Paclitaxel-coated balloon angioplasty versus drug-eluting stenting for the treatment of infrapopliteal long-segment arterial occlusive disease: the IDEAS randomized controlled trial

Drug Eluting Stents Below the Knee: Patency, Amputation-Rate, and Mortality-A Systematic Review of the Literature

BACKGROUND

Numerous meta-analyses and multicenter randomized controlled trials have demonstrated that drug-eluting stents (DES) offer superior outcomes in terms of primary patency and limb salvage compared to other endovascular modalities such as balloon angioplasty and bare metal stents. This review aims to systematically analyze the literature on the clinical outcomes of DES for the treatment of infrapopliteal arterial occlusions.

METHODS

This study is a systematic review. Comprehensive searches were conducted in the MEDLINE, EMBASE, Ovid, Cochrane, DAR, and BVS databases. Eligible studies were those that reported outcomes of DES in the treatment of infrapopliteal arterial disease, with no restrictions on time frame, publication status, or language. The primary outcome assessed was the primary patency of the stent, while secondary outcomes included the rates of re-occlusion and mortality.

RESULTS

A total of 27 studies involving 2470 patients were included in the analysis, in which 1191 patients come from prospective multicenter studies. The mean age of the participants was 73.4 years. Approximately, 50% of the patients had diabetes mellitus and/or chronic renal failure, and 33.3% had heart disease. The fibular artery was the most frequently affected by stenosis, involved in 50.2% of cases, followed by the anterior tibial artery in 34.6% of cases and the posterior tibial artery in 15.2% of cases. The average patency rate following DES treatment was 72.2% at 12 months. The rate of re-occlusion was 21.6%, and the mortality rate was 16.6%. However, due to the heterogeneity of the sample and incomplete data, it was not possible to draw definitive correlations between patency, amputation rates, and mortality.

CONCLUSION

This systematic review and analysis revealed significant limitations due to the heterogeneity of the sample and incomplete data, preventing a comprehensive stratification of the findings. As a result, we are not yet able to fully address the research questions posed. Further studies with extended follow-up periods are needed to standardize the treatment of infrapopliteal arterial occlusions and provide more definitive conclusions.Clinical ImpactThis review assessed the efficacy and safety of drug-eluting stents for below-the-knee lesions, showing promising patency and safety results. Their use in daily practice may aid in treating lesions prone to recoil and dissection after angioplasty. Despite some data inconsistencies, the findings remain encouraging. Drug-eluting stents demonstrated better outcomes than Bare-metal Stent, supporting their consideration in clinical practice for below-the-knee vascular treatment.

The Impact of Intravascular Ultrasound Use on 1-Year Outcomes After Infrapopliteal Endovascular Intervention

Background

Data supporting the use of intravascular ultrasound (IVUS) in aortoiliac and femoropopliteal endovascular intervention are becoming increasingly robust, but data in the infrapopliteal circulation remain limited. The aim of this study was to evaluate the association between IVUS use and 1-year outcomes after infrapopliteal intervention.

Methods

All infrapopliteal endovascular interventions that occurred between 2018-2021 at a single academic medical center were retrospectively reviewed. Cases were separated into 2 cohorts based on the use of IVUS. Clinical characteristics, procedural data, and imaging were collected up to 1-year postintervention. The primary outcome of interest was 1-year binary restenosis. Secondary outcomes included rates of 1-year target lesion revascularization, amputation, major adverse limb events, and all-cause mortality.

Results

One hundred patients with 142 lesions were included. IVUS was used in 23% of cases. Baseline characteristics, lesion characteristics, and treatment modalities did not differ significantly between cohorts. At 1 year, cases with IVUS utilization had significantly lower rates of binary restenosis (22% vs 57%; P = .004) and substantially lower rates of target lesion revascularization (13% vs 33%; P = .06). Rates of amputation, major adverse limb events, and mortality did not differ significantly. In multivariate analysis, lesions treated with IVUS were significantly less likely to have binary restenosis at 1 year when compared with angiography alone (odds ratio, 0.18; 95% CI, 0.05-0.62; P = .007).

Conclusions

Intravascular ultrasound use was associated with lower rates of 1-year restenosis when compared to angiography alone, even after correcting for differences in clinical and procedural characteristics. These findings support the need for a prospective randomized trial evaluating the impact of IVUS use on outcomes after infrapopliteal endovascular intervention.

