Safety and efficacy of drug‐coated balloon for peripheral artery revascularization—A systematic review and meta‐analysis

Differences in Pharmacokinetic and Histopathological Effects of Five Drug-Coated Balloons: An Experimental Study in Rabbit

BACKGROUND

The optimal design concept and the safety of drug-coated balloons (DCBs) have not been completely determined yet. Also, the optimal approach for DCB-based revascularization of peripheral artery diseases still remains undefined. This study was designed to explore the in vivo pharmacokinetic and histopathological effects of DCBs using Ranger and 4 Chinese DCBs after implantation and administration in New Zealand rabbits.

MATERIALS AND METHODS

Fifty New Zealand rabbits were divided into 5 groups with 10 rabbits in each group according to the DCB used: Ranger (Boston Scientific), Orchid (Acotec), Reewarm (Endovastec), Ultrafree (Zylox), and Yaohang (Polyrey). After being guided to the lower segment of the abdominal aorta, the DCB was inflated for 3 minutes. Plasma, inflated infrarenal aorta, vastus lateralis muscle, anterior tibial muscle, and right toes were harvested for histological and paclitaxel concentration analyses 4 hours or 28 days after the angioplasty.

RESULTS

At 4 hours after aortic angioplasty, the overall paclitaxel concentrations in aortic wall were not statistically different (p = 0.050), but the paclitaxel concentrations in vastus lateralis muscle (p = 0.002), anterior tibial muscle (p = 0.006) and toe (p < 0.001) were not totally same according to the results of Kruskal-Wallis test. In toe, concentrations of paclitaxel were significantly lower for the Ranger (120.8 ng/g) DCB than for the Orchid (1880 ng/g; p = 0.008), Reewarm (347 ng/g; p = 0.016), and Ultrafree (261 ng/g; p = 0.016) DCBs. Concentrations of paclitaxel in the toe were not statistically different between Ranger and Yaohang DCBs (p = 0.421). Neointimal area (p < 0.001), neointimal thickness (p < 0.001), and percentage of luminal stenosis (p < 0.001) were less for Ranger DCB than for other DCBs 28 days after aortic angioplasty. The differences in paclitaxel concentrations in tissues 28 days after aortic angioplasty were not statistically significant.

CONCLUSION

Different design concepts will make a difference in the in vivo pharmacokinetic and histopathological effects of DCBs. The Ranger DCB can achieve similar drug delivery efficiency as other higher-dose DCBs and fewer neointimal hyperplasia. Although clinical implications remain to be further investigated, the present results may provide implications for the design and use of DCBs.Clinical ImpactThe current preclinical study suggested that different design concepts would make a difference in the pharmacokinetic and histopathological effects of drug-coated balloons (DCBs). Though Ranger DCB had the lowest paclitaxel loading in this study, it still achieved similar drug delivery efficiency with other higher-dose DCBs. Also, neointimal hyperplasia was less for the Ranger DCB than for the other DCBs 28 days after aortic angioplasty. Although clinical implications remain to be further investigated, the present results may provide implications for the design and use of DCBs.

Chronic Kidney Disease Requiring Hemodialysis as a Significant Predictor of Target Lesion Revascularization After Endovascular Treatment of Femoropopliteal Occlusive Lesions with a Drug-Coated Balloon

Background: Drug-coated balloons (DCBs) have been reported to have lowered the rate of restenosis and revascularization after endovascular treatment (EVT) of femoropopliteal (FP) lesions. Meanwhile, chronic kidney disease requiring hemodialysis (HD), which is becoming more prevalent in Japanese clinical settings, has been associated with poorer outcomes after EVT for FP lesions. This study aimed to retrospectively analyze the impact of HD on the outcomes of EVT using a DCB in a single center. Methods: This study included 161 consecutive FP lesions in 127 patients treated with a DCB between September 2018 and May 2023, stratified into HD (34.6%) and non-HD (65.4%) groups. The primary endpoint was clinically driven target lesion revascularization (CDTLR), and the secondary endpoints were major amputation and all-cause mortality. Results: The median observation period after EVT using a DCB was 336 days. Although a Rutherford's category of 4 or higher was significantly predominant in the HD group (82.3%) than the non-HD group (53.5%), a Rutherford's category of 4 or higher itself was not a statistically significant factor of the primary endpoint. The ratio of occluded lesion was significantly higher in the non-HD group (21.2%) than the HD group (8.1%). The duration of freedom from clinically driven target lesion revascularization (CDTLR) assessed via the Kaplan-Meier method was significantly shorter in the HD group (744 days) compared to the non-HD group (1533 days). The HD group had a higher incidence of CDTLR (odds ratio 4.48, p = 0.03) compared to the non-HD group. Conclusions: HD patients had significantly worse prognoses in EVT of FP lesions using a DCB.

Comparison of clinical outcomes of drug-coated balloons angioplasty vs. plain old balloons angioplasty for peripheral arterial disease: an umbrella meta-analysis

Background

Peripheral artery disease (PAD) affects millions globally, causing significant morbidity. Traditional treatments like plain old balloon angioplasty (POBA) have limited success due to high restenosis rates. Drug-coated balloon angioplasty (DCBA) has emerged as a promising alternative, locally delivering antiproliferative drugs like paclitaxel to reduce restenosis. However, the clinical outcomes of DCBA compared to POBA remain inconsistent across various studies.

Objective

This umbrella meta-analysis aimed to compare the clinical outcomes of DCBA and POBA in PAD patients, synthesizing data from multiple meta-analyses to provide a more robust evidence base.

