Meta-analysis of outcomes from drug-eluting stent implantation in femoropopliteal arteries

OBJECTIVE

In recent years, studies of drug-eluting stent (DES) for femoropopliteal artery diseases (FPADs) have been gradually published. To explore whether this type of stent is superior to the traditional bare metal stent (BMS), we performed this study.

METHODS

A systematic search for randomized controlled trials (RCTs) in Excerpta Medica Database (Embase), PubMed, Web of Science (WOS), and Cochrane Library was performed on November 29, 2022. We innovatively adopted the hazard ratio (HR), the most appropriate indicator, as a measure of the outcomes that fall under the category of time-to-event data. The HRs was extracted directly or indirectly. Then, the meta-analyses using random effects model were performed. The bias risks of included papers were assessed by the Cochrane Risk of Bias 2.0 tool. This study was registered on the PROSPER platform (CRD42023391944) and not funded.

RESULTS

Seven RCTs involving 1,889 participants were found. After pooled analyses, we obtained results without propensity on each of the following 3 outcomes of interest: in-stent restenosis (ISR) -free survival, primary patency (PP) survival, and target lesion revascularization (TLR) -free survival (P >0.05, respectively). Because the results of pooled analyses of the other two outcomes of interest (all-cause death free survival and clinical benefit survival) had high heterogeneity both, they were not accepted by us.

CONCLUSION

For FPADs, the DES has not yet demonstrated superiority or inferiority to BMS, in the ability to maintain PP, avoid ISR and TLR.

Long-term clinical outcomes after self-expandable bare nitinol stent implantation for femoropopliteal occlusive disease in hemodialysis patients

OBJECTIVES

To compare the long-term clinical outcomes after self-expandable bare nitinol stent (BNS) implantation between hemodialysis (HD) and non-HD patients with femoropopliteal (FP) disease.

BACKGROUND

Although a BNS has been commonly used in patients with FP disease, the long-term efficacy of BNSs in HD patients remains unknown.

METHODS

In total, 427 HD patients treated with a BNS for FP disease were enrolled, along with 157 non-HD patients as a control group. Over the following 5 years, the incidence of target lesion revascularization (TLR), major amputation and mortality was investigated. We also performed propensity-score matching analysis.

RESULTS

The 5-year TLR rate (45.2 vs. 32.5%, p = .013) and mortality rate (39.3 vs. 14.0%, p = .0002) were significantly higher in the HD group than in the non-HD group. The major amputation rate was comparable between the groups (7.2% in the HD group vs. 2.8% in the non-HD group, p = .16). In the propensity-score-matched cohort, the TLR rate, and mortality rate were remained higher in the HD group than in the non-HD group (48.9 vs. 34.1%, hazard ratio [HR] 2.11, 95% confidence interval [CI] 1.30-3.49, p = .0024, and 47.9 vs. 12.0%, HR 3.38, 95% CI 1.86-6.56, p < .0001, respectively). The adjusted amputation rate was consistently similar between the groups (1.7% in the HD group vs. 2.7% in the non-HD group, HR 0.90, 95% CI 0.26-2.99, p = .86).

CONCLUSIONS

The TLR rate and mortality at 5 years post BNS implantation for FP disease were significantly higher in HD patients than in non-HD patients, though the limb salvage rate was similar.

Possible effect of direct oral anti-coagulant for preventing long stenting lesion from in-stent restenosis in femoropopliteal segment: Case report with angioscopy findings

A 64-year-old female underwent a successful first percutaneous intervention using MISAGO stents for a de novo femoropopliteal lesion. Subsequently, three more effective procedures were done using balloon catheters for in-stent restenosis. In May 2016, a fourth procedure using Zilver PTX stent for in-stent restenosis was carried out. For this final procedure, we added direct oral anti-coagulant as she had additional problem of popliteal vein thrombosis and her femoropopliteal segment remained clear. A Zilver PTX stent, a drug-eluting stent for a peripheral artery, was expected to bring superior outcomes compared to conventional bare nitinol stents (i.e. MISAGO stent). But subsequent studies reported that Zilver PTX stent was not more effective than conventional bare nitinol stents. In our above mentioned case, her angioscopy findings suggest that her successful outcome appears to be related to the added direct oral anti-coagulant.

Angioplasty or bare metal stent versus drug-eluting endovascular treatment in femoropopliteal artery disease: a systematic review and meta-analysis

INTRODUCTION

Endovascular treatment represents nowadays the preferred therapeutic approach for disabling femoro-popliteal arterial occlusive disease in fit patients. In the latest years, in order to improve short- and long-term outcomes, drug eluting devices have been developed. Drug coated balloons (DCB) and drug eluting stents (DES) are today employed in clinical practice, and several studies has been completed to assess their performance in different clinical scenarios. Objective of the present review and meta-analysis is to compare clinical results of different endovascular treatment modalities in the published literature in the last 10 years.

