMS (n = 70), one trial compared PBA vs. atherectomy (n = 50), and one trial compared BMS vs. DCB (n = 104). None of the revascularisation strategies significantly reduced the risk of major amputation or death compared with PBA. Using the network estimates, GRADE certainty of evidence for improvement in major amputation outcomes for DCB was moderate, for atherectomy and BMS was low, and for DCS was very low compared with PBA. Risk of bias was low in 16 trials, of some concerns in six trials, and high in one trial, respectively. CONCLUSION There is no current evidence from RCTs to reliably conclude that BMS, DCB, DCS, or atherectomy are superior to PBA in preventing major amputation and death in patients with CLTI. Larger comparative RCTs are needed to identify the best endovascular revascularisation strategy.
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Affiliation(s)
- Shivshankar Thanigaimani
- Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - David Sun
- Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
| | - Usama Ahmad
- Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Naomi Anning
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Kevin Tian
- Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia.
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Takahashi EA, Lookstein RA, Misra S. Best Endovascular versus Best Surgical Therapy in Patients with CLI (BEST-CLI) Trial: A Misleading Trial Name. J Vasc Interv Radiol 2023; 34:718-719. [PMID: 36639118 DOI: 10.1016/j.jvir.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/04/2023] [Indexed: 01/12/2023] Open
Affiliation(s)
- Edwin A Takahashi
- Division of Vascular and Interventional Radiology, Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905
| | - Robert A Lookstein
- Division of Interventional Radiology, the Mount Sinai Hospital, New York, NY
| | - Sanjay Misra
- Division of Vascular and Interventional Radiology, Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905.
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Safety of paclitaxel-coated devices in the femoropopliteal arteries: A systematic review and meta-analysis. PLoS One 2022; 17:e0275888. [PMID: 36227807 PMCID: PMC9560511 DOI: 10.1371/journal.pone.0275888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/26/2022] [Indexed: 11/05/2022] Open
Abstract
Background Clinical benefit of paclitaxel-coated devices for patients with peripheral arterial disease has been confirmed in randomized controlled trials (RCTs). A meta-analysis published in 2018 identified late mortality risk over a long follow-up period due to use of paclitaxel-coated devices in the femoropopliteal arteries, which caused enormous controversy and debates globally. This study aims to further evaluate the safety of paclitaxel-coated devices by incorporating the most recently published data. Methods We searched for candidate studies in PubMed (MEDLINE), Scopus, EMBASE (Ovid) online databases, government web archives and international cardiovascular conferences. Safety endpoints of interest included all-cause mortality rates at one, two and five years and the risk ratio (RR) was used as the summary measure. The primary analysis was performed using random-effects models to account for potential clinical heterogeneity. Findings Thirty-nine RCTs including 9164 patients were identified. At one year, the random-effects model yielded a pooled RR of 1.06 (95% CI [0.87, 1.29]) indicating no difference in short-term all-cause deaths between the paclitaxel and control groups (crude mortality, 4.3%, 214/5025 versus 4.5%, 177/3965). Two-year mortality was reported in 26 RCTs with 382 deaths out of 3788 patients (10.1%) in the paclitaxel arm and 299 out of 2955 patients (10.1%) in the control arm and no association was found between increased risk of death and usage of paclitaxel-coated devices (RR 1.08, 95% CI [0.93, 1.25]). Eight RCTs recorded all-cause deaths up to five years and a pooled RR of 1.18 (95% CI [0.92, 1.51]) demonstrated no late mortality risk due to use of paclitaxel-coated devices (crude mortality, paclitaxel 18.2%, 247/1360 versus control 15.2%, 122/805). Conclusions We found no significant difference in either short- or long-term all-cause mortalities between patients receiving paclitaxel-coated and uncoated devices. Further research on the longer-term safety of paclitaxel usage (e.g., 8- or 10-year) is warranted. Registration PROSPERO, CRD42021246291.
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Aoi S, Kakkar AM, Sanina C, Wiley JM. Superficial Femoral Artery Interventions. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Giannopoulos S, Strobel A, Rudofker E, Kovach C, Schneider PA, Armstrong EJ. Association of Postangioplasty Femoropopliteal Dissections With Outcomes After Drug-Coated Balloon Angioplasty in the Femoropopliteal Arteries. J Endovasc Ther 2021; 28:593-603. [PMID: 34002659 DOI: 10.1177/15266028211016441] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Balloon angioplasty for the treatment of femoropopliteal lesions is often complicated by postangioplasty dissections. While dissections are known to affect patency and reintervention after balloon angioplasty, the association between dissections and major adverse limb event (MALE) after drug-coated balloon (DCB) angioplasty remains uncertain. Thus, the postangioplasty dissection and bailout stenting patterns were investigated. MATERIALS AND METHODS This was a single-center retrospective study enrolling patients with de novo femoropopliteal lesions treated with DCB with/without stenting. Postangioplasty target vessel dissection was graded based to the coronary artery classification grades A-F, with grade C-F considered "severe." Cox regression analysis was performed to examine the association of dissection severity with outcomes during 2-year follow up, among nonstented cases. RESULTS In 85.3% of the cases (N=203/238) a postangioplasty dissection was observed. The average dissection length was 55.57 mm (SD 36.71 mm), with 1 dissection present in 91.8% (N=180/196) and 2 or more dissections present in 8.2% (N=16/196). Dissection severity was grade A (19.8%), B (20.6%), C (23.1%), D (10.9%), E (10.1%), and F (0.8%). Bailout stenting was required in 40.4% of the patients, being more prevalent among grade C and grade E cases. Among 142 nonstented cases, dissections were present in 85.2%. A total of 75 (52.8%) of these dissections were grade A and B, while 46 (32.4%) were grade C to F. Among nonstented cases, grade C (hazard ratio [HR] 5.83; 95% CI 1.25 to 27.31; p=0.025) and grade D (HR 6.32; 95% CI 1.39 to 28.86; p=0.017) vs grade A dissections were associated with a higher risk for 2-year MALE. Multivariate analysis adjusting for several lesion characteristics demonstrated a statistically significant higher risk for 2-year MALE among the severe dissection group (HR 2.94; 95% CI 1.27 to 6.79; p = 0.012). Interestingly, the risks of limb loss (HR 1.30; 95% CI 0.22 to 7.79; p=0.774) and repeat revascularization (HR 0.95; 95% CI 0.40 to 2.26; p=0.905) during follow-up were similar between the 2 groups. CONCLUSION This study indicated that nonstented moderate and severe postangioplasty dissections after DCB angioplasty were associated with higher risk for MALE. Future studies are needed to validate our results and determine other dissection characteristics (eg, total dissection length, lumen area, total number of dissections) that may affect the efficacy of DCB.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Aaron Strobel
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Eric Rudofker
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Christopher Kovach
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco, CA, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Del Giudice C, Galloula A, Tiercelin C, Vilfaillot A, Alsac JM, Messas E, Déan CL, Larger E, Sapoval M. "Ranger BTK" a Prospective Single-Centre Cohort Study on a New Drug-Coated Balloon for Below the Knee Lesions in Patients with Critical Limb Ischemia. Cardiovasc Intervent Radiol 2021; 44:1017-1027. [PMID: 33948700 DOI: 10.1007/s00270-021-02833-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/24/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Restenosis remains a limitation of endovascular angioplasty with a patency of 30% in BTK at 12 months. Several studies on drug-coated balloons have not demonstrated any improvements in terms of patency and target lesions revascularization in BTK lesions. This prospective single-centre cohort study evaluates the safety and efficacy of a new generation low-dose drug-coated balloon (DCB) with a reduced crystalline structure to treat below the knee (BTK) lesions in patients with critical limb ischemia (CLI). MATERIALS AND METHODS Between November 2016 and November 2017, 30 consecutive patients (mean 68.8 ± 12.7 years, 6 female) with BTK lesions and CLI were included in this single-centre, prospective non-randomized cohort study. All patients with rest pain and/or ischemic wound associated with BTK lesions were included in the study. Mean lesion length was 133.6 ± 94.5 mm and 18(60%) were chronic total occlusions. The primary safety outcome parameter was a composite of all-cause mortality and major amputation at 6 months. The primary efficacy outcome parameter was the primary angiographic patency at 6 months (defined as freedom from clinically driven target lesion revascularization and the absence of significant restenosis (> 50%) as determined by core laboratory angiography assessment. Immediate technical success, late lumen loss (LLL), clinical target lesion revascularization (TLR) and ulcer healing rates at 12 months were also evaluated. RESULTS Immediate technical success was 97%(29/30): one patient had an acute thrombosis at the completion of index procedure. Primary safety outcome parameter was 94%(28/30): one patient underwent major amputation and one patient died of other comorbidities at 2 months. Another patient had a major amputation at 7.5 months. Angiographic follow-up was available in 20 patients. Primary angiographic patency was 57%(12/21 lesions), and LLL was 0.99 ± 0.68 mm at 6 months. Freedom from TLR was 89% at 12 months. The rate of ulcer healing was 76% at 12 months. CONCLUSION Ranger DCB balloons to treat CLI patients demonstrated a positive trend with good safety outcomes parameters. Further randomized studies are needed to understand the usefulness compared to POBA.
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Affiliation(s)
- Costantino Del Giudice
- Department of Radiology, Interventional Radiology, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.
