Cutting balloon angioplasty in percutaneous carotid interventions

Usefulness of non-slip element percutaneous transluminal angioplasty scoring balloons in treating severe calcified lesions of the carotid artery for carotid artery stenting: A case report

Background

Treatment of calcified lesions with conventional angioplasty balloons can be difficult due to insufficient lumen expansion, high dissection rates, and repeated revascularization. We report a case in which a scoring balloon was used in lesions resistant to angioplasty with a semi-compliant balloon.

Case Description

A 72-year-old man presented with severe stenosis and a highly calcified lesion in the right cervical internal carotid artery. Right carotid artery stenting (CAS) was planned to prevent future ischemic stroke events. Conventional semi-compliant balloon angioplasty was unsuccessful. Three inflations of a non-slip element (NSE) percutaneous transluminal angioplasty (PTA) scoring balloon (Nipro, Osaka, Japan) successfully achieved CAS without complications.

Conclusion

This is the first report to describe the use of this scoring balloon in de novo carotid artery disease. NSE PTA scoring balloon catheters can be a useful option for refractory, highly calcified stenosis.

Comparison of peripheral cutting balloon angioplasty with conventional balloon angioplasty for recurrent hemodialysis vascular access stenosis: A prospective randomized controlled trial

PURPOSE

This study aimed to compare the efficacy and safety of cutting balloon angioplasty (CBA) and conventional balloon angioplasty (control group) for recurrent vascular access stenosis in arteriovenous fistulas.

MATERIALS AND METHODS

This prospective, randomized single-center clinical trial included patients with hemodynamically significant recurrent vascular access stenosis of an arteriovenous fistula. The Kaplan-Meier method was used to assess primary patency, whereas the log-rank test was used to evaluate differences in patency between groups. Functional evaluations were performed using Doppler ultrasonography.

RESULTS

Patients (n = 122) were randomly assigned to undergo CBA or conventional balloon angioplasty between December 2012 and November 2017. The clinical success rate was 100% in both groups. The anatomical success rates were 65% and 56% in the CBA and control groups, respectively. The primary patency of the target lesion was significantly better in the CBA group (33.3%) than in the control group (16.1%) at 6 months (hazard ratio, 0.50; 95% confidence interval, 0.33-0.77; p = 0.00171). The stenosis percentage decreased significantly after angioplasty in the CBA group (Δ-50.7%) compared with the control group (Δ-41.9%) (p = 0.0008). Access flow, measured using duplex Doppler ultrasonography, improved after angioplasty in both groups (300-526 ml/min in the control group and, 268-546 ml/min in the CBA group). Change in access flow (Δ + 278 ± 162) in the CBA group tended to be greater than that in the control group (Δ + 226 ± 151) (p = 0.07). However, the difference was not statistically significant.

CONCLUSION

In patients with recurrent vascular access stenosis of the arteriovenous fistula CBA is effective and superior to conventional angioplasty.

Highly-calcific carotid lesions endovascular management in symptomatic and increased-stroke-risk asymptomatic patients using the CGuard™ dual-layer carotid stent system: Analysis from the PARADIGM study

OBJECTIVES

To assess feasibility, safety, angiographic, and clinical outcome of highly-calcific carotid stenosis (HCCS) endovascular management using CGuard™ dual-layer carotid stents.

BACKGROUND

HCCS has been a challenge to carotid artery stenting (CAS) using conventional stents. CGuard combines a high-radial-force open-cell frame conformability with MicroNet sealing properties.

METHODS

The PARADIGM study is prospectively assessing routine CGuard use in all-comer carotid revascularization patients; the focus of the present analysis is HCCS versus non-HCCS lesions. Angiographic HCCS (core laboratory evaluation) required calcific segment length to lesion length ≥2/3, minimal calcification thickness ≥3 mm, circularity (≥3 quadrants), and calcification severity grade ≥3 (carotid calcification severity scoring system [CCSS]; G0-G4).

RESULTS

One hundred and one consecutive patients (51-86 years, 54.4% symptomatic; 106 lesions) received CAS (16 HCCS and 90 non-HCCS); eight others (two HCCS) were treated surgically. CCSS evaluation was reproducible, with weighted kappa (95% CI) of 0.73 (0.58-0.88) and 0.83 (0.71-0.94) for inter- and intra-observer reproducibility respectively. HCCS postdilatation pressures were higher than those in non-HCCS; 22 (20-24) versus 20 (18-24) atm, p = .028; median (Q1-Q3). Angiography-optimized HCCS-CAS was feasible and free of contrast extravasation or clinical complications. Overall residual diameter stenosis was single-digit but it was higher in HCCS; 9 (4-17) versus 3 (1-7) %, p = .002. At 30 days and 12 months HCCS in-stent velocities were normal and there were no adverse clinical events.

CONCLUSION

CGuard HCCS endovascular management was feasible and safe. A novel algorithm to grade carotid artery calcification severity was reproducible and applicable in clinical study setting. Larger HCCS series and longer-term follow-up are warranted.

Selective-versus-Standard Poststent Dilation for Carotid Artery Disease: A Systematic Review and Meta-Analysis

BACKROUND

The safety and efficacy of standard poststent angioplasty in patients undergoing carotid artery stent placement have not been well-established.

