Combination of rotational atherothrombectomy and Paclitaxel-coated angioplasty for femoropopliteal occlusion

Usage of rotational atherectomy and drug-coated balloon angioplasty for isolated popliteal artery lesions: two-year results of a retrospective study

OBJECTIVES

In this study, perioperative properties and early and mid-term clinical outcomes of endovascular revascularization with a combined usage of rotational atherectomy (RA) and drug-coated balloon angioplasty (DCB) angioplasty for isolated popliteal artery lesion were reported.

METHODS

A total of 28 patients with isolated popliteal artery stenosis who underwent combined RA and DCB angioplasty between December 2018 and September 2022 were analyzed retrospectively. Temren atherectomy system (Invamed, Ankara, Turkey) and Extender paclitaxel-coated drug-coated balloon catheter (Invamed, Ankara, Turkey) were used in all cases. The main outcome was primary patency; secondary outcomes were technical success, freedom from amputation, and mortality.

RESULTS

The mean age of patients was 64.2 ± 9.1 years and the majority of the patients were male (n = 20; 71.4%). Types of the lesions were total occlusion in 24 limbs and critical stenosis in 4 limbs. The mean total occlusion length was 65.2 ± 14.2 mm. Flow-limiting dissection was seen in lesions of 2 patients (7.1%) and treated with prolonged balloon dilatation without bail-out stenting requirement. Technical success defined as an adequate vascular lumen (less than 30% stenosis) was achieved in 26 (92.8%) with a mean follow-up of 17.2 ± 8.2 months. The mean primary patency rates at 12 months and 24 months were 92.3% ± 3.2 and 81.2% ± 3.2, respectively. Complications included 1 distal embolization following RA, 2 flow-limiting dissections, and 3 puncture site hematomas.

CONCLUSIONS

Endovascular procedures using combined RA and DCB angioplasty seem to be effective alternative treatment modalities for the treatment of popliteal artery lesions with high rates of primary patency and freedom from TLR.

Jetstream Atherectomy with Paclitaxel-Coated Balloons: Two-Year Outcome of the Prospective Randomized JET-RANGER Study

Background

The JET-RANGER study (NCT03206762) was a multicenter (11 US centers) randomized trial, core lab adjudicated, designed to demonstrate the superiority of Jetstream + Paclitaxel coated balloon (JET+PCB) versus angioplasty (PTA) + PCB in treating femoropopliteal (FP) arterial disease. The one-year primary endpoint of JET-RANGER has been recently published. The 2-year outcome data are presented in this report.

Methods

There were 43 patients who completed the 1-year follow-up. Two were lost to follow-up and one died prior to the 2-year follow-up, resulting in 40 patients. Fifteen patients were randomized to PTA+PCB and 25 patients to JET +PCB. Kaplan Meier Survival analysis was performed to estimate the freedom from TLR. Bailout stenting was not considered a TLR in this analysis. Statistical significance was determined by a p-value < 0.05.

Results

Freedom from TLR was similar between the 2 groups at 2 years. There was also no significant difference in the change of ABI between the PTA + PCB and JET + PCB from baseline at 6-months, (p-value = 0.7890), 1-year (p-value = 0.4070), and 2-year (p-value=0.7410). There was also no statistical difference between the JET + PCB and PTA + PCB arms for RCC improvement by one or more category, (p-value= 1.000). There were no minor or major amputations for either arm throughout the 2-year follow up. One JET + PCB patient died before the 2-year specified window.

Conclusion

JET + PCB had similar freedom from TLR and improvement in ABI and RCC at 2-year follow-up when compared to PTA + PCB with no difference in amputation or mortality between the 2 arms.

Clinical Trial Registration

NCT03206762.

[Application of Rotarex mechanical thrombectomy system in treating in-stent restenosis of lower extremity arteriosclerosis obliterans]

OBJECTIVE

To evaluate the role of Rotarex mechanical thrombectomy system in treating instent restenosis of peripheral artery disease (PAD).

METHODS

The clinical data of 7 in-stent restenosis (ISR) cases of lower extremity PAD from June 2017 to Dec 2018 were retrospectively analyzed. There were 5 males and 2 females and the mean age was (70.0±7.6) years from 59.0 to 76.0 years. All the cases were treated by Rotarex mechanical thrombectomy system. In the 7 cases, time interval from the previous stent implantation to ischemia recurrence was 1.0 to 72.0 months, and the median time was 6.0 months. The period from ischemia recurrence to endovascular therapy was 3 days to 2 years, and the median time was 62 days. Rotarex mechanical debulking catheter and percutaneous transluminal angioplasty (PTA) were used in all the cases, and the stent was used only when it was necessary. Anticoagulation was used for 24 hours after procedures and then antiplatelet agents were used as usual. Doppler ultrasonography was taken during the followed-up.