| | - Alexandre Galloula
- Department of Vascular Medicine, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
| | - Clarisse Tiercelin
- Diabetology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
| | - Aurélie Vilfaillot
- Clinical Investigation Unit, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
| | - Jean Marc Alsac
- Vascular Surgery, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France.,Université de Paris, INSERM U970, 75015, Paris, France
| | - Emmanuel Messas
- Department of Vascular Medicine, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France.,Université de Paris, INSERM U970, 75015, Paris, France
| | - Carole L Déan
- Vascular and Oncological Interventional Radiology, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
| | - Etienne Larger
- Diabetology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
| | - Marc Sapoval
- Université de Paris, INSERM U970, 75015, Paris, France.,Vascular and Oncological Interventional Radiology, Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, 75015, Paris, France
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Giannopoulos S, Armstrong EJ. Clinical considerations after endovascular therapy of peripheral artery disease. Expert Rev Cardiovasc Ther 2021; 19:369-378. [PMID: 33870848 DOI: 10.1080/14779072.2021.1914590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Patients with peripheral artery disease (PAD) are at higher risk for all-cause mortality, driven by increased cardiovascular mortality rates. In this manuscript we review the literature on guideline-recommended therapies and discuss the major clinical considerations after endovascular therapy of PAD.Areas covered: Current guidelines recommend smoking cessation, aspirin, statin, and renin-angiotensin system inhibitors in order to reduce the risk of cardiovascular and limb-related adverse events. Nonetheless, studies have shown that patients with PAD are undertreated with these important medical therapies. Additionally, there is lack in evidence regarding the most optimal follow up imaging approach for early detection of disease recurrence and re-intervention among patients undergoing endovascular therapy for PAD. We also describe the benefits of supervised walking exercise for patients with PAD that undergo revascularization procedures and are fit for such interventions.Expert opinion: Adherence to guideline recommended medical therapy is crucial for improved outcomes in PAD management. Systematic assessment of risk-reduction interventions could help increase adherence to clinically beneficial interventions and improve the overall prognosis of patients with PAD undergoing revascularization procedures. Additionally, optimization of current follow up protocols is needed, with the optimal goal to develop standardized cost-effective algorithms regarding early detection of disease recurrence and re-intervention.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Giannopoulos S, Mustapha J, Gray WA, Ansel G, Adams G, Secemsky EA, Armstrong EJ. Three-Year Outcomes From the LIBERTY 360 Study of Endovascular Interventions for Peripheral Artery Disease Stratified by Rutherford Category. J Endovasc Ther 2021; 28:262-274. [DOI: 10.1177/1526602820962972] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Purpose: To report the 3-year results of the LIBERTY 360 study, which investigated outcomes of endovascular treatment of symptomatic peripheral artery disease (PAD). Materials and Methods: The LIBERTY trial ( ClinicalTrials.gov identifier NCT01855412) was a prospective, observational, core laboratory–assessed, multicenter study of endovascular interventions enrolling >1200 participants treated at 51 sites. Data from 1189 patients were stratified according to Rutherford category (RC) and analyzed [RC 2-3 (n=500), RC 4-5 (n=589), and RC 6 (n=100)]. The primary outcomes were major amputation of the target limb and all-cause death; secondary outcomes were target vessel revascularization (TVR) or target lesion revascularization (TLR); major adverse events (MAEs; death within 30 days, TVR or TLR, and major amputation); death or major amputation combined; and change in self-reported quality of life (QoL) measures (VascuQol-25). The Kaplan-Meier (KM) method was employed to estimate the outcomes; estimates are presented with the 95% confidence intervals (CI). Predictors of 3-year MAE, death, TVR, and major amputation were analyzed using Cox proportional hazard regression modeling. Results: The 36-month KM survival rates were 86.0% in RC 2-3, 79.8% in RC 4-5, and 62.0% in RC 6 groups. The KM estimates of freedom from major amputation at 36 months were 98.5% in RC 2-3, 94.0% in RC 4-5, and 79.9% in RC 6. The 36-month KM estimates for freedom from TVR/TLR were 71.1% in RC 2-3, 64.2% in RC 4-5 and 61.9% in RC 6 groups. Patients with claudication at baseline were at lower risk for MAEs compared with RC 4-5 and RC 6 patients during the 36-month follow-up. Vascular QoL improved from baseline and persisted up to 36 months in all patients. Conclusion: Endovascular therapy is a viable treatment option for patients with symptomatic PAD, with sustained improved quality of life in both claudicants and patients with chronic limb-threatening ischemia. These results provide important point estimates for midterm outcomes after modern endovascular interventions for PAD.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Jihad Mustapha
- Advanced Cardiac and Vascular Centers for Amputation Prevention, Grand Rapids, MI, USA
| | - William A. Gray
- Lankenau Heart Institute/Main Line Health, Philadelphia, PA, USA
| | - Gary Ansel
- OhioHealth Heart and Vascular Physicians, Columbus, OH, USA
| | - George Adams
- Department of Cardiology, North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, NC, USA
| | - Eric A. Secemsky
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ehrin J. Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Nowakowski P, Uchto W, Hrycek E, Kachel M, Ludyga T, Polczyk F, Żurakowski A, Kaźmierczak P, Granada JF, Nowakowska I, Kiesz RS, Milewski KP, Buszman PE, Buszman PP. Microcrystalline paclitaxel-coated balloon for revascularization of femoropopliteal artery disease: Three-year outcomes of the randomized BIOPAC trial. Vasc Med 2021; 26:401-408. [DOI: 10.1177/1358863x20988360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The aim of the BIOPAC trial was to determine long-term safety and efficacy of a novel microcrystalline paclitaxel-coated balloon (mcPCB) with a biocompatible polymer as an excipient in the treatment of occlusive femoropopliteal lesions. In this first-in-human prospective controlled randomized trial, 66 patients with femoropopliteal, symptomatic (Rutherford stages 2B to 5) occlusive arterial disease were randomized to either mcPCB (study group) or POBA (plain old balloon angioplasty) (control group) on a 1:1 basis. Late lumen loss (LLL) at 6 months was the primary endpoint of the study and serious adverse events (SAE: death, amputation, repeated revascularization) were considered a composite secondary endpoint. Routine angiography was scheduled for all study subjects at 6-month follow-up; outpatient appointments were scheduled at 12 and 36 months after intervention. At 6 months, the LLL was 63% lower in the mcPCB group compared to the POBA group (0.52 ± 1.2 vs 1.39 ± 1.1 mm; psup < 0.01). Binary restenosis occurred in 23% vs 52% of patients ( p = 0.02). At 3 years, the prevalence of SAE was significantly lower in the mcPCB group (33.3 vs 63.3%; p = 0.02), which mainly resulted from a twofold reduction in target vessel revascularization rate (28.6 vs 59.3%; p = 0.02). The difference in mortality was nonsignificant (7.4 vs 14.3%; p = 0.42). Patients with mcPCB were less symptomatic and less likely to adhere to secondary prevention measures. In this pivotal trial, a novel mcPCB proved superior to POBA concerning LLL at 6-month follow-up, and SAE at 12 months. This result was sustained up to 3 years. There was no difference between groups regarding mortality. ClinicalTrials.gov Identifier: NCT02145065
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Affiliation(s)
- Przemysław Nowakowski
- Lesser Poland Cardiovascular Center of American Heart of Poland, Chrzanów, Poland
- University of Technology, Katowice, Poland
| | - Wojciech Uchto
- Lesser Poland Cardiovascular Center of American Heart of Poland, Chrzanów, Poland
| | - Eugeniusz Hrycek
- Lesser Poland Cardiovascular Center of American Heart of Poland, Chrzanów, Poland
- Andrzej Frycz-Modrzewski, Kraków University, Kraków, Poland
| | - Mateusz Kachel
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland
| | | | | | - Aleksander Żurakowski
- Lesser Poland Cardiovascular Center of American Heart of Poland, Chrzanów, Poland
- Andrzej Frycz-Modrzewski, Kraków University, Kraków, Poland
| | - Paweł Kaźmierczak
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland
| | - Juan F Granada
- Skirbal Center for Innovation, Cardiovascular Research Foundation, Orangeburg, NY, USA
| | - Iwona Nowakowska
- Department of Balneoclimatology and Biological Regeneration, Chair of Physiotherapy, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Radosław S Kiesz
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland
- San Antonio Heart and Endovascular Institute, San Antonio, TX, USA
| | - Krzysztof P Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland
| | - Paweł E Buszman
- Department of Epidemiology, Medical University of Silesia, Katowice, Poland
| | - Piotr P Buszman
- Andrzej Frycz-Modrzewski, Kraków University, Kraków, Poland
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland
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Li BH, Chan YC, Cheng SW. Evidence for treatment of lower limb in-stent restenosis with drug eluting balloons. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:626-631. [PMID: 33231030 DOI: 10.23736/s0021-9509.20.07968-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Restenosis by myointimal hyperplasia after peripheral arterial angioplasty or stenting often limits long term patency. Drug-eluting balloons (DEBs) which inhibit the proliferation of neo-intimal growth of vascular smooth muscle cells may prevent restenosis. The aim of this paper was to examine the evidence in published literature on the use of DEBs in the treatment of peripheral arterial in-stent restenosis (ISR). EVIDENCE ACQUISITION A systematic literature review was undertaken of all published literature on the treatment of peripheral ISR with drug eluting balloon using Medline and cross-referenced. All published papers on the use of DEBs in peripheral arterial disease (PAD) were used. Cochrane Central Register of Controlled Trials and electronic databases were also searched for on-going studies. EVIDENCE SYNTHESIS There were no level 1 or 2 evidence published on this subject. The number of high-quality publications is few, and consequently a sufficient analysis is not possible. Recently data from non-randomized cohort studies showed encouraging results with DEB as treatment modality for ISR, whether used alone or as combined strategies. CONCLUSIONS Evidence from the published literature suggests that DEBs are safe in preventing peripheral ISR. Despite strong corporate pressure for the use of DEBs, there is only circumstantial evidence that this is a useful modality for ISR. Results from on-going studies may allow further meta-analysis for efficiency and cost-effectiveness.
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Affiliation(s)
- Brian H Li
- School of Medicine, Kings College Hospital, London, UK
| | - Yiu C Chan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre, Hong Kong, China -
| | - Stephen W Cheng
- Division of Vascular and Endovascular Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre, Hong Kong, China
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Feng H, Chen X, Guo X, Zhang Z, Zhang Z, Liu B, Lian L. Comparison of efficacy and safety of drug-eluting versus uncoated balloon angioplasty for femoropopliteal arterial occlusive disease: a meta-analysis. BMC Cardiovasc Disord 2020; 20:395. [PMID: 32867681 PMCID: PMC7457510 DOI: 10.1186/s12872-020-01667-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 08/13/2020] [Indexed: 12/14/2022] Open
Abstract
Background This quantitative meta-analysis was conducted to evaluate the efficacy and safety of drug-eluting balloon (DEB) vs. uncoated balloon (UCB) in patients with femoropopliteal arterial occlusive disease. Methods Electronic databases were searched to identify randomized controlled trials (RCTs) that compared DEB and UCB till November 2018. The random-effects model was used for conducting pooled analyses. Results Seventeen RCTs with 2706 patients were included in the final meta-analysis. Patients who received DEB had higher levels of minimal luminal diameter (MLD) at 6 (WMD: 0.77; 95%CI: 0.53 to 1.02; P < 0.001) and 12 months (WMD: 1.33; 95%CI: 0.93 to 1.73; P < 0.001) than those who received UCB. DEB reduced the late lumen loss (LLL) levels after 6 (WMD: -0.57; 95%CI: − 1.07 to − 0.06; P = 0.029) and 12 months (WMD: -0.95; 95%CI: − 1.28 to − 0.62; P < 0.001). DEB was found not superior over UCB on primary patency after 6 months (RR: 1.44; 95%CI: 0.88–2.35; P = 0.149), whereas DEB increased the primary patency after 12 (RR: 1.51; 95%CI: 1.25–1.83; P < 0.001) and 24 months (RR: 1.51; 95%CI: 1.30–1.77; P < 0.001). Patients who received DEB had reduced the risk of restenosis after 6 (RR: 0.47; 95%CI: 0.33–0.67; P < 0.001) and 12 months (RR: 0.55; 95%CI: 0.35–0.85; P = 0.008). DEB reduced the risk of major adverse events after 6 (RR: 0.30; 95%CI: 0.14–0.61; P = 0.001), 12 (RR: 0.49; 95%CI: 0.32–0.76; P = 0.001) and 24 months (RR: 0.62; 95%CI: 0.41–0.92; P = 0.018). Conclusions DEB yielded additional benefits on MLD, LLL, primary patency, restenosis, TLR, and major adverse events than UCB in patients with femoropopliteal arterial occlusive disease.
