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Buril GDO, Lins EM, Silva ETAGBDBE, da Rocha FA, de Siqueira Charamba JC, Caldas RPDAS, Vieira IÍF, da Silva PKA. Correlation between the vascular resistance index and arteriography for assessment of the distal arterial bed in chronic limb threatening ischemia. J Vasc Bras 2024; 23:e20230071. [PMID: 38433983 PMCID: PMC10903956 DOI: 10.1590/1677-5449.202300712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 11/08/2023] [Indexed: 03/05/2024] Open
Abstract
Background Patients with chronic limb threatening ischemia (CLTI) of the lower limbs (LL) undergo arteriography for revascularization surgery planning. Doppler ultrasound (DU) is non-invasive and can provide information about the distal arteries through measurement of the resistance index (RI). Objectives To correlate the Rutherford Angiographic Classification with the RI for assessment of the distal arterial bed of the LL. Methods A cross-sectional study, conducted at a public tertiary hospital with 120 patients with LL CLTI, from September 2019 to April 2022. The RI of arteries that were candidates for revascularization was compared with the images of the same arteries obtained using arteriography, using the Rutherford Angiographic Classification of the distal bed. Results A total of 120 LL were assessed in 120 patients with a mean age of 68.6 years. The sample was 50.0% male and 90.0% of the patients in the sample were classified as Rutherford category five. The RI values found for the arteries of the leg exhibited a statistically significant positive correlation with the Rutherford Classification (anterior tibial, p< 0.01; posterior tibial, p = 0.012 fibular, p = 0.034; and dorsalis pedis, p < 0.001). Conclusions In this study, RIs for the arteries of the leg measured using Doppler ultrasound exhibited a positive correlation with the Rutherford Classification. This index could be useful for assessment of the distal arterial bed of the lower limbs of patients with chronic limb threatening ischemia.
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Affiliation(s)
| | - Esdras Marques Lins
- Universidade Federal de Pernambuco - UFPE, Centro de Ciências Médicas - CCM, Recife, PE, Brasil.
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Ho TG, Tang TY, Yap CJQ, Yap HY, Chan SWY, Leong CR, Chan DYS. USE of IMplanting the Biotronik PassEo-18 Lux drug coated balloon to treat failing haemodialysis arteRiovenous FIstulas and grafts (SEMPER FI Study). J Vasc Access 2023:11297298231209070. [PMID: 37978343 DOI: 10.1177/11297298231209070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Plain old balloon angioplasty has been the mainstay of treatment for arteriovenous fistula (AVF) stenoses. Recent studies suggest that drug coated balloons (DCB) may significantly reduce re-intervention rates on native and recurrent lesions. The Passeo-18 Lux DCB (Biotronik AG, Buelach, Switzerland) is packaged with a 3.0 µg/mm2 dose of paclitaxel. The hypothesis is that its use provides better target lesion primary patency (TLPP), primary assisted patency (PP), secondary patency (SP) rates and reduces the number of visits for re-intervention in a cohort of patients with stenotic AVF and arteriovenous grafts (AVGs). METHODS The USE of IMplanting the Biotronik PassEo-18 Lux DCB to treat failing haemodialysis arteRiovenous FIstulas and grafts trial (SEMPER FI) was a prospective double-centre, multi-investigator, non-consecutive, non-blinded single-arm study investigating the efficacy and safety of the Passeo-18 Lux DCB in patients with stenotic AVF/AVG lesions between January 2021 and January 2022. Patient demographics, clinical characteristics, vascular access history, operative indications, details and outcomes were collected prospectively. TLPP, circuit access primary patency (CAP), PP, SP and deaths 6- and 12-months post-intervention were studied. RESULTS Ninety-one patients with 110 lesions were recruited across the two centres. 62.6% (n = 57) were male with a median age of 63.5 years (SD = 10.5). 62.6% (n = 57) were taking anti-platelets. Eighty-five AVFs and six AVGs were treated. 60% (n = 54) of AVFs intervened were radiocephalic. 52.7% (n = 58) of targeted lesions were juxta-anastomotic stenosis (JAS) and one-third (n = 33) at the AVF/AVG outflow. 70.9% (n = 78) of lesions were recurrent. Median time from last intervention was 219 days. 78% of target lesions (n = 85) and circuits (n = 70) were patent at 6-months, of which 96.7% (n = 87) of those requiring assisted intervention were patent. CONCLUSION This study shows that the Passeo-18 Lux DCB can be an effective and safe tool in the treatment of failing haemodialysis AVFs/AVGs.