RESULTS

All the 7 cases were successful in technology, 3 of which were implanted with new stents for the fracture of the old ones. while for the other four cases, no new stent was implanted. The ankle-brachial index (ABI) increased from 0.31±0.08 to 0.86±0.08 after treatment (t=-12.84, P < 0.001). Thrombectomy was applied urgently in one case because of acute thrombosis in the stent, and the result was good. There was no other complications in hospital. All the patients were followed up for 5.0-22.0 months, and the median time was 14.0 months. No death and amputation occurred during the follow-up. One patient stopped antiplatelet agents because of gastrointestinal bleeding, which resulted in acute thrombosis. in-stent restenosis reappeared in 3 cases.

CONCLUSION

Debulking using Rotarex catheter is safe and effective in treating in-stent restenosis of PAD, especially in reducing stents implantation, but is not good at dealing with old thrombus and proliferating intima, and can do nothing about fractured stents and hyperplasia of intima, so it needs to be combined with stents and drug coated balloons.

Mechanical rotational thrombectomy in long femoropopliteal artery and bypass occlusions: risk factors for periprocedural peripheral embolization

PURPOSE

We aimed to examine lesion characteristics influencing technical outcome and periprocedural peripheral embolization (PPE) during percutaneous mechanical rotational thrombectomy (PMT) of long femoropopliteal artery and bypass occlusions.

METHODS

Retrospectively, 65 consecutive patients (43 male patients, mean age 70±12 years; Rutherford category I-III), undergoing PMT (Rotarex®, Straub Medical AG) with acutely/subacutely occluded femoropopliteal arteries/bypasses were included. Occlusions (mean length, 217±98 mm) were treated by PMT followed by percutaneous transluminal angioplasty (PTA) plus drug-coated balloon or PTA plus stenting/stentgrafting. Technical success was defined as residual stenosis <30%. Follow-up included duplex ultrasound and ankle-brachial index (ABI) after 12 months. Endpoints were technical success, complications, improvement of Rutherford category, ABI, and patency (re-stenosis <50%). The influence of lesion length, duration, and thrombus density (measured in preinterventional computed tomography angiography) on technical success and PPE was analyzed.

RESULTS

Technical success was 18% (12/65) after PMT alone, 92% (60/65) after additional means. Four patients (6%) underwent bypass surgery and one patient (2%) amputation. PPE occurred in 11% (7/65). During the 12-month follow-up, three patients (5%) were lost to follow-up. ABI increased from baseline 0.5±0.12 to 0.81±0.14 (p = 0.001) and Rutherford category increased by at least one level in 57 patients at 12-month follow-up (clinical success, 88%). At 12 months, primary patency was 57.4% (95% CI, 45.8%-68.9%) and secondary patency was 75.0% (95% CI, 59.8%-72.3%). As risk factors for PPE, we identified lesion length >200 mm (15%; 6/39; OR 4.5; 95% CI, 0.5-40; p = 0.014) and thrombus density ≤45 HU (20%; 2/10; OR 3.0; 95% CI, 0.2-38.9; p = 0.05). No significant relation between risk factors and technical success was found.

CONCLUSION

PMT followed by PTA or implantation of stent (grafts) appears to be effective and safe for revascularization of acute/subacute long occlusions. Thrombus density <45 HU and lesion length above 20 cm represent risk factors for PPE during PMT.

Chronic Femoropopliteal Occlusions: Comparison of Drug-Eluting Balloon Angioplasty with or without Prior Rotational Thrombectomy

BACKGROUND

The aim of this study was to compare drug eluting balloon (DEB) angioplasty with and without mechanical thrombectomy system in patients with chronic (> 6 months) femoropopliteal occlusions.

METHODS

We retrospectively identified patients from May 2012 to September 2014 at our clinic with severely diseased femoropopliteal arteries treated by endovascular approach with or without adjunctive thrombectomy system. All patients had ankle-brachial index (ABI) measured before and after the intervention, and regular clinical follow-up with Doppler ultrasonography performed at 1 month, 6 months and 1 year. Patients underwent peripheral angiography if needed.

RESULTS

Mechanical thrombectomy system (MTS + DEB) was used in 33 patients (31 enrolled 2 patients were lost to follow-up, mean lesion length 149.7mm ± 82.69). The remaining 33 patients were treated without MTS (31 enrolled 2 patients were lost to follow-up DEB N = 31 mean lesion length 157.3 mm ± 92.90). There were 5 restenosis in the MTS + DEB group (83.3% patency rate) and 5 restenosis in the DEB group (82.8% patency rate) at 1 year. The technical success rate was 93.5% in both groups. A statistically significant increase in the ABI (MTS + DEB before 0.47 ± 0.11 vs. after 0.92 ± 0.11 p < 0.01 DEB before 0.47 ± 0.11 vs. after 0.90 ± 0.14 p < 0.01) and improvement in Rutherford staging (p < 0.01) was noted in both groups following intervention.

CONCLUSIONS

DEB angioplasty is effective in the treatment of chronic total femoropopliteal occlusions. Combining DEB angioplasty and thrombectomy system does not appear to improve outcomes for treatment of chronic femoropopliteal occlusions.

Comparison of drug-eluting balloon angioplasty with self-expanding interwoven nitinol stent deployment in patients with complex femoropopliteal lesions

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.