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Affiliation(s)
- Hai Feng
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
| | - Xueming Chen
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Xiaobo Guo
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhe Zhang
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhiwen Zhang
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Bin Liu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Lishan Lian
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
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12
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Ang H, Koppara TR, Cassese S, Ng J, Joner M, Foin N. Drug-coated balloons: Technical and clinical progress. Vasc Med 2020; 25:577-587. [PMID: 32634046 DOI: 10.1177/1358863x20927791] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The advancement of drug-coated balloons (DCB) presents an alternative nonstent method in the percutaneous treatment of atherosclerotic lesions. While the current generation of drug-eluting stents (DES) are the device of choice, especially in coronary artery disease (CAD), DCB has potential applications in the treatment of de novo lesions, in-stent restenosis (ISR), bifurcations, and in peripheral artery disease (PAD). In terms of coronary clinical experience, DCB is used most in ISR scenarios and more data are collected to support the use of DCB in de novo lesions compared to best-in-class DES. The use of DCB in bifurcation side branch treatment has demonstrated safety, and with good angiographic and clinical outcomes, but more data from randomized trials will be required to assess its clinical value. For PAD, the clinical outcomes of DCB with and without debulking devices in diseased femoropopliteal arteries and treatment of below-the-knee (BTK) vessels with DCB are discussed. Current data demonstrated conflicting long-term safety outcomes in the use of paclitaxel devices in the femoral and/or popliteal arteries, while the role of DCB in BTK disease remains uncertain due to a lack of randomized controlled trial data. In summary, this review provides an overall view of current DCB technologies and progress, followed by an update on DCB clinical data in the treatment of CAD and PAD.
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Affiliation(s)
- Huiying Ang
- National Heart Centre Singapore, Singapore.,Biomedical Engineering, National University of Singapore, Singapore
| | - Tobias R Koppara
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Jaryl Ng
- National Heart Centre Singapore, Singapore.,Biomedical Engineering, National University of Singapore, Singapore
| | - Michael Joner
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Nicolas Foin
- National Heart Centre Singapore, Singapore.,Duke-NUS Medical School, Singapore
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13
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Giannopoulos S, Jeon-Slaughter H, Kahlon RS, Tejani I, Baskar A, Banerjee S, Armstrong EJ. Comparative 12-Month Outcomes of Drug-Coated Balloon Versus Non-Drug-Coated Balloon Revascularization Strategy in Chronic Limb-Threatening Ischemia: Results From the XLPAD Registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1276-1284. [PMID: 32249170 DOI: 10.1016/j.carrev.2020.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Endovascular therapy is often the preferred first treatment option for chronic limb threatening ischemia (CLTI) patients. Drug coated balloons (DCB) reduce restenosis rates compared to percutaneous transluminal angioplasty (PTA), however DCB use has not been studied systematically in patients with CLTI. Thus, the optimal treatment option for these complex lesions remains controversial. METHODS We report on 327 patients with CLTI treated either with DCB (n = 105) or non-DCB (n = 222) for femoropopliteal disease. Data were retrieved from the Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851). Two DCB types were used at the discretion of the operator: Lutonix® (BARD Peripheral Vascular, Inc., Tempe, AZ, USA) and IN.PACT AdmiralTM (Medtronic, Santa Rosa, CA, USA). Odds ratios and the respective 95% confidence interval were synthesized to examine the association between the two groups in terms of all-cause mortality, target limb repeat endovascular or surgical revascularization, target vessel revascularization (TVR), major and minor amputation at 12 months of follow up. RESULTS The mean lesion length was 150.0 mm (SD:123.2) and 151.2 mm (SD:108.3) for the DCB and non-DCB group respectively. No difference between the two groups was detected in terms of all-cause mortality (2.86%vs2.7%,p = .94), target limb repeat endovascular or surgical revascularization (16.19%vs12.61%,p = .25), TVR (16.19%vs.11.71%,p = .26) or minor amputation (15.24%vs10.81%,p = .25) at 12 months of follow up. Although a higher incidence of 12 months major amputation was observed in the DCB group (11%vs.4%,p = .01), after adjusting for several risk factors the odds of major amputation were not statistically different between the DCB and non-DCB groups (OR:1.54;95%CI:0.53-4.51;p = .43). CONCLUSIONS Both DCB and non-DCB strategies are effective modalities for revascularization of patients with CLTI. No differences were identified between the DCB and non-DCB group in terms of late outcomes during 12 months of follow up.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, University of Colorado, Rocky Mountain Regional VA Medical Center, CO, USA
| | - Haekyung Jeon-Slaughter
- Department of Internal Medicine, University of Texas Southwestern Medical Center, VA North Texas Healthcare System, Dallas, TX, USA
| | - Ravi S Kahlon
- Division of Cardiology, University of Colorado, Rocky Mountain Regional VA Medical Center, CO, USA
| | - Ishita Tejani
- Department of Internal Medicine, University of Texas Southwestern Medical Center, VA North Texas Healthcare System, Dallas, TX, USA
| | - Amutha Baskar
- Department of Internal Medicine, University of Texas Southwestern Medical Center, VA North Texas Healthcare System, Dallas, TX, USA
| | - Subhash Banerjee
- Department of Internal Medicine, University of Texas Southwestern Medical Center, VA North Texas Healthcare System, Dallas, TX, USA
| | - Ehrin J Armstrong
- Division of Cardiology, University of Colorado, Rocky Mountain Regional VA Medical Center, CO, USA.
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14
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Yazar O, Provoost A, Broughton A, Ghijselings L, Leclef Y, Van Calster K, Reginster F, Fourneau I. Paclitaxel drug-coated balloon angioplasty for the treatment of failing arteriovenous fistulas: a single-center experience. Acta Chir Belg 2020; 120:85-91. [PMID: 30633638 DOI: 10.1080/00015458.2018.1561796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objectives: To report our experience of angioplasty with Lutonix (Bard Peripheral Vascular, Inc., Tempe, AZ) drug-coated balloon (DCB) for the treatment of failing arteriovenous fistulas (AVF).Materials and methods: Retrospective, single-center analysis consisting of 14 patients treated with Lutonix paclitaxel DCBs in the period from July 2015 through April 2017. We analyzed technical success, clinical success, primary patency of the target lesion, primary patency of the dialysis circuit, and the rate of complications. Regular follow-up of AVF patency was realized by clinical examination and duplex ultrasonography. The Kaplan-Meier survival method was applied to determine the cumulative primary patency of the target lesion and the dialysis circuit.Results: Technical success was 100% and clinical success 92.9%. There were no major or minor complications. Cumulative target lesion primary patency after DCB was 69.2% at 6 months and 31.6% at 12 months. Cumulative vascular circuit primary patency was 61.5% at 6 months and 31.6% at 12 months.Conclusion: Compared to results reported in literature with plain old balloon angioplasty (POBA), Lutonix paclitaxel DCB angioplasty proved a short-term patency benefit in treatment of dialysis AVF stenosis.
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Affiliation(s)
- O. Yazar
- Department of Surgery, Europe Hospitals Brussels, Brussels, Belgium
| | - A. Provoost
- Department of Surgery, Europe Hospitals Brussels, Brussels, Belgium
| | - A. Broughton
- Department of Nephrology, Europe Hospitals Brussels, Brussels, Belgium
| | - L. Ghijselings
- Department of Radiology, Europe Hospitals Brussels, Brussels, Belgium
| | - Y. Leclef
- Department of Surgery, Europe Hospitals Brussels, Brussels, Belgium
| | - K. Van Calster
- Department of Surgery, Europe Hospitals Brussels, Brussels, Belgium
| | - F. Reginster
- Department of Nephrology, Europe Hospitals Brussels, Brussels, Belgium
| | - I. Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
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15
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Bertges DJ, Sedrakyan A, Sun T, Eslami MH, Schermerhorn M, Goodney PP, Beck AW, Cronenwett JL, Eldrup-Jorgensen J. Mortality After Paclitaxel Coated Balloon Angioplasty and Stenting of Superficial Femoral and Popliteal Artery in the Vascular Quality Initiative. Circ Cardiovasc Interv 2020; 13:e008528. [PMID: 32069110 DOI: 10.1161/circinterventions.119.008528] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND To compare mortality after treatment of superficial femoral-popliteal artery disease with paclitaxel and nonpaclitaxel devices using a multicenter vascular registry. METHODS Patients (N=8376) undergoing endovascular treatment of superficial femoral-popliteal artery disease in the Society for Vascular Surgery Vascular Quality Initiative were studied from October 2016 to December 2017. One-year mortality was compared between 3 groups; plain balloon angioplasty (N=2104) versus paclitaxel-coated balloon angioplasty (N=3543), bare-metal stenting (N= 2045) versus paclitaxel-eluting stents (N=684), and combined paclitaxel versus nonpaclitaxel devices. Mortality rates with hazard ratios (HR) and 95% CI were compared in unadjusted and propensity-matched cohorts and illustrated by Kaplan-Meier analysis with subgroup analysis for intermittent claudication, chronic limb-threatening ischemia, and secondary interventions. RESULTS In propensity-matched analyses, mortality was similar after plain balloon angioplasty (12.6%) and paclitaxel-coated balloon angioplasty (9.6%; HR=0.84 [95% CI, 0.66-1.06], P=0.14). In propensity-matched groups, mortality was similar after bare-metal stenting (9.8%) and paclitaxel-eluting stenting (8.8%; HR=0.93 [95% CI, 0.62-1.41], P=0.75). In the combined, matched analysis mortality was significantly lower in the paclitaxel device group (8.5%) compared with the nonpaclitaxel device group (11.5%; HR=0.82 [95% CI, 0.68-0.98], P=0.03). Secondary interventions were similar after nonpaclitaxel (N=1113/4149, 26.8%) and paclitaxel device use (N=1113/4227, 26.3%). For intermittent claudication, mortality was lower after paclitaxel device use (1.6%) compared with nonpaclitaxel devices (4.4%; adjusted HR=0.59 [95% CI, 0.39-0.89], P=0.01). For chronic limb-threatening ischemia, the mortality difference was not significant; paclitaxel (12.8%) versus nonpaclitaxel devices (15.5%; adjusted HR=0.85 [95% CI, 0.72-1.00], P=0.05). CONCLUSIONS At 1 year, mortality was similar if not lower after treatment of femoral-popliteal occlusive disease with paclitaxel versus nonpaclitaxel devices. This work highlights the potential use of the Society for Vascular Surgery Vascular Quality Initiative for surveillance of the safety of new peripheral arterial devices.
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Affiliation(s)
- Daniel J Bertges
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT (D.J.B.)
| | - Art Sedrakyan
- Department of Health Care Policy and Research, Cornell Weill College of Medicine, New York, NY (A.S., T.S.)
| | - Tianyi Sun
- Department of Health Care Policy and Research, Cornell Weill College of Medicine, New York, NY (A.S., T.S.)
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA (M.H.E.)
| | - Marc Schermerhorn
- Division of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA (M.S.)
| | - Philip P Goodney
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH (P.P.G., J.L.C.)
| | - Adam W Beck
- Division of Vascular Surgery, University of Alabama at Birmingham (A.W.B.)
| | - Jack L Cronenwett
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH (P.P.G., J.L.C.)
| | - Jens Eldrup-Jorgensen
- Division of Vascular Surgery, Maine Medical Center, Division of Vascular Surgery, Portland, ME (J.E.-J.)