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Affiliation(s)
- Tze Gek Ho
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Tjun Yip Tang
- The Vascular & Endovascular Clinic, Gleneagles Medical Centre, Singapore, Singapore
| | - Charyl Jia Qi Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Hao Yun Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Shaun Wen Yang Chan
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chuo Ren Leong
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
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Forrestal BJ, Zhang C, Case BC, Yerasi C, Craig PE, Torguson R, Bernardo NL, Waksman R. A patient-level, pooled analysis of mortality rates with the Passeo-18 Lux paclitaxel drug-coated balloon in peripheral arterial disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 33:49-54. [PMID: 34090794 DOI: 10.1016/j.carrev.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recent meta-analyses have raised concerns about mortality with paclitaxel drug-coated balloons (DCB). This pooled, patient-level analysis of the BIOLUX P-I, P-II, and P-III studies was performed to evaluate the safety and efficacy of Passeo-18 Lux DCB. MATERIALS AND METHODS Individual patient-level demographic, clinical, diagnostic, and procedural data from the BIOLUX P-I, BIOLUX P-II, and BIOLUX P-III studies were pooled in a common database. Clinical safety (all-cause mortality and cardiovascular mortality) and efficacy (any amputation, target lesion/vessel revascularization) were extracted. Cox proportional modeling was used to assess the effect of critical limb ischemia at the time of enrollment and the occurrence of new amputation as a time-dependent variable on mortality. RESULTS A total of 1009 patients were included in the analysis. Sixty-six patients were treated with percutaneous transluminal angioplasty (PTA) and 943 underwent DCB angioplasty. The cumulative incidence of all-cause mortality did not differ between the groups (PTA 6.7%, DCB 6.7%, p = 0.65). The composite efficacy endpoint of freedom from any amputation and target lesion/vessel revascularization was superior in the DCB arm compared to PTA [PTA 28.8%, DCB 16.7%, p = 0.02]. Both in unadjusted and adjusted Cox proportional models (adjusted for critical limb ischemia and amputation), the use of DCB was not associated with any mortality at 1 year. CONCLUSIONS Our patient-level analysis shows that overall the use of the Passeo-18 Lux paclitaxel DCB in infrainguinal arteries was not associated with increased mortality at 1 year and reinforces the efficacy of DCB angioplasty in preventing amputation or the need for reintervention.
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Affiliation(s)
- Brian J Forrestal
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Charan Yerasi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Paige E Craig
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Rebecca Torguson
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Nelson L Bernardo
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
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Tepe G, Zeller T, Moscovic M, Corpataux JM, Christensen JK, Keirse K, Nano G, Schroeder H, Binkert CA, Brodmann M. Paclitaxel-Coated Balloon Angioplasty for the Treatment of Infrainguinal Arteries: 24-Month Outcomes in the Full Cohort of BIOLUX P-III Global Registry. Cardiovasc Intervent Radiol 2020; 44:207-217. [PMID: 33083853 PMCID: PMC7806550 DOI: 10.1007/s00270-020-02663-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/19/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE After promising small randomized trials, the aim of BIOLUX P-III was to further investigate the safety and performance of the Passeo-18 lx drug-coated balloon in infrainguinal arteries under real-world conditions. METHODS BIOLUX P-III is a global prospective single-arm study with follow-up at 6, 12 and 24 months. The primary safety endpoint was freedom from major adverse events (MAE) within 6 months. The primary performance endpoint was freedom from clinically driven target lesion revascularization (TLR) within 12 months. RESULTS 877 patients/1084 lesions were enrolled. Diabetes mellitus was present in 47.7%, and 42.1% had critical limb ischemia (CLI). The mean lesion length was 89.0 mm with 76.1% of calcified lesions, and 24.9% occluded. At 24 months, freedom from MAE was 83.1% in the full cohort; 84.9% in the femoropopliteal population (592 patients, 691 lesions); 77.7% for long lesions (187 subjects/192 lesions); and 72.5% in the in-stent restenosis (ISR) subgroup (103 subjects/116 lesions). Twenty-four-month freedom from clinically driven TLR was 88.1% in the full cohort; 88.9% in the femoropopliteal population; 80.3% for the long lesions; and 78.4% for ISR. Twenty-four-month all-cause mortality was 12.0% in the full cohort, 10.2% in the femoropopliteal population, 14.8% for the long lesions and 12.0% for ISR. There was no device- or procedure-related death up to 24-month follow-up. CONCLUSION The BIOLUX P-III 24-month outcomes confirm the safety and performance of Passeo-18 lx in infrainguinal arteries in a large population treated under real-world conditions with low complication rates and good clinical outcomes (NCT02276313).
