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

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.

Long term data of endovascularly treated patients with severe and complex aortoiliac occlusive disease

AIM

This paper presents the recent data of the largest series (20 patients) of endovascularly treated patients and the first long term data of 9 patients with severe aortoiliac occlusive disease.

METHODS

Between 2003 and 2012, 20 consecutive patients (14 men; 70 %) with Leriche syndrome underwent recanalization with solely endovascular means at our centre. The treatment strategy comprised the antegrade (transbrachial) recanalization of the occluded segments followed by retrograde (transfemoral) angioplasty with selective stent placement in the infrarenal aorta and primary stent placement in the iliac arteries. Before discharge, after 30 days and every year after the procedure, a clinical, as well as a duplex ultrasonographic examination including measurement of the ankle-brachial index was done.

RESULTS

Bilateral success was achieved in 17 patients (85%). Unilateral success was achieved in three patients (15%). In one patient (5%) an early reocclusion of the stented segments occurred, necessitating bypass grafting. In nine patients long term data were evaluated. Here, the ankle brachial index (ABI) significantly increased (0.85 ± 0.15 vs. 0.51 ± 0.11 at baseline; P=0.002). Compared to baseline, the difference in the distribution of Rutherford category and the improvement of walking capacity were statistically significant (P=0.0006, P=0.01, respectively).

CONCLUSION

This study shows the feasibility of solely endovascular management of severe aortoiliac occlusive disease with a high rate of success and low rate of complications. Significant clinical improvement of patients in long term follow up makes the endovascular approach a viable alternative to open surgery.

Prospective observational study for perioperative volume replacement with 6% HES 130/0,42, 4% gelatin and 6% HES 200/0,5 in cardiac surgery

Background

The constantly growing amount of different kinds of colloid fluids necessitates comparative investigations with regards to the safety and effectivity in clinical use of these preparations. Hence we compared three colloid fluids in an observational study. The objective was the exploration of the influence of these three colloids on blood coagulation, hemodynamics and renal function of the cardiac surgical patient.

Methods

We included 90 patients undergoing an elective open-heart surgery with the use of the heart-lung machine and observed them consecutively. Group 1 [gelatin 4% (n = 30)], Group 2 [HES 200/0,5 (n = 30)] and Group 3 [HES 130/0,42 (n = 30)]. We measured the perioperative volume replacement, the administration of blood- and coagulation-products, the application of catecholamines, the renal function, blood gas and the platelet aggregation using multiplate electrode analyzer (Multiplate^®, Dynabyte medical, Munich, Germany).

Results

The gelatin-group needed significantly more norepinephrine than the HES 130/0.42 group. The responsible surgeon considered the blood coagulation in the HES 200/0.5 group most frequently as impaired. Furthermore we saw a significant decrease in platelet function in the HES 200/0.5 group when performing the multiplate^®-analysis (ADP-and COL-test). HES 130/0.4 as well as gelatin 4% showed no significant change in platelet function. The gelatin-group and the HES 200/0.5 needed significantly more aprotinine than the HES 130/0.4 group. We saw no significant difference with regards to administration of blood and coagulation products between the three groups. The urinary excretion during the intervention was significantly higher in the HES 200/0.5 group and in the gelatin group than in the HES 130/0.4 group.

Conclusions

Our results confirm the lower stabilizing effect of gelatin on circulation during fluid resuscitation. The blood coagulation was mostly impaired due to HES 200/0.5 confirmed by the multiplate^®-analysis as well as by different clinical findings.

Effects of physical exercise versus rosiglitazone on endothelial function in coronary artery disease patients with prediabetes

We conducted a three-arm, parallel-group, randomized, controlled trial to compare the effects of rosiglitazone and physical exercise on endothelial function in patients with coronary artery disease and impaired fasting glucose or impaired glucose tolerance over a 6-month period. Group A received rosiglitazone tablets 8 mg daily (n = 16), group B underwent a structured physical exercise programme (n = 15) and group C served as a control group (n = 12). At baseline and after 6 months, brachial artery ultrasound imaging was performed to assess reactive flow-mediated dilation (FMD). Rosiglitazone treatment and exercise both led to significant improvements in insulin resistance at 6 months, whereas no change was observed in control patients. FMD improved significantly in physical exercise patients, whereas no change could be observed in patients receiving rosiglitazone or in the control group. Between-group comparisons also showed a significant relative improvement in FMD in exercise patients compared with rosiglitazone.

Percutaneous interventions below the knee in patients with critical limb ischemia using drug eluting stents

AIM

Midterm technical and clinical evaluation of stent angioplasty with drug-eluting stents in infrapopliteal lesions in patients with critical limb ischemia (CLI).

METHODS

Percutaneous stent angioplasty was performed in 128 limbs in 114 patients presenting with 320 vascular lesions. Lesions with up to 6 cm in length and at least one patent vessel below the obstruction were treated; 341 drug-eluting Cypher(R) stents (diameter of 2.5-3.5 mm; length of 18-33 mm) were implanted. Follow-up examinations were performed up to 18 months postinterventionally using clinical examination, ankle-brachial index (ABI) calculation, and color coded Duplex sonography. Patency rates were calculated on the basis of the Kaplan-Meier life-table analysis.