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16
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Klumb C, Lehmann T, Aschenbach R, Eckardt N, Teichgräber U. Benefit and risk from paclitaxel-coated balloon angioplasty for the treatment of femoropopliteal artery disease: A systematic review and meta-analysis of randomised controlled trials. EClinicalMedicine 2019; 16:42-50. [PMID: 31832619 PMCID: PMC6890981 DOI: 10.1016/j.eclinm.2019.09.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/16/2019] [Accepted: 09/10/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Paclitaxel-coated balloons (DCB) are suitable to reduce the risk of restenosis after angioplasty of atherosclerotic femoropopliteal lesions. However, numerous types of DCBs are distinguished by drug density and coating. Conflicting evidence exists about the risk of mortality. This study sought to evaluate benefit and risk of DCB angioplasty compared to plain old balloon angioplasty (POBA). METHODS Randomised trials published between January 1, 2005 and February 3, 2019 were identified by searching MEDLINE, CENTRAL, and Clinical.trials.gov. Studies on DCB versus POBA for the treatment of femoropopliteal artery disease were included, and those focused on in-stent restenosis or critical limb ischemia were excluded. Random-effects meta-analysis was conducted to assess the main outcomes of freedom from target lesion revascularisation (FfTLR) and all-cause mortality. FINDINGS Of 552 identified records, 14 studies including 2504 patients were eligible. DCB significantly increased the risk of FfTLR with substantial heterogeneity (12-month: risk ratio [RR] 1·24 [95% CI 1·14-2·27], I 2 = 66%; 24-month RR 1·39 [95% CI 1·39-1·52], I 2 = 21%). The risk of 24-month all-cause mortality was increased after DCB (random-effects model: RR 1·53 [95% CI 0·94-2·50], p = 0·09; fixed-effect model: RR 1·74 [95% CI 1·08-2·81], p = 0·02). INTERPRETATION Efficacy of DCB differs substantially across studies. Effect size depends on the type of DCB, treatment strategy, and lesion complexity. The risk of 2-year all-cause mortality at 2 years was increased, but without evidence of causation.
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Affiliation(s)
- Christof Klumb
- Department of Radiology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Thomas Lehmann
- Center for Clinical Studies, Jena University Hospital, Salvador-Allende-Platz 27, 07747 Jena, Germany
| | - René Aschenbach
- Department of Radiology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Niklas Eckardt
- Department of Radiology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Ulf Teichgräber
- Department of Radiology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
- Corresponding author at: Universitätsklinikum Jena, Institut für Diagnostische und Interventionelle Radiologie, Am Klinikum 1, 07747 Jena, Germany.
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17
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Zheng J, Cui J, Meiyan Qing J, Irani Z. Safety and effectiveness of combined scoring balloon and paclitaxel-coated balloon angioplasty for stenosis in the hemodialysis access circuit. Diagn Interv Imaging 2019; 100:31-37. [DOI: 10.1016/j.diii.2018.05.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/25/2018] [Accepted: 05/14/2018] [Indexed: 11/28/2022]
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18
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Katsanos K, Spiliopoulos S, Kitrou P, Krokidis M, Karnabatidis D. Risk of Death Following Application of Paclitaxel-Coated Balloons and Stents in the Femoropopliteal Artery of the Leg: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2018; 7:e011245. [PMID: 30561254 PMCID: PMC6405619 DOI: 10.1161/jaha.118.011245] [Citation(s) in RCA: 592] [Impact Index Per Article: 98.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 11/07/2018] [Indexed: 02/05/2023]
Abstract
Background Several randomized controlled trials ( RCT s) have already shown that paclitaxel-coated balloons and stents significantly reduce the rates of vessel restenosis and target lesion revascularization after lower extremity interventions. Methods and Results A systematic review and meta-analysis of RCT s investigating paclitaxel-coated devices in the femoral and/or popliteal arteries was performed. The primary safety measure was all-cause patient death. Risk ratios and risk differences were pooled with a random effects model. In all, 28 RCT s with 4663 patients (89% intermittent claudication) were analyzed. All-cause patient death at 1 year (28 RCT s with 4432 cases) was similar between paclitaxel-coated devices and control arms (2.3% versus 2.3% crude risk of death; risk ratio, 1.08; 95% CI, 0.72-1.61). All-cause death at 2 years (12 RCT s with 2316 cases) was significantly increased in the case of paclitaxel versus control (7.2% versus 3.8% crude risk of death; risk ratio, 1.68; 95% CI, 1.15-2.47; -number-needed-to-harm, 29 patients [95% CI , 19-59]). All-cause death up to 5 years (3 RCT s with 863 cases) increased further in the case of paclitaxel (14.7% versus 8.1% crude risk of death; risk ratio, 1.93; 95% CI , 1.27-2.93; -number-needed-to-harm, 14 patients [95% CI , 9-32]). Meta-regression showed a significant relationship between exposure to paclitaxel (dose-time product) and absolute risk of death (0.4±0.1% excess risk of death per paclitaxel mg-year; P<0.001). Trial sequential analysis excluded false-positive findings with 99% certainty (2-sided α, 1.0%). Conclusions There is increased risk of death following application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the lower limbs. Further investigations are urgently warranted. Clinical Trial Registration URL : www.crd.york.ac.uk/PROSPERO . Unique identifier: CRD 42018099447.
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19
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Baumhäkel M, Chkhetia S, Kindermann M. Treatment of femoro-popliteal lesions with scoring and drug-coated balloon angioplasty: 12-month results of the DCB-Trak registry. ACTA ACUST UNITED AC 2018; 24:153-157. [PMID: 29770768 DOI: 10.5152/dir.2018.17466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Debulking strategies prior to drug-coated balloon (DCB) angioplasty were suggested to improve clinical results in femoro-popliteal lesions. Currently, there are no data regarding plaque modification with a scoring balloon with subsequent DCB-angioplasty. Recently published 6-month results of the DCB-Trak registry in patients treated with scoring-balloon angioplasty and DCB-angioplasty were promising without any safety concerns. Herein, we report the 12-month follow-up data. METHODS In a single center registry, 29 consecutive patients with 32 femoro-popliteal lesions were treated with a scoring-balloon (VascuTrak®) and a DCB subsequently. The primary endpoint was the clinically driven target lesion revascularization (TLR). Secondary endpoints were clinically driven target vessel revascularization (TVR), binary restenosis (peak systolic velocity ratio > 2.4), change in Rutherford classification and ankle-brachial-index (ABI). Safety endpoints were major cardiovascular events (cardiovascular death, myocardial infarction, stroke, death) and need for amputation. RESULTS The procedure was successful in 29 lesions. There were no clinically driven TLRs after 12 months. Two patients required clinically driven TVR and one patient had a binary restenosis. ABI significantly increased after the procedure (0.87±0.24 to 1.04±0.18, P < 0.01) without a relevant change after 6 months (1.01±0.15, P < 0.05) or 12 months (1.01±0.20, P < 0.05). Rutherford classification improved in more than 90% of patients after 6 and 12 months. There was one major cardiovascular event at 6-month follow-up, but no amputations at 6- or 12-month follow-up. CONCLUSION Vessel preparation with a scoring-balloon and subsequent DCB-angioplasty was safe and effective in patients with femoro-popliteal lesions. Further multicenter trials have to validate these results.
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Affiliation(s)
- Magnus Baumhäkel
- Department of Interventional Cardiology/ Angiology), CaritasKlinikum St. Theresia Saarbrücken Klinik, Saarbrücken, Germany
| | - Shalva Chkhetia
- Department of Interventional Cardiology/ Angiology), CaritasKlinikum St. Theresia Saarbrücken Klinik, Saarbrücken, Germany
| | - Michael Kindermann
- Department of Interventional Cardiology/ Angiology, CaritasKlinikum St. Theresia Saarbrücken Klinik, Saarbrücken, Germany
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20
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Shishehbor MH, White CJ, Beckman JA, Misra S, Schneider PA, Lookstein RA, Kashyap VS, Clair D, Jones WS, Rosenfield K, Katzen BT, Jaff MR. Centers for Medicare & Medicaid Services' decision on drug-coated balloons: No additional reimbursement despite higher cost and highest levels of scientific evidence. Vasc Med 2018; 23:558-559. [PMID: 30238852 DOI: 10.1177/1358863x18802969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Mehdi H Shishehbor
- 1 Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH, USA
| | | | | | | | | | | | - Vikram S Kashyap
- 1 Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Daniel Clair
- 7 Palmetto Health USC Medical Group, Columbia, SC, USA
| | - W Schuyler Jones
- 8 Duke University and Duke Clinical Research Institute, Durham, NC, USA.,9 Massachusetts General Hospital, Boston, MA, USA
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21
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Roh JW, Ko YG, Ahn CM, Hong SJ, Shin DH, Kim JS, Kim BK, Choi D, Hong MK, Jang Y. Risk Factors for Restenosis after Drug-coated Balloon Angioplasty for Complex Femoropopliteal Arterial Occlusive Disease. Ann Vasc Surg 2018; 55:45-54. [PMID: 30118857 DOI: 10.1016/j.avsg.2018.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/02/2018] [Accepted: 06/13/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Currently, there exist limited data on patient outcomes following the use of drug-coated balloons (DCBs) to treat complex femoropopliteal arterial occlusive lesions. The aim of the this study is to investigate the outcomes of patient treated with DCBs and to identify the predictors of restenosis. METHODS We retrospectively investigated medical records from 120 patients (137 limbs) treated with DCBs for femoropopliteal lesions at a single center between 2013 and 2016. Primary patency, target lesion revascularization (TLR), and risk factors of restenosis were analyzed. RESULTS There were 80 de novo and 57 in-stent restenosis lesions. Mean lesion length was 22.2 ± 11.6 cm. The clinical primary patency was 85.2% at 1 year and 65.3% after 2 years. The TLR-free survival rate was 93.0% at 1 year and 87.1% after 2 years. Critical limb ischemia (CLI; hazard ratio [HR] 5.80, 95% confidence interval [CI] 1.26-26.68, P = 0.024) and hypercholesterolemia (HR 4.66, 95% CI 1.30-16.76, P = 0.018) were identified as independent predictors of restenosis. In addition, nonuse of cilostazol and popliteal artery involvement showed trends toward an increased risk of restenosis. CONCLUSIONS Treatment with DCBs showed excellent primary patency and TLR-free survival at 1 year after the procedure. However, the primary patency continuously deteriorated beyond 1 year, suggesting a late catch-up phenomenon. The risk of restenosis after treatment with DCBs was significantly associated with CLI and hypercholesterolemia.
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Affiliation(s)
- Ji Woong Roh
- Division of Cardiology, Bucheon St. Mary's Hospital, The Catholic University College of Medicine, Bucheon, South Korea
| | - Young-Guk Ko
- Division of Cardiology, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea.
| | - Chul-Min Ahn
- Division of Cardiology, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung-Jin Hong
- Division of Cardiology, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong-Ho Shin
- Division of Cardiology, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung-Sun Kim
- Division of Cardiology, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Donghoon Choi
- Division of Cardiology, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yangsoo Jang
- Division of Cardiology, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea
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22
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Cassese S, Ndrepepa G, Kufner S, Byrne RA, Giacoppo D, Ott I, Laugwitz KL, Schunkert H, Kastrati A, Fusaro M. Drug-coated balloon angioplasty for in-stent restenosis of femoropopliteal arteries: a meta-analysis. EUROINTERVENTION 2018; 13:483-489. [PMID: 28169215 DOI: 10.4244/eij-d-16-00735] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Our aim was to perform a meta-analysis to investigate the outcomes of patients undergoing percutaneous revascularisation with drug-coated balloon (DCB) angioplasty because of femoropopliteal in-stent restenosis (ISR). METHODS AND RESULTS We searched scientific databases for studies of DCB angioplasty for femoropopliteal ISR. The primary outcome was target lesion revascularisation (TLR). The main secondary outcome was recurrent ISR. Other outcomes of interest were Rutherford class (RC) improvement, ankle-brachial index (ABI) and death. A total of 367 patients enrolled in four studies received DCB (n=188) or plain balloon angioplasty (n=179). Median follow-up was 12 months. Patients treated with DCB angioplasty displayed a lower risk for TLR (odds ratio [OR] 0.20, 95% confidence interval [CI]: 0.07-0.55, p=0.002) and recurrent ISR (OR 0.24, 95% CI: 0.09-0.61, p=0.003), and a sustained RC improvement (OR 2.57, 95% CI: 1.40-4.72, p=0.002) with similar ABI and mortality as compared to those patients treated with plain balloon angioplasty. CONCLUSIONS In comparison to plain balloon angioplasty, DCB therapy for femoropopliteal ISR is associated with superior clinical and antirestenotic efficacy. Further randomised trials comparing DCB with therapies alternative to plain balloon, in a larger number of patients, and with extended follow-up are needed to address definitively the role of DCB for femoropopliteal ISR.