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Affiliation(s)
- Gunnar Tepe
- Department of Radiology, Klinikum Rosenheim, Rosenheim, Germany. .,Institut für Diagnostische Und Interventionelle Radiologie, RoMed Klinikum Rosenheim, Pettenkoferstr. 10, 83022, Rosenheim, Germany.
| | - Thomas Zeller
- Clinic Cardiology and Angiology II, Universitäts-Herzzentrum Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Matej Moscovic
- Angiology Clinic, Institute of Cardiovascular Diseases, Kosice, Slovakia
| | - Jean-Marc Corpataux
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Koen Keirse
- Department of Vascular Surgery, Regional Hospital Heilig Hart, Tienen, Belgium
| | - Giovanni Nano
- 1st Vascular Surgery Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Henrik Schroeder
- Center for Diagnostic Radiology and Minimally Invasive Therapy, Jewish Hospital, Berlin, Germany
| | | | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University Graz, Graz, Austria
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Nazari I, Mousavi SM, Sadeghpour A, Alamshah SM, Dastoorpoor M. Comparison of Effectiveness of Drug-Coated Balloon Angioplasty versus Plain Balloon Angioplasty in Chronic Lower Extremity Ischemia Patients. Int J Gen Med 2020; 13:609-615. [PMID: 32982378 PMCID: PMC7501961 DOI: 10.2147/ijgm.s256240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/19/2020] [Indexed: 11/25/2022] Open
Abstract
Background Occlusive lesions of superficial femoral artery (SFA) in endovascular candidate patients are treated with balloon angioplasty with or without stenting. Recently, introduction of drug-coated balloon (DCB) angioplasty as a superior treatment option to plain balloon (PB) has been challenging. Objective The purpose of this study was to compare the effectiveness of DCB versus PB angioplasty in chronic lower extremity ischemia patients. Patients and Methods In this clinical trial, 2 groups were matched at baseline; among 68 patients with peripheral artery disease, 23 patients were treated by DCB and 45 by PB. They were followed up for 6 months. Our findings of ABI, Rutherford and WIFI class changes, mortality, limb amputation, re-intervention and primary patency (PP) were collected and analyzed in comparative fashion between 2 groups. Results Mean patients age was 68.5 years (77.9% male). At 6 months, the increase in ABI in DCB was 0.37 and in PB was 0.32 (P>0.05). Mean decrease in Rutherford class in DCB and PB were 2.56, 2.28 (P>0.05). Mean decrease in WIFI class in DCB and PB were 1.48, 1.11 (P>0.05). In DCB group, 1 (4.3%) limb amputation, 3 (13%) re-interventions and no mortality with 87% PP were seen. In PB group, 2 (4.4%) limb amputation, 7 (15.6%) re-interventions, 1 (2.2%) mortality with 84.4% PP were seen. Conclusion Treatment of occlusive lesions of SFA with DCB probably may leads to improvement in ABI, Rutherford and WIFI class, higher pp and lower rate of re-interventions. Since Rutherford class and pp in DCB group have improved during 6 months compared to 1 month follow up (in our study), this improvement seems to be more significant statistically in longer term of follow up.