Methods

We conducted an umbrella meta-analysis following PRISMA guidelines, systematically reviewing Cochrane Library, Embase, PubMed, and Web of Science. Studies were included if they compared DCBA and POBA in PAD patients, focusing on primary outcomes such as target lesion revascularization (TLR), primary patency (PP), all-cause mortality (ACM), and amputation. Secondary outcomes included restenosis, late lumen loss (LLL), and major adverse events (MAE).

Results

Sixteen meta-analyses were included. DCBA significantly reduced the risk of TLR (OR: 0.41, 95% CI: 0.34-0.49), PP was significantly higher in DCBA (OR: 2.05, 95% CI: 1.53-2.75), and restenosis was lower (OR: 0.46, 95% CI: 0.41-0.51). No significant differences were found in ACM or amputation risk between the two groups. Heterogeneity was moderate to high across most outcomes.

Conclusion

DCBA provides significant advantages over POBA in reducing TLR and restenosis while maintaining vessel patency. However, the effects on ACM and amputation remain inconclusive. Future research should focus on long-term safety and identifying which patient subgroups benefit most from DCBA.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO [CRD42024591967].

Improvement of Outcome for Treatment of ‘Restenosis-prone’ Vascular Lesions? Potential Impact of the Paclitaxel dose on Late Lumen Loss in Porcine Peripheral Arteries

Purpose

Clinical data indicate that the drug density on drug-coated balloons (DCBs) might have a role on treatment effect and durability. The aim of the current study was to investigate inhibition of neointimal formation and potential adverse effects after treatment with a novel double-dose DCB in swine.

Material and methods

A four-week study was performed in peripheral arteries of 12 domestic pigs after vessel injury and stent implantation. The novel double-dose DCB with 6-µg paclitaxel (Ptx)/mm2 balloon surface (1 × 6) was compared to a standard DCB with 3.5 µg Ptx/mm2 (3.5) and uncoated balloons (POBA). Potential adverse effects were stimulated by using three fully overlapping DCBs with 6 µg Ptx/mm2 each (3 × 6). Quantitative angiography, histomorphometry and histopathological analyses were performed.

Results

Higher paclitaxel doses per square millimeter of treated arteries were associated with reduced late lumen loss (LLL) in quantitative angiography 4 weeks after treatment (POBA: 0.91 ± 0.75 mm; 3.5: 0.45 ± 0.53 mm; 1 × 6: 0.21 ± 0.41 mm; 3 × 6: − 0.38 ± 0.65 mm). In histomorphometry, maximal neointimal thickness and neointimal area were the lowest for the 1 × 6 group (0.15 ± 0.06 mm/1.5 ± 0.4 mm2), followed by 3 × 6 (0.20 ± 0.07 mm/1.8 ± 0.4 mm2), 3.5 (0.22 ± 0.12 mm/2.2 ± 1.1 mm2) and POBA (0.30 ± 0.07 mm/3.2 ± 0.7 mm2). Downstream tissue showed histopathological changes in all groups including POBA, in larger number and different quality (e.g., edema, inflammation, vessel wall necrosis, vasculitis and perivasculitis) in the 3 × 6 group, which did not cause clinical or functional abnormalities throughout the study.

Conclusion

Treatment with the double-dose DCB (6 µg Ptx/mm2) tended to increase inhibition of in-stent neointimal formation and to diminish LLL after peripheral intervention in the porcine model compared to a market-approved DCB with 3.5 µg Ptx/mm2.

Long-Term Outcomes of the 150 mm Drug-Coated Balloon Cohort from the IN.PACT Global Study

PURPOSE

Data on the long-term safety and effectiveness of drug-coated balloons (DCBs) for the treatment of long femoropopliteal atherosclerotic lesions in the real-world setting are rare. This study reports 3 year and 5 year outcomes of the pre-specified 150 mm balloon sub-cohort of the IN.PACT Global Study.

METHODS

The IN.PACT Global Study was a prospective, multicentre, international, single-arm study evaluating the performance of the IN.PACT Admiral DCB in real-world patients with femoropopliteal atherosclerotic disease. This pre-specified 150 mm DCB cohort analysis comprised 107 participants (111 lesions) with all target lesions treated with at least one 150 mm DCB.

RESULTS

Mean lesion length was 20.3 ± 9.2 cm; 18.0% had in-stent restenosis, 58.6% were totally occluded, and 17.1% were severely calcified. Through 60 months, the Kaplan-Meier estimate of freedom from clinically driven target lesion revascularization (CD-TLR) was 72.7% [95% confidence interval (CI):62.4%-80.5%]. The safety composite endpoint (freedom from device/procedure-related death through 30 days; freedom from target limb major amputation and clinically driven target vessel revascularization through 5 years) was 70.5%. The cumulative incidence of major amputation was 1.0% and all-cause mortality was 18.4% through 60 months. Freedom from CD-TLR rates in the provisional stented and non-stented subgroups through 36 months were 64.0% [95% CI: 46.1%-77.3%] and 81.9% [95% CI: 69.7%-89.6%] (log-rank p = 0.074), respectively.

CONCLUSIONS

The results demonstrate sustained long-term safety of the 150 mm IN.PACT Admiral DCB for long femoropopliteal atherosclerotic lesions in real-world patients. In particular, the results show that DCB angioplasty is an effective revascularization modality in long complex lesions.

CLINICALTRIALS

gov identifier: NCT01609296.

LEVEL OF EVIDENCE

Level 3, Cohort Study.