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Affiliation(s)
- Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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23
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Endovascular management of patients with peripheral vascular disease with cardiovascular multi-morbidity. COR ET VASA 2018. [DOI: 10.1016/j.crvasa.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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24
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Kim W, Choi D. Treatment of Femoropopliteal Artery In-stent Restenosis. Korean Circ J 2018; 48:191-197. [PMID: 29557105 PMCID: PMC5861311 DOI: 10.4070/kcj.2018.0074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 03/06/2018] [Indexed: 11/11/2022] Open
Abstract
Femoropopliteal (FP) artery-in stent restenosis (ISR) is a daunting management problem that we continue to face. FP artery-ISR rates after primary stent implantation are relatively high. Although repeat FP artery-ISR and the need for additional interventions remain all too common, little consensus exists regarding the best treatment algorithm. In this article, we review the limitations of the currently used devices for the endovascular treatment of FP artery-ISR and discuss which strategies are the most effective and safe.
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Affiliation(s)
- Wonho Kim
- Division of Cardiology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea
| | - Donghoon Choi
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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25
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Jaff MR, Nelson T, Ferko N, Martinson M, Anderson LH, Hollmann S. Endovascular Interventions for Femoropopliteal Peripheral Artery Disease: A Network Meta-Analysis of Current Technologies. J Vasc Interv Radiol 2017; 28:1617-1627.e1. [PMID: 29031986 DOI: 10.1016/j.jvir.2017.08.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 08/04/2017] [Accepted: 08/04/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To use network meta-analysis (NMA) to determine the optimal endovascular strategy for management of femoropopliteal peripheral artery disease (PAD) given the lack of multiple prospective randomized trials to guide treatment decisions. MATERIALS AND METHODS NMA is a new meta-analytic method that permits comparisons among any 2 therapies by combining results of a collection of clinical trials conducted in the same or similar patient population. NMA was used to analyze data from 15 randomized controlled trials (RCTs) and 10 prospective, multicenter, single-arm trials (combined evidence [CE] NMA) that evaluated target lesion revascularization (TLR) for 5 endovascular strategies: bare metal stent (BMS), polymer-covered metal stent (CMS), drug-eluting stent (DES), drug-coated balloon (DCB) and percutaneous transluminal angioplasty (PTA). RESULTS The RCT and CE NMAs included 2,912 (6,091) patients with 3,151 (6,786) person-years of follow-up. In the CE NMA, DCB provided a statistically significant 68% reduction in TLR compared with PTA and a statistically significant 53% reduction in TLR compared with BMS. BMS, CMS, and DES provided reductions in TLR of 33%, 48%, and 58% compared with PTA, with statistical significance achieved for CMS and DES. The significant reductions in TLR for DCB compared with PTA and BMS were replicated in the RCT NMA. CONCLUSIONS This NMA demonstrated that DCB provided better reduction in TLR rates compared with PTA and BMS.
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Affiliation(s)
- Michael R Jaff
- Department of Medicine, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA 02462.
| | | | - Nicole Ferko
- Cornerstone Research Group, Burlington, Ontario, Canada
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26
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Kronlage M, Wassmann M, Vogel B, Müller OJ, Blessing E, Katus H, Erbel C. Short vs prolonged dual antiplatelet treatment upon endovascular stenting of peripheral arteries. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2937-2945. [PMID: 29062225 PMCID: PMC5638576 DOI: 10.2147/dddt.s143226] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Peripheral artery disease (PAD) is a highly prevalent disorder with a substantial economical burden. Dual antiplatelet treatment (DAPT) upon endovascular stenting to prevent acute thrombotic reocclusions is an universally accepted practice for postinterventional management of PAD patients. However, the optimal period of time for DAPT upon endovascular stenting is not known. METHODS In the current nonrandomized, retrospective monocentric study, we evaluated the duration of DAPT upon endovascular stenting. A total of 261 endovascular SFA and iliac stenting procedures were performed on 214 patients and these patients were subdivided into a short (4-6 weeks) or a prolonged (8-12 weeks) DAPT regime group. More than 65% of the patients included were male, approximately 35% were diabetic, and 61% had a history of smoking. Of all the patients, 90% exhibited a Rutherford stage 2-3, and approximately half of the patients had a moderate-to-severe calcified target lesion with a length of >13 cm. Major safety end points were defined as any bleeding, compartment syndrome, and ischemic events. In addition to this, patency, all-cause mortality, as well as amputation were followed up over a period of 12 months upon intervention. RESULTS Twelve months after endovascular stenting, primary patency in our cohort was comparable between the groups (83.94% short vs 79.8% long DAPT, P>0.05). Major bleeding occurred in 18 cases without any difference between the groups (P>0.05). In addition, during the 12-month follow-up, 6 (3.4%) patients in the short and 3 (3.5%) in the prolonged DAPT regime suffered a stroke/transient ischemic attack (P>0.05). In addition, there was no difference regarding mortality and amputation rate comparing short vs prolonged DAPT regime in a 12-month follow-up. CONCLUSION In the current cohort, prolonged DAPT after endovascular stenting had no beneficial effect on the outcome in a 12-month follow-up.
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Affiliation(s)
- Mariya Kronlage
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg
| | - Maximilian Wassmann
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg
| | - Britta Vogel
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg
| | - Oliver J Müller
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg
| | | | - Hugo Katus
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg.,DZHK German Center for Cardiovascular Research, Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Christian Erbel
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg
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27
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Anderson JA, Lamichhane S, Vierhout T, Sherman A, Engebretson D, Pohlson K, Remund T, Kelly P. In vitro particulate and in vivo drug retention study of a novel polyethylene oxide formulation for drug-coated balloons. J Vasc Surg 2017; 67:1537-1545.e7. [PMID: 28843789 DOI: 10.1016/j.jvs.2017.03.442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 03/15/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the newly developed drug-coated balloon (DCB) using polyethylene oxide (PEO) as a platform and to compare it directly with a commercially available DCB in a preclinical experimental setting. METHODS The PEO balloon was characterized for coating morphology and degree of paclitaxel (PAT) crystallinity. PAT tissue levels were then measured up to 30 days in a healthy porcine model (10 swine, 20 vessels) after treatment with either a PEO balloon or a commercially available DCB. An in vitro bench-top model was used to compare the particulates released from the PEO balloon and commercially available DCB. RESULTS The coating on the PEO balloon was smooth and homogeneous with PAT in its amorphous state. From the porcine survival study, the PAT tissue levels were comparable between PEO balloon and commercially available DCB after 7 days of treatment. Both the PEO balloon and the commercially available DCB retained therapeutic drug up to 30 days. During the simulated in vitro model, the PEO balloon shed significantly fewer particulates that were smaller than those of the commercially available DCB. Most important, the PEO balloon shed 25 times fewer large particulates than the commercially available DCB. CONCLUSIONS The amorphous PAT in the PEO balloon provided comparable drug tissue retention levels to those of the commercially available DCB and fewer particulates. Thus prepared PEO balloon proved to be safe and effective in the preclinical experimental setting. The clinical outcomes of these findings need further investigation.
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Affiliation(s)
- Jordan A Anderson
- Biomedical Engineering Program, University of South Dakota, Sioux Falls, SDak
| | - Sujan Lamichhane
- Biomedical Engineering Program, University of South Dakota, Sioux Falls, SDak
| | - Thomas Vierhout
- Biomedical Engineering Program, University of South Dakota, Sioux Falls, SDak
| | - Andrea Sherman
- Sanford School of Medicine, University of South Dakota, Sioux Falls, SDak
| | - Daniel Engebretson
- Biomedical Engineering Program, University of South Dakota, Sioux Falls, SDak
| | | | | | - Patrick Kelly
- Division of Vascular Surgery, Sanford Health, Sioux Falls, SDak.
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28
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Haddad SE, Shishani JM, Qtaish I, Rawashdeh MA, Qtaishat BS. One Year Primary Patency of Infrapopliteal Angioplasty Using Drug- Eluting Balloons: Single Center Experience at King Hussein Medical Center. J Clin Imaging Sci 2017; 7:31. [PMID: 28852581 PMCID: PMC5559924 DOI: 10.4103/jcis.jcis_34_17] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/25/2017] [Indexed: 11/21/2022] Open
Abstract
Objective: Conventional percutaneous transluminal angioplasty (PTA) for long lesions in the below-the-knee (BTK) arteries in patients presenting with critical limb ischemia (CLI) has high restenosis rates at 1 year. Our goal is to evaluate whether paclitaxel drug-eluting balloons (DEB) have higher 1 year primary patency rates compared to conventional PTA. Methods: This is a single-center, prospective, randomized trial that was conducted from June 2013 to December 2015. The aim of the study was to compare 1 year primary patency rates of DEB and PTA in BTK arteries in CLI patients. Inclusion criteria were patients presenting with CLI (Rutherford class 4 or greater), stenosis or occlusion ≥30 mm of at least one tibial artery, and agreement to 12-month evaluation. Exclusion criteria were life expectancy <1 year, allergy to paclitaxel, and contraindication to combined antiplatelet treatment. Follow-up was performed by clinical assessment, ankle brachial pressure index, Doppler ultrasound imaging, and conventional angiogram if indicated. Primary end point was 1 year primary patency, and secondary end points were target lesion revascularization (TLR) and major amputation. Statistical analysis was performed using Fischer's exact test. Results: Ninety-three patients with 106 lesions in the BTK arteries were enrolled in this study. One year primary patency was achieved in 26 (65%) and seven (17%) in the DEB and PTA groups (P = 0.006), respectively. TLR was performed in nine lesions (23%) and 29 lesions (71%) in DEB and PTA groups (P = 0.009), respectively. Major amputations occurred in one limb (2%) and two limbs (4%) in DEB and PTA groups (P = 0.6), respectively. Conclusion: Paclitaxel DEB has significantly higher 1 year primary patency rate associated with significantly less TLR than conventional PTA, following endovascular recanalization of BTK arteries in patients presenting with CLI.