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Affiliation(s)
- Iraj Nazari
- Department of General Surgery, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyyed Masoud Mousavi
- Department of General Surgery, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ahmad Sadeghpour
- Department of General Surgery, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyyed Mansour Alamshah
- Department of General Surgery, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Dastoorpoor
- Department of Biostatistics and Epidemiology, Menopause Andropause Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Bosiers M, Deloose K, Torsello G, Scheinert D, Verbist J, van den Eynde W, Maene L, Beelen R, Keirse K, Hendriks J, Callaert J, Bosiers M, Wauters J. One-year outcome of the paclitaxel-eluting Legflow balloon catheter in the treatment of long and complex femoropopliteal lesions. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:471-477. [PMID: 32241092 DOI: 10.23736/s0021-9509.20.11236-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study is to investigate the efficacy of the paclitaxel-eluting Legflow balloon catheter in the treatment of "real-world" long and complex femoropopliteal lesions. METHODS The REFLOW study was a prospective, multi-national, non-randomized, single arm study evaluating the safety and efficacy of the Legflow paclitaxel-eluting balloon dilatation catheter in the treatment of stenotic or occlusive lesions >150 mm long in the femoropopliteal arteries of symptomatic patients (Rutherford 2-5). A total of 120 study subjects were enrolled in a period of 30 months, between October 2015 and May 2018. The mean age was 71.1 years and 79 patients were men (65.8%). Mean lesion length was 216.1 mm. 45.0% of the lesions were occluded, whereas 55.0% were stenotic. Primary endpoint was primary patency at 12 months, defined as absence of a hemodynamically significant stenosis on duplex ultrasound (systolic velocity ratio no greater than 2.4) at the target lesion and without TLR within 12 months. RESULTS Technical and procedural success (<30.0% residual angiographic stenosis without major complications) was achieved in all 120 cases (100.0%). Primary patency was 84.6% at 6 months and 71.1% at 1 year. Freedom from TLR was 79.9% at 1 year. CONCLUSIONS If longer term follow-up confirms there is no safety-concern on these paclitaxel device, the excellent results of the newer drug-eluting devices, and the Legflow paclitaxel-eluting balloon in particular, is a valid and effective alternative to treat long and complex "real-world" femoropopliteal lesions.
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Tepe G, Zeller T, Moscovic M, Corpataux JM, Christensen JK, Keirse K, Nano G, Schroeder H, Binkert CA, Brodmann M. Paclitaxel-Coated Balloon for the Treatment of Infrainguinal Disease: 12-Month Outcomes in the All-Comers Cohort of BIOLUX P-III Global Registry. J Endovasc Ther 2020; 27:304-315. [PMID: 31989855 PMCID: PMC7082893 DOI: 10.1177/1526602819898804] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Purpose: To further investigate the safety and performance of the Passeo-18 Lux drug-coated balloon (DCB) for the treatment of atherosclerotic infrainguinal disease under real-world conditions. Materials and Methods: BIOLUX P-III is an international, prospective, observational registry (ClinicalTrials.gov identifier NCT02276313) conducted at 41 centers in Europe, Asia, and Australia with follow-up visits at 6, 12, and 24 months. Of 700 patients (mean age 70.0±10.2 years; 439 men) with 863 lesions in the all-comers cohort, 330 (47.1%) patients had diabetes and 234 (37.7%) had chronic limb-threatening ischemia. The majority (79.3%) of lesions were in the femoropopliteal segment; of all lesions, 645 (74.9%) were calcified and 99 (11.5%) had in-stent restenosis (ISR). The mean lesion length was 84.7±73.3 mm. The primary clinical endpoint was major adverse events (MAEs) within 6 months, a composite of device- and procedure-related mortality through 30 days, major target limb amputation, and clinically-driven target lesion revascularization (TLR). The primary performance endpoint was clinically-driven TLR within 12 months. Results: At 6 and 12 months, freedom from MAEs was 94.0% and 89.5% in the all-comers cohort: 95.0% and 91.2% in the femoropopliteal group and 95.3% and 88.0% in the ISR subgroup, respectively. Freedom from clinically-driven TLR at 12 months was 93.1% in the all-comers cohort, 93.9% in the femoropopliteal lesions, and 89.4% for ISR lesions. All-cause mortality was 6.1% in the all-comers cohort: 5.9% in both the femoropopliteal and ISR subgroups. There were no device- or procedure-related deaths at up to 12 months. The Rutherford category improved in >80% of all subgroups at 12 months. Conclusion: In a real-world patient population, the safety and performance of the Passeo-18 Lux DCB for the treatment of atherosclerotic infrainguinal lesions are maintained, with good performance outcomes and low complication rates at 12 months.