RESULTS

Technical success was achieved in 99.06%. Minor complications (hematoma, distal emboli, and vessel dissection) were documented in 8.77% of the patients. The 6, 12, and 18 months primary patency rate as controlled by Duplex sonography was 89.8, 84.2 and 83.3%, respectively; 77.6% of the lesions healed postinterventionally. The cumulative limb salvage rate was 95.6%.

CONCLUSION

Drug-eluting stent (DES) angioplasty in infrapopliteal arteries is a safe and effective technique for the treatment of patients with CLI. The use of a DES results in favorable technical and clinical outcome in the midterm follow-up.

New techniques for endovascular treatment of peripheral artery disease with focus on chronic critical limb ischemia

Chronic critical limb ischemia (CLI) represents the most advanced stage of peripheral arterial disease. CLI is associated with a high risk for limb loss and revascularization, either by surgical or endovascular means, is absolutely mandatory. With traditional techniques such as balloon angioplasty, limb salvage was reported in 80 to 90%. However, in case of failed revascularization attempt, limb loss was 40 to 50% and mortality approximately 20%. This review summarizes new developments in endovascular techniques which increase the acute and chronic success rate of endovascular procedures and therefore potentially further improve limb salvage rates. Special crossing and re-entry devices designed for femoro-popliteal application may even facilitate recanalization of long chronic occlusions. Improved stent design, atherectomy devices and drug coated balloons improve patency rates and may result in improved wound healing rates. Moreover, downsizing the catheter tools for infrapopliteal artery disease opens new horizons also for the treatment of complex below-the-knee lesions representing an increasing patient population due to the increasing prevalence of diabetes and end-stage renal failure.

Incidence of venous thrombosis following peripheral arterial interventions. A prospective study

BACKGROUND

The objective of the study was to investigate the incidence of deep vein thrombosis (DVT) at the puncture site following peripheral interventions and to assess if there is a difference between using a vascular closure by means of vascular closure systems or compression bandages.

PATIENTS AND METHODS

We prospectively included 474 consecutive patients after peripheral arterial interventions. The day after peripheral arterial intervention we performed venous compression ultrasound to exclude DVT in the area of the groin. We recorded management of arterial closure and subsequent antithrombotic treatment of the patient. Four weeks after intervention follow-up was performed by phone to exclude clinical DVT, pulmonary embolism (PE), and death.

RESULTS

We included 474 consecutive patients (mean age 69 y; 298 male / 176 female). All patients were under oral antiplatelet therapy. Vascular closure was achieved in 296 patients (62.44%) by Femostoptrade mark followed by compression bandage and in 178 (37.56 %) by using a vascular closure device alone. Sonography revealed no DVT the day after intervention, no clinical PE occurred. Four weeks follow-up showed no DVT, but there was one patient in the compression bandage group who had PE without proven deep vein thrombosis. Two patients died from other reasons than PE.

CONCLUSIONS

The immediate and mid-term risk of DVT after peripheral arterial interventions is extremely low and is not increased if compression bandages are used for vascular closure.

Coil embolisation of an internal iliac artery aneurysm after surgical repair of an infrarenal aortic aneurysm

We report a case of an 86-year-old asymptomatic patient, who underwent a repair of the infrarenal abdominal aortic aneurysm 13 years ago. He presented with a left internal iliac artery (IIA) aneurysm with a short neck of 3 mm, and a partially thrombosed lumen with a cross sectional diameter of 5.6 cm and a length of 8.9 cm. With respect to the high morbidity and mortality and awareness of the recommendation to treat aneurysms larger than 3 cm in diameter, we discussed the optimal treatment options. As endoprosthesis implantation was not feasible we performed a selective coil embolisation of the distal branches of the left internal artery, which successively lead to a complete thrombosis of the aneurysm. Although coiling additive to other procedures is applied frequently, only few cases of internal iliac aneurysm were treated with coil embolisation alone. During a first outpatient visit 2 months following the procedure the aneurysm was still completely thrombosed.

ACE I/D but not AGT (-6)A/G polymorphism is a risk factor for mortality in ARDS

The intrapulmonary renin-angiotensin system via tissue concentration of angiotensin II or bradykinin may have multiple effects on pulmonary pathophysiology. Therefore, it was investigated whether the presence of the D allele of the angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism or the A allele of angiotensinogen (AGT) promoter polymorphism (-6)A/G are independent risk factors for 30-day survival in acute respiratory distress syndrome (ARDS) patients. In a prospective study, adults (Germans of Caucasian ethnicity) with ARDS (n = 84) were recruited from the current authors' intensive care unit and genotyped for the ACE I/D and the AGT (-6)A/G polymorphisms, as were 200 healthy Caucasian controls. Mortality was increased in the ACE DD genotype compared with the I allele, and the ACE I/D polymorphism was an independent prognostic factor for 30-day survival. Patients with a homozygous DD genotype were at highest risk for death (hazard ratio 5.7; 95% confidence interval 1.7-19.2) compared with the II genotype. In contrast, the AGT (-6)A/G polymorphism was neither associated with an increased risk for development of ARDS nor with outcome. In patients with acute respiratory distress syndrome, the angiotensin-converting enzyme insertion/deletion polymorphism but not the angiotensinogen (-6)A/G promoter polymorphism is an independent risk factor with a pronounced effect on 30-day survival.