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Affiliation(s)
- Sizeph Edward Haddad
- Department of Interventional Radiology, King Hussein Medical Center, Amman, Jordan
| | - Jan Mohammad Shishani
- Department of Vascular Surgery, Vascular Surgery Unit, King Hussein Medical Center, Amman, Jordan
| | - Izzeddin Qtaish
- Department of Interventional Radiology, King Hussein Medical Center, Amman, Jordan
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29
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Ott I, Cassese S, Groha P, Steppich B, Voll F, Hadamitzky M, Ibrahim T, Kufner S, Dewitz K, Wittmann T, Kasel AM, Laugwitz KL, Schunkert H, Kastrati A, Fusaro M. ISAR-PEBIS (Paclitaxel-Eluting Balloon Versus Conventional Balloon Angioplasty for In-Stent Restenosis of Superficial Femoral Artery): A Randomized Trial. J Am Heart Assoc 2017; 6:JAHA.117.006321. [PMID: 28743787 PMCID: PMC5586321 DOI: 10.1161/jaha.117.006321] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Paclitaxel‐eluting balloon (PEB) angioplasty has superior efficacy compared with conventional balloon angioplasty (BA) for de novo lesions of superficial femoral artery (SFA). Studies investigating the angiographic and clinical performance of PEB angioplasty versus BA for in‐stent restenosis of SFA are limited. We performed a randomized trial to investigate angiographic and clinical performance of PEB versus BA for in‐stent restenosis of SFA. Methods and Results Patients with symptomatic in‐stent restenosis of SFA were randomly assigned to either PEB or BA at 2 centers in Munich, Germany. The primary end point was the percentage diameter stenosis at 6‐ to 8‐month follow‐up angiography. Secondary end points were the rate of binary restenosis at follow‐up angiography and target lesion revascularization, target vessel thrombosis, ipsilateral amputation, bypass surgery of the affected limb, and all‐cause mortality at 24‐month follow‐up. Seventy patients were assigned to PEB (n=36) or BA (n=34). Mean lesion length was 139±67 mm, and roughly one third of lesions were completely occluded at the time of the index procedure. At control angiography, the percentage diameter stenosis (44±33% versus 65±33%, P=0.01) and binary restenosis were significantly reduced with PEB versus BA (30% versus 59%, P=0.03). At 24‐month follow‐up, PEB was associated with a significant reduction of target lesion revascularization in comparison to BA (19% versus 50%, P=0.007). There was no difference with respect to other outcomes of interest. Conclusions In patients with in‐stent restenosis of SFA, a percutaneous therapy with PEB compared with BA has superior angiographic performance at 6 to 8 months and improved clinical efficacy up to 24‐month follow‐up. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01083394.
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Affiliation(s)
- Ilka Ott
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Philipp Groha
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Birgit Steppich
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Felix Voll
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Martin Hadamitzky
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Tareq Ibrahim
- 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Sebastian Kufner
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Karl Dewitz
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Theresa Wittmann
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Albert Markus Kasel
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Karl-Ludwig Laugwitz
- 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Massimiliano Fusaro
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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30
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Kamioka N, Soga Y, Kuramitsu S, Iida O, Hirano K, Suzuki K, Kawasaki D, Yamaoka T, Suematsu N, Shintani Y, Miyashita Y, Takahashi H, Tsuchiya T, Shinozaki N, Okazaki S, Ando K. Clinical outcomes of balloon angioplasty alone versus nitinol stent implantation in patients with small femoropopliteal artery disease: Observations from the Retrospective Multicenter Analysis for Femoropopliteal Stenting (REAL-FP). Catheter Cardiovasc Interv 2017; 90:790-797. [PMID: 28722294 DOI: 10.1002/ccd.27192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 04/17/2017] [Accepted: 06/08/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We sought to assess whether balloon angioplasty (BA) alone for small femoropopliteal disease improved the outcome following endovascular therapy as compared with stent implantation. BACKGROUND The optimal strategy of endovascular therapy for small vessel arteries in femoropopliteal disease remains unclear. METHODS We performed a multicenter retrospective analysis of 337 consecutive patients (371 limbs) with femoropopliteal arteries 4.0 mm or less in diameter and 150 mm or less in length. RESULTS Cumulative 3-year incidence of primary patency was significantly higher in the BA group than in the stent group (53.8% vs. 34.2%, P = 0.002). While assisted-primary patency and freedom from any major adverse limb events were also significantly higher in the BA group than in the stent group (70.9% vs. 44.2%, P < 0.001 and 60.6% vs. 36.4%, P = 0.001, respectively), secondary patency did not significantly differ between the two groups (86.9% vs. 86.9%, P = 0.67). Predictors of restenosis were diabetes mellitus (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.14-2.31; P = 0.01), no administration of cilostazol (HR, 1.50; 95% CI, 1.07-2.13; P = 0.02), stent implantation (HR, 1.68; 95% CI, 1.15-2.41; P = 0.01), and lesion length >75.0 mm(HR, 2.09; 95% CI, 1.50-2.92; P < 0.001). CONCLUSIONS Lesions in small (<4.0 mm diameter) FP vessels demonstrated better primary patency at 3 years when successfully treated with balloon angioplasty alone as opposed to routine or bailout stenting. This difference was especially pronounced for lesions 75 to 150 mm in length.
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Affiliation(s)
- Norihiko Kamioka
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shoichi Kuramitsu
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Osamu Iida
- Kansai Rosai Hospital, Cardiovascular Center, Amagasaki, Japan
| | - Keisuke Hirano
- Department of Cardiology, Saiseikai Yokohama-City Eastern Hospital, Yokohama, Japan
| | - Kenji Suzuki
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | - Daizo Kawasaki
- Cardiovascular Division, Hyogo College of Medicine, Nishinomiya, Japan
| | - Terutoshi Yamaoka
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Nobuhiro Suematsu
- Department of Cardiology, Fukuoka Red Cross Hospital, Fukuoka, Japan
| | | | - Yusuke Miyashita
- Department of Advanced PAD Therapeutics, Shinshu University, Matsumoto, Japan
| | - Hiroki Takahashi
- Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Taketsugu Tsuchiya
- Division of Trans-Catheter Cardiovascular Therapeutics, Kanazawa Medical University Hospital, Ishikawa, Japan
| | | | - Shinya Okazaki
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
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31
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Teymen B, Akturk S, Akturk U, Tdjani M. Comparison of drug-eluting balloon angioplasty with self-expanding interwoven nitinol stent deployment in patients with complex femoropopliteal lesions. Vascular 2017; 26:54-61. [DOI: 10.1177/1708538117719580] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective The aim of this study was to compare the drug-eluting balloon with self-expanding interwoven nitinol stent deployment in patients with complex femoropopliteal lesions. Methods We retrospectively identified patients at our clinic with complex femoropopliteal artery lesions treated either with self-expanding interwoven nitinol stent or drug-eluting balloon. All patients had ankle-brachial index measured before and after the intervention, and regular clinical follow-up with Doppler ultrasonography was performed at six months and one year. Patients underwent peripheral angiography if needed. Results From April 2012 to July 2015, 107 patients with complex femoropopliteal lesions treated with using self-expanding interwoven nitinol stent ( N = 49, mean length 143.5 mm, mean follow-up of 14.1 ± 3.7 months) or drug-eluting balloon ( N = 58, mean length 140.6 mm, mean follow-up of 13.8 ± 4.1 months). The technical success rate was 100% in Supera® and 96.6% in drug-eluting balloon group. There were seven restenosis in self-expanding interwoven nitinol stent (SUS) group (84.8% patency) and 11 restenosis in drug-eluting balloon group (79.2% patency). A significant increase in the ankle-brachial index in both groups after intervention demonstrated a hemodynamic success (SUS group 0.45 ± 0.06, drug-eluting balloon group 0.43 ± 0.07). The mean Rutherford Becker Class significantly decreased in both groups after a follow-up of 12 months (SUS group 0.70 ± 0.73, drug-eluting balloon group 0.74 ± 0.75). Conclusion Deploying drug-eluting balloon or self-expanding interwoven nitinol stent in patients with complex femoropopliteal lesions are both safe and effective with high patency rates with no statistical difference for one-year primary patency rates between them.
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Affiliation(s)
- Burak Teymen
- Department of Cardiology, Emsey Hospital, Istanbul, Turkey
| | - Suleyman Akturk
- Department of Cardiology, Academic Hospital, Istanbul, Turkey
| | - Ulku Akturk
- Department of Cardiology, Sureyyapasa Hospital, Istanbul, Turkey
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32
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Jang SJ, Chou HH, Juang JMJ, Hsieh CA, Duan DM, Huang HL, Ko YL. Clinical Outcomes of Repetition of Drug-Coated Balloon for Femoropopliteal Restenosis After Drug-Coated Balloon Treatment. Circ J 2017; 81:993-998. [PMID: 28344208 DOI: 10.1253/circj.cj-17-0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND To compare the clinical outcomes of patients undergoing repeated drug-coated balloon (DCB) treatment for femoropopliteal (FP) DCB restenosis with those of patients without repetition-DCB.Methods and Results:From March 2013 to September 2014, 102 patients (118 affected legs) underwent DCB for symptomatic FP disease; 47 patients had restenosis, and 37 underwent reintervention over a 45-month follow-up. We compared the outcomes of repetition-DCB for DCB restenosis with those of patients without repetition. The baseline patient and lesion characteristics were similar between groups. The mean lesion length was 200.8±113.1 and 195.2±134.6 mm, P=0.894, respectively. In addition, the procedural and follow-up outcomes were not different. The rates of freedom from binary restenosis (70% vs. 14%, P=0.001) and clinically driven target lesion revascularization (CD-TLR) (78% vs. 38%, P=0.026) at 1 year were statistically different between groups. Cox regression analysis showed that repetition of DCB was the only predictor for freedom from binary restenosis (hazard ratio [HR]: 6.15, 95% confidence interval (CI) 1.60 to 23.6, P=0.008) and CD-TLR (HR: 5.37, 95% CI 1.32-22.0, P=0.019). CONCLUSIONS For FP DCB restenosis, repetition of DCB can potentially improve vessel patency and significantly reduce the need for reintervention compared with conventional treatment. However, these observations require further confirmation in larger scale studies.
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Affiliation(s)
- Shih-Jung Jang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Hsin-Hua Chou
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.,School of Medicine, Tzu Chi University
| | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine
| | - Chien-An Hsieh
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - De-Min Duan
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Hsuan-Li Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Yu-Lin Ko
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.,School of Medicine, Tzu Chi University
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Massara M, Finocchiaro P, Volpe A, Alberti A, Volpe P. Percutaneous drug-eluting balloon angioplasty to treat dialysis access stenosis. Semin Vasc Surg 2017; 30:67-69. [DOI: 10.1053/j.semvascsurg.2017.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ott I, Cassese S, Groha P, Steppich B, Hadamitzky M, Ibrahim T, Kufner S, Dewitz K, Hiendlmayer R, Laugwitz KL, Schunkert H, Kastrati A, Fusaro M. Randomized Comparison of Paclitaxel-Eluting Balloon and Stenting Versus Plain Balloon Plus Stenting Versus Directional Atherectomy for Femoral Artery Disease (ISAR-STATH). Circulation 2017; 135:2218-2226. [PMID: 28424222 DOI: 10.1161/circulationaha.116.025329] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 03/17/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Atherosclerosis in the superficial femoral artery is common in patients suffering from peripheral artery disease. Paclitaxel-eluting balloon (PEB) angioplasty, stenting, and directional atherectomy (DA) have provided new options for the treatment of superficial femoral artery disease; however, the comparative efficacy of these interventional strategies remains uncertain. METHODS One hundred and fifty-five patients with symptomatic peripheral artery disease due to de novo superficial femoral artery stenotic or occlusive lesions were randomized to treatment with plain balloon angioplasty (BA) followed by PEB angioplasty and stenting (n=48), BA and stenting (n=52), or DA with distal protection and bailout stenting (n=55). The primary end point of the study was percentage diameter stenosis after 6 months measured by angiography. Other end points included target lesion revascularization, thrombosis, ipsilateral amputation, binary restenosis, and all-cause mortality at 6 and 24 months. RESULTS Baseline and lesion characteristics were comparable in all groups with a mean lesion length of 65.9±46.8 mm and 56% total occlusions. At 6 months angiography, the percent diameter stenosis was significantly lower in patients treated by PEB angioplasty and stenting (34±31%) as compared with BA angioplasty and stenting (56±29%, P=0.009) or DA (55±29%, P=0.007). Similarly, binary restenosis was significantly lower after treatment with PEB and stenting as compared with BA and stenting or DA. Clinical follow-up at 24 months revealed a lower risk for target lesion revascularization after PEB angioplasty and stenting as compared with BA and stenting or DA. We found no difference in terms of target lesion thrombosis and mortality among groups, and no patient underwent amputation. CONCLUSIONS Treatment of de novo superficial femoral artery lesions with PEB angioplasty and stenting is superior to BA angioplasty and stenting or DA in terms of angiographic diameter stenosis at 6 months and target lesion revascularization at 24 months. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00986752.