"Evolution of Drug-Coated Devices for the Treatment of Chronic Limb Threatening Ischemia"

For patients with Chronic Limb Threatening Ischemia (CLTI), endovascular approaches to revascularization are often employed as a component of multimodality care aimed at limb preservation. However, patients with CLTI are also prone to treatment failure, particularly following balloon angioplasty alone. Drug-coated devices utilizing Paclitaxel were developed to decrease restenosis but have been primarily studied in patients presenting with claudication. In recent years, data have emerged which describe the efficacy of drug-coated devices in the treatment of patients with CLTI. Concurrently, there has been major controversy surrounding the use of drug-coated devices in peripheral arterial disease. A historical narrative of the development and use of drug-coated devices for peripheral arterial disease is presented, along with discussion of major trials. Evidence argues that paclitaxel-based therapies for peripheral arterial disease (PAD) do not increase mortality risk compared to nondrug-coated devices. In CLTI patients, paclitaxel-based balloons and stents provide superior patency and freedom reintervention compared to nondrug-coated devices when treating femoropopliteal disease. However, the use of Paclitaxel-based therapies for below-the-knee (BTK) interventions has not been shown to provide clinically meaningful outcomes compared to nondrug-based therapies. Newer generation antiproliferative agents (Sirolimus, Everolimus) and delivery systems (bioabsorbable scaffolds) hold promise for BTK interventions with early data suggesting decreased rates of major amputation or major adverse limb events.

Drug-eluting devices for lower limb peripheral arterial disease

Peripheral arterial disease is the third leading cause of cardiovascular morbidity after coronary artery disease and stroke. Lower limb peripheral arterial disease commonly involves infrainguinal arteries, may impair walking ability (intermittent claudication) and may confer a significant risk of limb loss (chronic limb-threatening ischaemia), depending on the severity of ischaemia. Endovascular treatment has become the mainstay revascularisation option in both the femoropopliteal and the below-the-knee arterial segments. After crossing and preparing the lesion, treatment results in these arterial segments can be enhanced by using drug-coated devices (drug-eluting stents and drug-coated balloons) that mitigate the occurrence of restenosis. As for other medical devices, the use of drug-eluting devices is based on their demonstrated safety and efficacy profiles when applied in the distinct segments of the lower limb vasculature. In this state-of-the-art narrative review we provide an overview of the safety and efficacy of drug-coated devices when used in the femoropopliteal and below-the-knee arterial segments.

Maglev-fabricated long and biodegradable stent for interventional treatment of peripheral vessels

While chronic limb-threatening ischemia is a serious peripheral artery disease, the lack of an appropriate stent significantly limits the potential of interventional treatment. In spite of much progress in coronary stents, little is towards peripheral stents, which are expected to be both long and biodegradable and thus require a breakthrough in core techniques. Herein, we develop a long and biodegradable stent with a length of up to 118 mm based on a metal-polymer composite material. To achieve a well-prepared homogeneous coating on a long stent during ultrasonic spraying, a magnetic levitation is employed. In vivo degradation of the stent is investigated in rabbit abdominal aorta/iliac arteries, and its preclinical safety is evaluated in canine infrapopliteal arteries. First-in-man implantation of the stent is carried out in the below-the-knee artery. The 13 months' follow-ups demonstrate the feasibility of the long and biodegradable stent in clinical applications.

Efficacy and Outcomes of Stenting Versus Balloon Angioplasty for Chronic Limb-Threatening Ischemia in Infrapopliteal Peripheral Arterial Disease: A Meta-Analysis of Randomized Controlled Trials