[Peri-interventional risk in 1,384 cardiac catheterizations in patients aged 80 years or older]

BACKGROUND AND OBJECTIVE

Because of the rising life expectancy in the industrialized countries, ever more cardiac catheterizations are performed in patients aged 80 years or older. Little is known about the incidence of peri-interventional events in this age group.

PATIENTS AND METHODS

Between January 1996 and September 2000, a total of 1,085 patients of that age (mean 82.6 +/- 2.6 years) underwent cardiac catheterization and intervention (3% of a total of 43,517 cardiac catheterizations).

RESULTS

827 patients (77%) had significant coronary artery stenoses. 373 of them (45%) were treated with balloon angioplasty, with or without stenting, and 331 (40%) underwent aortocoronary bypass procedures. 31 patients died while in hospital, 17 of them having been in cardiogenic shock on admission. Peri-interventional events, including damage to artery at the site of catheter entry occurred in 2.1% of patients undergoing diagnostic cardiac catheterization and in 11.6% in connection with a percutaneous interventional procedure.

CONCLUSION

Both cardiac catheterization and interventional procedures can be done with a justifiable risk in patients aged 80 years or older. These cardiac investigations/interventions should not be withheld in this group of patients for reasons of age.

[Therapeutic options in patients with diabetes mellitus type 2 and coronary artery disease: intensified secondary prevention versus percutaneous or surgical revascularization]

Diabetes mellitus is a major risk factor for coronary artery disease and is associated with accelerated disease progression and adverse prognosis. Although relief of symptoms can quickly be obtained by percutaneous intervention or bypass surgery, it does not change patients' prognoses, with the exception of stenoses of the left main stem or left anterior descending artery. A multifactorial intervention, which consists of a low-fat diet, glucose and arterial blood pressure control, smoking cessation and regular physical exercise, emerges as an alternative strategy since it leads to improvement of the modifiable risk factors, exercise tolerance and quality of life.

Exercise training in chronic heart failure: why, when and how

The management of patients with chronic congestive heart failure has changed considerably during the last decade. Until recently, restriction of physical activity was recommended for patients with chronic heart failure. However, the knowledge that training influences largely the periphery rather than the heart itself has led to a dramatic change in the approach toward training in patients with chronic heart failure. Why to train patients with chronic heart failure: Training increases exercise tolerance by an average of 20% in chronic heart failure regardless of etiology (ischemic or non-ischemic cardiomyopathy) or severity of left ventricular dysfunction. Available data, while limited, demonstrate that increases in exercise capacity are paralleled by an improvement in quality of life. Studies have consistently demonstrated that training has no deleterious effect on central haemodynamics, left ventricular remodeling, systolic or diastolic function, or myocardial metabolism. At present, there are insufficient data to determine the effect of training on prognosis, but trials are currently underway to address this. When to train patients with chronic heart failure: Exercise training should be performed only with the patients that have been in a stable clinical condition for a period of at least 3-4 weeks. Clinical stability is defined as no change in symptoms, weight, drug regimen, or NYHA class over this period. How to train patients with chronic heart failure: Initially, the program should be supervised for a period of 2 to 4 weeks; home-based programs are usually appropriate thereafter. Activities that can be maintained for a lifetime should be encouraged, and the focus should be on aerobic-type activities. The intensity level should be targeted to about 50%-70% of peak VO2 and/or Borg ratings of 12-14 ("walk and talk").

Exercise training in chronic heart failure: why, when and how

The management of patients with chronic congestive heart failure has changed considerably during the last decade. Until recently, restriction of physical activity was recommended for patients with chronic heart failure. However, the knowledge that training influences largely the periphery rather than the heart itself has led to a dramatic change in the approach toward training in patients with chronic heart failure. Why to train patients with chronic heart failure: Training increases exercise tolerance by an average of 20% in chronic heart failure regardless of etiology (ischemic or non-ischemic cardiomyopathy) or severity of left ventricular dysfunction. Available data, while limited, demonstrate that increases in exercise capacity are paralleled by an improvement in quality of life. Studies have consistently demonstrated that training has no deleterious effect on central haemodynamics, left ventricular remodeling, systolic or diastolic function, or myocardial metabolism. At present, there are insufficient data to determine the effect of training on prognosis, but trials are currently underway to address this. When to train patients with chronic heart failure: Exercise training should be performed only with the patients that have been in a stable clinical condition for a period of at least 3-4 weeks. Clinical stability is defined as no change in symptoms, weight, drug regimen, or NYHA class over this period. How to train patients with chronic heart failure: Initially, the program should be supervised for a period of 2 to 4 weeks; home-based programs are usually appropriate thereafter. Activities that can be maintained for a lifetime should be encouraged, and the focus should be on aerobic-type activities. The intensity level should be targeted to about 50%-70% of peak VO2 and/or Borg ratings of 12-14 ("walk and talk").