PURPOSE

We conducted a systematic review of the literature to evaluate the safety and efficacy of carotid artery stent placement and analyzed outcomes of standard-versus-selective poststent angioplasty.

DATA SOURCES

A systematic search of MEDLINE, EMBASE, Scopus, and the Web of Science was performed for studies published between January 2000 and January 2015.

STUDY SELECTION

We included studies with >30 patients describing standard or selective poststent angioplasty during carotid artery stent placement.

DATA ANALYSIS

A random-effects meta-analysis was used to pool the following outcomes: periprocedural stroke/TIA, procedure-related neurologic/cardiovascular morbidity/mortality, bradycardia/hypotension, long-term stroke at last follow-up, long-term primary patency, and technical success.

DATA SYNTHESIS

We included 87 studies with 19,684 patients with 20,378 carotid artery stenoses. There was no difference in clinical (P = .49) or angiographic outcomes (P = .93) in carotid artery stent placement treatment with selective or standard poststent balloon angioplasty. Both selective and standard poststent angioplasty groups had a very high technical success of >98% and a low procedure-related mortality of 0.9%. There were no significant differences between both groups in the incidence of restenosis (P = .93) or procedure-related complications (P = .37).

LIMITATIONS

No comparison to a patient group without poststent dilation could be performed.

CONCLUSIONS

Our meta-analysis demonstrated no significant difference in angiographic and clinical outcomes among series that performed standard poststent angioplasty and those that performed poststent angioplasty in only select patients.

Towards the characterisation of carotid plaque tissue toughness: Linking mechanical properties to plaque composition

The morphological manifestation of calcification within an atherosclerotic plaque is diverse and the response to cutting balloon angioplasty remains an elusive target to predict in the presence of extensive calcification. This study examines the resistance of plaque tissue to blade penetration by characterising the underlying toughness properties and stratifying the upper and lower scale toughness limits based on the strong mechanical influence of calcification. Mechanical toughness properties of the common, bifurcation and internal carotid artery (n=62) were determined using guillotine-cutting tests measuring the energy required to pass a surgical blade through a unit length of plaque tissue. The corresponding structural composition of the dissected plaque segments was characterised using Fourier transform infrared analysis, electron microscopy and energy dispersive x-ray spectroscopy. Mechanical results reveal a clear distinction in toughness properties within each region of the carotid vessel with significantly tougher properties localised in the bifurcation (p=0.004) and internal region (p=0.0003) compared to the common. The severity of the intra-plaque variance is highest in plaques with high toughness localised in the bifurcation region (p<0.05). Structural examination reveals that the diverse mechanical influence of the level of calcification present is characteristic of specific regions within the carotid plaque. The energy required to overcome the calcific resistance and propagate a controlled cut in the calcified tissue at each region varies further with the degree of plaque progression. The identification of the localised calcification characteristics is a key determinant in achieving successful dissection of the severely toughened plaque segments during cutting balloon angioplasty.

STATEMENT OF SIGNIFICANCE

Calcification plays a fundamental role in plaque tissue mechanics and demonstrates a diverse range of material moduli properties. This work addresses the characterisation of the toughness properties in human carotid plaque tissue using a fracture mechanics approach. Toughness determines the energy required to propagate a controlled cut in the plaque material. This parameter is crucial for predicting the cutting forces required during endovascular cutting balloon angioplasty intervention. Results demonstrate that a strong relationship exists between the structural calcification configurations, fracture mechanisms and associated toughness properties that are characteristic of specific regions within the carotid artery plaque. The identification of the morphological characteristics of localised calcification may serve as a valuable quantitative measure for cutting balloon angioplasty treatment.

Cutting Balloon Angioplasty in the Treatment of Short Infrapopliteal Bifurcation Disease

PURPOSE

To evaluate the safety, feasibility, and effectiveness of cutting balloon angioplasty in the management of infrapopliteal bifurcation disease.

METHODS

Between November 2010 and March 2013, 23 patients (mean age 69.6±9.01 years, range 56-89; 16 men) suffering from critical limb ischemia were treated using cutting balloon angioplasty (single cutting balloon, T-shaped double cutting balloon, or double kissing cutting balloon technique) for 47 infrapopliteal artery bifurcation lesions (16 popliteal bifurcation and 9 tibioperoneal bifurcation) in 25 limbs. Follow-up consisted of clinical examination and duplex ultrasonography at 1 month and every 3 months thereafter.

RESULTS

All treatments were technically successful. No 30-day death or adverse events needing treatment were registered. No flow-limiting dissection was observed, so no stent implantation was necessary. The mean postprocedure minimum lumen diameter and acute gain were 0.28±0.04 and 0.20±0.06 cm, respectively, with a residual stenosis of 0.04±0.02 cm. Primary and secondary patency rates were estimated as 89.3% and 93.5% at 6 months and 77.7% and 88.8% at 12 months, respectively; 1-year primary and secondary patency rates of the treated bifurcation were 74.2% and 87.0%, respectively. The survival rate estimated by Kaplan-Meier analysis was 82.5% at 1 year.

CONCLUSION

Cutting balloon angioplasty seems to be a safe and effective tool in the routine treatment of short/ostial infrapopliteal bifurcation lesions, avoiding procedure-related complications, overcoming the limitations of conventional angioplasty, and improving the outcome of catheter-based therapy.