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Affiliation(s)
- Ilka Ott
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.).
| | - Salvatore Cassese
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Philipp Groha
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Birgit Steppich
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Martin Hadamitzky
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Tareq Ibrahim
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Sebastian Kufner
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Karl Dewitz
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Regina Hiendlmayer
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Karl-Ludwig Laugwitz
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Heribert Schunkert
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Adnan Kastrati
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
| | - Massimiliano Fusaro
- From Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (I.O., S.C., P.G., B.S., M.H., S.K., K.D., R.H., H.S., A.K., M.F.); 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (T.I., K.-L.L.); and German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (K.-L.L., H.S., A.K.)
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How should recent endovascular trials for femoropopliteal artery disease be interpreted? Cardiovasc Interv Ther 2017; 32:106-113. [DOI: 10.1007/s12928-017-0463-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/14/2017] [Indexed: 10/20/2022]
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Candy N, Ng E, Velu R. Paclitaxel-coated balloon reduces target lesion revascularization compared with standard balloon angioplasty. J Vasc Surg 2017; 65:558-570.e10. [DOI: 10.1016/j.jvs.2016.10.089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
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Herten M, Stahlhoff S, Imm B, Schönefeld E, Schwindt A, Torsello GB. [Drug-coated balloons in the treatment of peripheral artery disease (PAD). History and current level of evidence]. Radiologe 2016; 56:240-53. [PMID: 26885653 DOI: 10.1007/s00117-015-0073-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite initially encouraging technical success after femoropopliteal PTA, restenosis remains the major challenge in patients with peripheral artery disease (PAD). The main cause of restenosis is neointimal hyperplasia which can be suppressed by antiproliferative drugs. Drug-coated balloons (DCB) or drug-eluting stents (DES) are used for the inhibition of restenosis. OBJECTIVES The present article gives an overview of DCB development, actual DCB systems for femoro- and infrapopliteal use, displays the outcomes of randomized clinical trials and the discusses the evidence for the DCB treatment in PAD. METHODS A systematic literature search was performed in i) medical journals (i. e. MEDLINE), ii) in international registers for clinical studies (i. e. www.clinicaltrials.gov ) and in iii) scientific session abstracts. RESULTS The clinical evidence of the PTX-DCB of the first and following generation has been shown in several controlled randomized trials. CONCLUSIONS Major advantages of the DCBs lie in leaving no stent scaffold behind, the immediate release of high drug concentrations with a single dosage, their efficacy in areas, where stents have been contra-indicated until now and its use for secondary interventions. As their effect seems to be limited in severely calcified lesions, prior plaque preconditioning or removal could be advantageous. First positive results data supporting this hypothesis do exist.
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Affiliation(s)
- M Herten
- Klinik für Vaskuläre und Endovaskuläre Chirurgie, Universitätsklinikum Münster, Münster, Deutschland.
| | - S Stahlhoff
- Gefäßchirurgie, St. Franziskus-Hospital Münster, Münster, Deutschland
| | - B Imm
- Klinik für Vaskuläre und Endovaskuläre Chirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - E Schönefeld
- Institut für Ausbildung und Studienangelegenheiten (IfAS), Medizinischen Fakultät, Westfälischen Wilhelms-Universität Münster, Münster, Deutschland
| | - A Schwindt
- Gefäßchirurgie, St. Franziskus-Hospital Münster, Münster, Deutschland
| | - G B Torsello
- Klinik für Vaskuläre und Endovaskuläre Chirurgie, Universitätsklinikum Münster, Münster, Deutschland.,Gefäßchirurgie, St. Franziskus-Hospital Münster, Münster, Deutschland
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Arain SA, White CJ. The Price Is Right (But Buyer Beware). JACC Cardiovasc Interv 2016; 9:2353-2355. [PMID: 27884361 DOI: 10.1016/j.jcin.2016.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 09/29/2016] [Accepted: 10/02/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Salman A Arain
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Health Sciences Center-Houston, Houston, Texas.
| | - Christopher J White
- Department of Medicine, The Ochsner Clinical School, University of Queensland, New Orleans, Louisiana
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Sanina C, Cox-Alomar PR, Krishnan P, Wiley JM. Superficial Femoral Artery Interventions. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
| | | | - Prakash Krishnan
- The Zena and Michael A. Weiner Cardiovascular Institute; Icahn School of Medicine at Mount Sinai; New York NY USA
| | - Jose M. Wiley
- Albert Einstein College of Medicine; Montefiore Einstein Center for Heart & Vascular Care; Bronx NY USA
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40
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Oz II, Serifoglu I, Bilici M, Altinbas NK, Oz EB, Akduman EI. Comparison of Drug-Eluting Balloon and Standard Balloon Angioplasty for Infrapopliteal Arterial Diseases in Diabetic Patients. Vasc Endovascular Surg 2016; 50:534-540. [PMID: 28081691 DOI: 10.1177/1538574416676019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To consider the clinical outcomes and restenosis rates of drug-eluting balloons (DEBs) and percutaneous transluminal angioplasty (PTA) in diabetic patients with infrapopliteal (IP) arterial disease. MATERIALS AND METHODS This retrospective, single-center study included 51 patients (37 males; mean age: 63.43 ± 9.81 years) with diabetes mellitus having IP arterial disease, from October 2012 to September 2014. Twenty-two patients were treated with PTA, and 29 patients were treated with DEBs. After intervention, the patients were evaluated in the first week and every 3 months, clinically and radiologically. Univariate and multivariate analyses were used to evaluate the clinical outcomes of diabetic patients with IP arterial disease who were treated with either DEBs or PTA. RESULTS There were no statistically significant differences between the groups in terms of age and gender, risk factors, characteristics of lesions, or the diameters or length of the balloons ( P > .05). Primary patency was higher in the DEB group than in the PTA group (97.8% vs 81.1%, P = .020) in the first 3 months. However, there was no statistically significant difference at 1-year follow-up (68.2% vs 48.5%, P = .131). At the 12-month follow-up, there was no difference in clinical improvement between the groups ( P = .193). CONCLUSION The findings of this study reveal that DEB is a safe alternative treatment method for IP arterial disease in diabetic patients.
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Affiliation(s)
- Ibrahim Ilker Oz
- 1 Department of Radiology, School of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - Ismail Serifoglu
- 2 Department of Radiology, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Muammer Bilici
- 3 Department of Internal Medicine, School of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - Namik Kemal Altinbas
- 4 Department of Radiology, School of Medicine, Ankara University, Ankara, Turkey
| | - Evrim Bozay Oz
- 5 Department of Anesthesiology and Reanimation, Zonguldak State Hospital, Zonguldak, Turkey
| | - Ece Isin Akduman
- 6 Department of Radiology, School of Medicine, Saint Louis University, St Louis, MO, USA
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Wu R, Tang S, Wang M, Li Z, Yao C, Wang S. Drug-eluting balloon versus standard percutaneous transluminal angioplasty in infrapopliteal arterial disease: A meta-analysis of randomized trials. Int J Surg 2016; 35:88-94. [DOI: 10.1016/j.ijsu.2016.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 07/07/2016] [Accepted: 09/11/2016] [Indexed: 11/29/2022]
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Jongsma H, Bekken JA, de Vries JPP, Verhagen HJ, Fioole B. Drug-eluting balloon angioplasty versus uncoated balloon angioplasty in patients with femoropopliteal arterial occlusive disease. J Vasc Surg 2016; 64:1503-1514. [DOI: 10.1016/j.jvs.2016.05.084] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/31/2016] [Indexed: 11/30/2022]
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Abstract
Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as nonhealing ulcers or gangrene, related to peripheral artery disease. CLI has a high short-term risk of limb loss and cardiovascular events. Noninvasive or invasive angiography help determine the feasibility and approach to arterial revascularization. An endovascular-first approach is often advocated based on a lower procedural risk; however, specific patterns of disease may be best treated by open surgical revascularization. Balloon angioplasty and stenting form the backbone of endovascular techniques, with drug-eluting stents and drug-coated balloons offering low rates of repeat revascularization. Combined antegrade and retrograde approaches can increase success in long total occlusions. Below the knee, angiosome-directed angioplasty may lead to greater wound healing, but failing this, any straight-line flow into the foot is pursued. Hybrid surgical techniques such as iliac stenting and common femoral endarterectomy are commonly used to reduce operative risk. Lower extremity bypass grafting is most successful with a good quality, long, single-segment autogenous vein of at least 3.5-mm diameter. Minor amputations are often required for tissue loss as a part of the treatment strategy. Major amputations (at or above the ankle) limit functional independence, and their prevention is a key goal of CLI therapy. Medical therapy after revascularization targets risk factors for atherosclerosis and assesses wound healing and new or recurrent flow-limiting disease. The ongoing National Institutes of Health-sponsored Best Endovascular Versus Best Surgical Therapy in Patients With Critical Limb Ischemia (BEST-CLI) study is a randomized trial of the contemporary endovascular versus open surgical techniques in patients with CLI.