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Affiliation(s)
- Gunnar Tepe
- Department of Radiology, Klinikum Rosenheim, Rosenheim, Germany
| | - Thomas Zeller
- Clinic Cardiology and Angiology II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Matej Moscovic
- Angiology Clinic, Institute of Cardiovascular Diseases, Kosice, Slovakia
| | - Jean-Marc Corpataux
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Koen Keirse
- Department of Vascular Surgery, Regional Hospital Heilig Hart, Tienen, Belgium
| | - Giovanni Nano
- 1st Vascular Surgery Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Henrik Schroeder
- Center for Diagnostic Radiology and Minimally Invasive Therapy, Jewish Hospital, Berlin, Germany
| | | | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University Graz, Austria
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Tang TY, Tan CS, Yap C, Tan RY, Tay HH, Choke E, Chong TT. Helical stent (SUPERA™) and drug-coated balloon (Passeo-18 Lux™) for recurrent cephalic arch stenosis: Rationale and design of arch V SUPERA-LUX Study. J Vasc Access 2019; 21:504-510. [PMID: 31621477 DOI: 10.1177/1129729819881589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The treatment options for cephalic arch stenosis are limited and standard of care remains at crossroads - none are ideal and there is currently no gold standard. Endovascular techniques are now the preferred primary therapeutic option because they are minimally invasive and better tolerated by haemodialysis patients who have multiple comorbidities. However, conventional plain old balloon angioplasty, bare metal stenting and stent grafts all have their limitations. The aim of this trial is to evaluate whether the helical SUPERA™ stent (Abbott Vascular, Santa Clara, CA, USA), which has a higher degree of flexibility and resistance to compressive forces compared to traditionally laser-cut nitinol stents, combined with a drug-coated balloon (Biotronik Passeo-18 Lux™) to minimize the neointimal hyperplasia effect, can improve patency and reduce reintervention rates. METHODS AND RESULTS Arch V SUPERA-LUX is a pilot investigator-initiated single-centre, single-arm prospective study. Twenty patients with a brachiocephalic fistula within 6 months of initial plain old balloon angioplasty for significant cephalic arch stenosis will be recruited for treatment with SUPERA and drug-coated balloon. The primary objectives are immediate angiographic and procedural success, primary patency and functional fistula at 1 week, 8 weeks, 6 and 12 months. The results from eight patients treated prospectively as proof of concept have shown primary patency of 83.3% at 1 year with 100% technical and procedural success rates. Enrolment for the Arch V SUPERA-LUX study is expected to be completed at the end of 2019. CONCLUSION The Arch V SUPERA-LUX study is the first trial to evaluate whether SUPERA stent implantation and drug-coated balloon use can provide superior protection against restenosis compared to traditional angioplasty, bare metal stents and stent grafts in recurrent cephalic arch stenosis. Initial pilot results are encouraging but longer follow-up is required to truly test this technique. TRIAL REGISTRATION This study is registered on ClinicalTrials.gov NCT03891693.
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Affiliation(s)
- T Y Tang
- Duke-NUS Medical School, Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - C S Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Cjq Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - R Y Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - H H Tay
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Etc Choke
- Department of General Surgery, Sengkang General Hospital, Singapore
| | - T T Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
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