EVIDENCE ACQUISITION

A systematic review and meta-analysis following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement on the literature regarding direct comparisons between DCB, DES, bare metal stents (BMS) and Plain Old Balloon Angioplasty (POBA) has been conducted. Primary outcomes were considered Primary Patency and Target Lesion Revascularization (TLR) at 12 months. Analysis of late survival in different treatment groups was outside the scope of the present study and was therefore not included as main end point.

EVIDENCE SYNTHESIS

Meta analysis results confirm that DCB outperforms POBA in both primary patency (estimate OR=3.17, 95% CI: 2.10-4.76) and TLR (POBA estimate OR=3.59, 95% CI= 2.31-5.56). No clear evidences emerged comparing DES and BMS; however, DES were shown to fare better than BMS in terms of TLR when analyzing lesions <15 cm (OR 0.36, 95% CI: 0.35-0.36). Comparison of DCB and DES revealed higher rates of TLR for DES (OR 1.26 95% CI: 1.07-1.49), however no significant differences have been found regarding primary patency analyzing such long lesions (range 14-19.4 cm) as those included in the studies.

CONCLUSIONS

While confirming that DCB outperforms POBA in terms of primary patency and TLR at 12 months, only TLR benefits are noted for DES vs. BMS and DCB vs. DES in limited clinical settings. Further RCTs are needed to strongly assess the compared performance of drug eluting devices in relation to lesion length and controlling possible confounders.

Comparison of Drug-Eluting Stent with Bare-Metal Stent Implantation in Femoropopliteal Artery Disease: A Systematic Review and Meta-Analysis

BACKGROUND

This study aimed to perform a systematic review and meta-analysis of current evidence comparing the drug-eluting stent (DES) with the bare-metal stent (BMS) in the treatment of femoropopliteal artery disease (FPAD).

METHODS

All relevant articles reporting the results of DES versus BMS implantation in FPAD were systematically searched in MEDLINE, EMBASE, and Cochrane database. Randomized controlled trial (RCT), cohort, and retrospective study were all included. The efficacy end points included late lumen loss (LLL), binary restenosis, primary patency rate, freedom from target lesion revascularization (TLR), and stent fracture. Related data of the follow-up outcomes were extracted and pooled. For each end point, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 9 studies with 776 patients were included in this meta-analysis. There was no statistically significant difference between the DES and BMS groups in terms of LLL at 6 months (standard mean difference = -0.37, P = 0.07); binary restenosis at 6, 12, and 24 months (OR = 0.44, P = 0.20; OR = 0.75, P = 0.74; and OR = 0.62, P = 0.36; respectively); primary patency rate at 6, 12, and 24 months (OR = 1.18, P = 0.73; OR = 1.43, P = 0.70; OR = 1.25, P = 0.68, respectively); freedom from TLR at 12 months (OR = 1.13, P = 0.79); and stent fracture at 6 months (OR = 1.67, P = 0.38). A sensitivity analysis demonstrated that there was a significant benefit in the DES group over the BMS group in binary restenosis at 6 months (OR = 0.22, P = 0.008) after excluding a retrospective study, whereas no significant difference was observed when eliminating any other study. A subgroup analysis did not reveal any significant difference between a subgroup (sirolimus-eluting stent or paclitaxel-eluting stent) and the BMS group in FPAD.

CONCLUSIONS

According to current evidence, DES was not superior to BMS in the treatment of FPAD. Further larger RCTs are needed to provide more evidence in the comparison between DES and BMS for FPAD.

Penetration rate of the placement of a drug-eluting stent for the treatment of superficial femoral artery lesions in Japan

Stent placement for treating superficial femoral artery (SFA) lesions has been approved. The Zilver PTX stent, a drug-eluting stent (DES) for treating SFA lesions, has been available in Japan since 2012. However, the penetration rate of this DES has not yet been reported. This prospective multicenter registry study enrolled 314 patients (354 limbs) to be treated by stent placement in 2014 (UMIN000011551). The primary endpoint was the measurement of the penetration rate of the DES. The secondary endpoints were measuring the freedom from restenosis, freedom from target lesion revascularization (TLR), freedom from major adverse limb event (MALE), and the survival rate at 12 months postoperatively. Female patients comprised 28% participants. The mean age was 73.1 ± 9.2 years. A total of 56% patients had diabetes mellitus (DM), 36% patients were receiving hemodialysis, and 30% used cilostazol at baseline. The mean lesion length was 156 ± 101 mm, and the percentage of TASC II C/D lesions was 58%. Critical limb ischemia (CLI) was observed in 32% limbs. The penetration rates of the Zilver PTX stent were only 8%. The primary patency rate was similar between DES and bare-metal stents (BMS) at 12 months postoperatively (77 vs. 84%, p = 0.52). In this study, the rates of freedom from restenosis, freedom from TLR, freedom from MALE, and the survival rate at 12 months postoperatively were 83, 86, 85, and 89%, respectively. The penetration rate of a first-generation DES placement for treating SFA lesions is low in Japan. On the other hand, BMS is well utilized and its primary patency is acceptable.