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Affiliation(s)
- Scott Kinlay
- From the Cardiovascular Division, Department of Medicine, VA Boston Healthcare System, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Lawall H, Huppert P, Espinola-Klein C, Rümenapf G. The Diagnosis and Treatment of Peripheral Arterial Vascular Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:729-736. [PMID: 27866570 PMCID: PMC5150211 DOI: 10.3238/arztebl.2016.0729] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 06/02/2016] [Accepted: 07/21/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND In peripheral arterial occlusive disease (PAOD), arterial stenosis or occlusion impairs perfusion in the territory of the distal portion of the aorta and the iliac and leg arteries. In Germany, the prevalence of PAOD rises with age, reaching 20% among persons over age 70. METHODS This guideline was prepared by a collaboration of 22 medical specialty societies and two patient self-help organizations on the basis of pertinent publications that were retrieved by a systematic search in PubMed for articles that appeared from 2008 to April 2014, with a subsequent update to May 2015. RESULTS 294 articles were assessed, including 34 systematic reviews and 98 randomized controlled trials (RCTs). The diagnostic assessment of PAOD is based on physical examination, blood pressure at the ankles, and color-coded duplex ultrasonography (grade A recommendation). Other tomographic imaging methods can be used for suitable indications. The main elements of the treatment of PAOD are the control of cardiovascular risk factors and structured vascular exercise (grade A recommendation). Acetylsalicylic acid and statins are the main drugs for symptomatic PAOD (grade A recommendation). Patients with claudication and correlated structural findings can undergo an endo - vascular or open surgical procedure. Critical ischemia is an indication for arterial revascularization as soon as possible (grade A recommendation); this may be performed either by open surgery or by an endovascular procedure of one of the types that are now undergoing rapid development, or one of the crural treatment options. There is inadequate evidence concerning the optimal drug regimen after revascularization procedures. CONCLUSION The diagnostic assessment of PAOD is based on physical examination, measurement of the ankle-brachial index (ABI), and duplex ultrasonography. Acetylsalicylic acid and statins are indicated for patients with symptomatic PAOD. Endovascular procedures should be used if indicated. Randomized studies are needed to provide better evidence on many open questions in the treatment of PAOD.
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Affiliation(s)
- Holger Lawall
- Cardiovascular Department Ettlingen, Max Grundig Klinik Bühlerhöhe
| | - Peter Huppert
- Department of Diagnostic and Interventional Radiology, Klinikum Darmstadt GmbH
| | - Christine Espinola-Klein
- Department of Cardiology I – Medical Clinic for Cardiology, Angiology and Intensive Care, University Medical Center, Johannes Gutenberg University Mainz
| | - Gerhard Rümenapf
- Clinic for Vascular Surgery, Diakonissen-Stiftungs-Krankenhaus Speyer
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Teichgräber U, Aschenbach R, Scheinert D, Zeller T, Brechtel K, Thieme M, Blessing E, Treitl M, Lichtenberg M, von Flotow P, Vogel B, Werk M, Riambau V, Wienke A, Lehmann T, Sixt S. The effectiveness of the paclitaxel-coated Luminor® balloon catheter versus an uncoated balloon catheter in superficial femoral and popliteal arteries in preventing vessel restenosis or reocclusion: study protocol for a randomized controlled trial. Trials 2016; 17:528. [PMID: 27793175 PMCID: PMC5084407 DOI: 10.1186/s13063-016-1657-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 10/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this investigator-initiated trial is to evaluate the safety and efficacy of the novel Luminor® paclitaxel-coated drug-eluting balloon (DEB) catheter (iVascular, S.L.U., Barcelona, Spain) in inhibiting restenosis and in ensuring long-term vascular patency. METHODS/DESIGN This is a multicenter randomized controlled trial to evaluate the Luminor® paclitaxel-coated DEB catheter for stenotic or occlusive lesions (length ≤15 cm) in the superficial femoral artery (SFA) and the popliteal artery (PA) up to the P1 segment compared to the noncoated, plain old balloon angioplasty (POBA) catheter. In total 172 subjects will be treated with either the DEB catheter or the POBA catheter in 11 German study centers in a 1:1 randomization study design. The primary endpoint is late lumen loss (LLL) at 6 months. Secondary endpoints are patency rate, target lesion/vessel revascularization, quality of life (assessed with the Walking Impairment Questionnaire (WIQ) and the EQ-5D), change of Rutherford stage and ankle-brachial index, major and minor amputation rate at the index limb, number of dropouts and all-cause mortality. DISCUSSION EffPac represents a randomized controlled trial that will provide evidence on the effectiveness of the Luminor® paclitaxel-coated DEB catheter for the reduction of restenosis compared to the POBA catheter for the SFA and the PA. The results of EffPac will allow direct comparison to other already-completed RCTs applying paclitaxel-coated DEBs from different manufacturers with different coating technologies in the same target vessel. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02540018 , registered on 17 August 2015. Protocol version: CIP Version Final04, 11 February 2016. EUDAMED No: CIV-15-03-013204.
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Affiliation(s)
- U Teichgräber
- Universitätsklinikum Jena, Institut für Diagnostische und Interventionelle Radiologie, Am Klinikum 1, 07747, Jena, Germany.
| | - R Aschenbach
- Universitätsklinikum Jena, Institut für Diagnostische und Interventionelle Radiologie, Am Klinikum 1, 07747, Jena, Germany
| | - D Scheinert
- Universitätsklinikum Leipzig, Abteilung für Interventionelle Angiologie, Philipp-Rosenthal-Straße 27 C, 04103, Leipzig, Germany
| | - T Zeller
- Herzzentrum Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany
| | - K Brechtel
- Ihre-Radiologen Berlin Gemeinschaftspraxis für Radiologie, Budapester Straße 15-19, 13347, Berlin, Germany
| | - M Thieme
- Medinos Kliniken Sonneberg Angiologie/Kardiologie/Diabetologie, Neustadter Str. 61, 96515, Sonneberg, Germany
| | - E Blessing
- SRH Klinikum Karlsbad-Langensteinbach, Guttmannstr. 1, 76307, Karlsbad, Germany
| | - M Treitl
- Klinikum der Ludwig Maximilians Universität München - Campus Innenstadt, Institut für Klinische Radiologie, Pettenkoferstraße 8a, 80336, München, Germany
| | - M Lichtenberg
- Klinikum Arnsberg Angiologie, Stolte Ley 5, 59759, Arnsberg, Germany
| | - P von Flotow
- Westpfalz-Klinikum GmbH Standort II Kusel, Im Flur 1, 66869, Kusel, Germany
| | - B Vogel
- Ruprecht-Karls-Universität Heidelberg, Analysezentrum III/Innere Medizin III, Im Neuenheimer Feld 669, 69120, Heidelberg, Germany
| | - M Werk
- Martin-Luther-Krankenhausbetrieb GmbH, Caspar-Theyß-Straße 27-31, 14193, Berlin, Germany
| | - V Riambau
- Hospital Clínic de Barcelona, Carrer de Villarroel, 170, 08036, Barcelona, Spain
| | - A Wienke
- Martin-Luther-Universität Halle-Wittenberg, Institut für Medizinische Epidemiologie, Biometrie und Informatik, 06097, Halle (Saale), Germany
| | - T Lehmann
- Universitätsklinikum Jena, Zentrum für Klinische Studien (ZKS), Postfach, 07740, Jena, Germany
| | - S Sixt
- Angiologikum Hamburg, Wördemanns Weg 25-27, 22527, Hamburg, Germany
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Xiong GM, Ang H, Lin J, Lui YS, Phua JL, Chan JN, Venkatraman S, Foin N, Huang Y. Materials technology in drug eluting balloons: Current and future perspectives. J Control Release 2016; 239:92-106. [DOI: 10.1016/j.jconrel.2016.08.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/17/2016] [Accepted: 08/19/2016] [Indexed: 10/21/2022]
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47
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Feasibility and Safety of Robotic Peripheral Vascular Interventions. JACC Cardiovasc Interv 2016; 9:2058-2064. [DOI: 10.1016/j.jcin.2016.07.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/13/2016] [Accepted: 06/30/2016] [Indexed: 11/22/2022]
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48
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Liistro F, Bolognese L. Drug-Coated Balloon in Complex Clinical and Anatomical Scenario: Evidence or Hope? JACC Cardiovasc Interv 2016; 9:1950-2. [PMID: 27659573 DOI: 10.1016/j.jcin.2016.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 07/20/2016] [Accepted: 07/28/2016] [Indexed: 10/21/2022]
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49
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Usefulness of paclitaxel-releasing high-pressure balloon associated with cutting balloon angioplasty for treatment of outflow stenoses of failing hemodialysis arteriovenous shunts. Radiol Med 2016; 122:69-76. [PMID: 27601144 DOI: 10.1007/s11547-016-0680-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/18/2016] [Indexed: 10/21/2022]
Abstract
AIM To evaluate the technical and clinical success, primary patency (PP) and complications of angioplasty performed with paclitaxel-coated balloon (PCBs) associated with cutting balloon and for the treatment of the outflow stenoses of failing hemodialysis arteriovenous shunt. MATERIAL AND METHODS From September 2014 to September 2015, 50 patients with 66 stenoses were registered. Vascular accesses were autogenous (n = 20) and prosthetic (n = 30). Stenosis were documented during follow-up with routine echo-color Doppler, clinical evaluation and in the remaining incidentally during fistulography. Angioplasty was performed with cutting balloon and afterward with PCB. The mean follow-up time was 8 months (range 6-15 months). Technical success, clinical success, primary patency and complications were registered. RESULTS Technical success was 100 %. Clinical success was 94.7 %. Primary patency rate was 87.7 %; in five patients, a significant re-stenosis (≥50 %) was registered. A residual asymptomatic stenosis (<30 %) was registered in four cases (7 %). No major complications were registered. CONCLUSIONS A short-term patency benefit may be obtained including PCB in angioplasty treatment of failing hemodialysis arteriovenous shunts.
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50
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Herten M, Torsello GB, Schönefeld E, Stahlhoff S. Critical appraisal of paclitaxel balloon angioplasty for femoral-popliteal arterial disease. Vasc Health Risk Manag 2016; 12:341-56. [PMID: 27621646 PMCID: PMC5010165 DOI: 10.2147/vhrm.s81122] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Peripheral arterial disease, particularly critical limb ischemia, is an area with urgent need for optimized therapies because, to date, vascular interventions often have limited life spans. In spite of initial encouraging technical success after femoropopliteal percutaneous transluminal angioplasty or stenting, postprocedural restenosis remains the major problem. The challenging idea behind the drug-coated balloon (DCB) concept is the biological modification of the injury response after balloon dilatation. Antiproliferative drugs administered via DCBs or drug-eluting stents are able to suppress neointimal hyperplasia, the main cause of restenosis. This article reviews the results of DCB treatments of femoropopliteal and infrapopliteal lesions in comparison to standard angioplasty with uncoated balloons. A systematic literature search was performed in 1) medical journals (ie, MEDLINE), 2) international registers for clinical studies (ie, www.clinicaltrials.gov), and 3) abstracts of scientific sessions. Several controlled randomized trials with follow-up periods of up to 5 years demonstrated the efficacy of paclitaxel –DCB technology. However, calcified lesions seem to affect the efficacy of DCB. Combinations of preconditioning methods with DCBs showed promising results. Although the mechanical abrasion of calcium via atherectomy or laser ablation showed favorable periprocedural results, the long-term impact on restenosis and clinical outcome has to be demonstrated. Major advantages of the DCBs are the rapid delivery of drug at uniform concentrations with a single dose, their efficacy in areas wherein stents have been contraindicated until now (ie, bifurcation, ostial lesions), and in leaving no stent scaffold behind. Reinterventions are easier to perform because DCBs leave no metal behind. Various combinations of DCBs with other treatment modalities may prove to be viable options in future. The follow-up results of clinical studies will evaluate the long-term impact of DCBs.
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Affiliation(s)
- Monika Herten
- Department of Vascular and Endovascular Surgery, University Hospital Münster
| | - Giovanni B Torsello
- Department of Vascular and Endovascular Surgery, University Hospital Münster; Department of Vascular Surgery, St Franziskus Hospital, Münster
| | - Eva Schönefeld
- Institute for Education and Student Affairs, University Hospital Münster, Münster, Germany
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