Peripheral arterial disease (PAD) and its severe complication, chronic limb-threatening ischemia (CLTI) are associated with significant morbidity and mortality worldwide. Conventionally, balloon angioplasty has been regarded as superior to stenting in CLTI associated with infrapopliteal PAD. Stenting is often considered a "rescue" or "bail-out" procedure in managing CLTI. However, stenting using newer generation stents coated with antiproliferative drugs such as paclitaxel has demonstrated noninferior results compared with balloon angioplasty in terms of risk of restenosis. However, the current data comparing stenting to balloon angioplasty for other outcomes is rather inconsistent. Major bibliographic databases were searched systematically to identify randomized controlled trials (RCTs) comparing stenting to balloon angioplasty in CLTI in infrapopliteal PAD patients. Risk ratios (RR) with 95% confidence intervals (CI) were pooled in a random-effects model with statistical significance considered at P < 0.05. 9 RCTs with 1125 patients (634, stenting; 491, balloon angioplasty) were included. Stenting was associated with a statistically significant reduction in the risk of binary restenosis (RR, 0.61; 95% CI, 0.38-0.97; P = 0.04] compared with balloon angioplasty. However, no statistically significant difference in technical success, all-cause mortality, clinically driven target lesion revascularization, major limb amputation, and primary patency was observed between the 2 groups. In infrapopliteal PAD associated with CLTI, stenting is noninferior to balloon angioplasty. Future large multicentric RCTs are warranted, particularly evaluating the newer generation drug-eluting stents, in a diverse patient population with longer follow-up periods to corroborate the results of this meta-analysis.

Liquid Drug Delivery Approaches for the Treatment of Occlusive Arterial Disease: A Systematic Review

OBJECTIVE

Local Liquid drug (LLD) delivery devices have recently emerged as a novel approach to treat peripheral arterial disease. This systemic review aims to identify and evaluate the clinical utility of the most commonly used delivery devices.

METHODS

A systemic review was performed using the Medical Subjects Heading terms of "drug delivery," "liquid," "local," and "cardiovascular disease" in PubMed, Google Scholar, and Scopus.

RESULTS

Four commonly used delivery devices were identified, including (1) the Bullfrog Micro-Infusion Device, (2) the ClearWay RX Catheter, (3) the Occlusion Perfusion Catheter, and (4) the Targeted Adjustable Pharmaceutical Administration. All have shown to successfully deliver liquid therapeutic into the target lesion and have exhibited favorable safety and efficacy profiles in preclinical and clinical trials. The LLD devices have the ability to treat very long or multiple lesions with a single device, providing a more economical option. The safety profile in LLD clinical studies is also favorable in view of recent concerns regarding adverse events with crystalline-paclitaxel-coated devices.

CONCLUSION

There is clear clinical evidence to support the concept of local liquid delivery to treat occlusive arterial disease.

CLINICAL IMPACT

The 'leave nothing behind' strategy has been at the forefront of the most recent innovations in the field of interventional cardiology and vascular interventions. Although drug coated balloons have overcome limitations associated with plain old balloon angioplasty and peripheral stents, recent safety concerns and cost considerations have impacted their usage. In this review, various liquid drug delivery devices are presented, showcasing their capabilities and success in both preclinical and clinical settings. These innovative liquid delivery devices, capable of targeted delivery and their ability to be re-used for multiple treatment sites, may provide solutions for current unmet clinical needs.

Current Status of and Future Prospects for Drug-Eluting Stents and Scaffolds in Infrapopliteal Arteries

Background: Chronic limb-threatening ischaemia can be a debilitating disease and may result in limb amputation if untreated. Atherosclerotic disease of the infra-popliteal arteries is particularly challenging to treat due to the small caliber of the vessels and the heavy burden of atherosclerotic plaque. Percutaneous transluminal angioplasty is the conventional first-line approach and is advantageous due to its minimal invasiveness, repeatability, and cost-effectiveness but is limited by high rates of elastic recoil, dissection, and short- to mid-term re-stenosis. Methods: This review analyses the growing body of published and presented clinical data from multiple randomised controlled trials that have investigated the role of coronary drug-eluting stents in the treatment of infrapopliteal disease. Results: Coronary drug-eluting stents demonstrate superior primary patency compared with angioplasty and/or bare metal stenting alone but are limited to application in short-segment disease and have not been widely adopted due to the nature of the permanent implant. Conclusions: Newer devices like drug-eluting resorbable scaffolds are promising as they allow the restoration of vessel wall vasomotion without a residual foreign body and can be used to treat longer, complex lesions.

Surgical and Endovascular Therapies for Below-the-Knee Peripheral Arterial Disease: A Contemporary Review

Peripheral arterial disease (PAD) represents one of the most prevalent cardiovascular disease processes and carries a high burden of morbidity and mortality. Patients with chronic limb-threatening ischemia (CLTI), the most severe manifestation of PAD, have the highest rates of cardiovascular morbidity and mortality of the overall PAD population. Patients with below-the-knee (BTK) PAD have an increased propensity toward CLTI due to small-vessel caliber and the frequently comorbid conditions of end-stage renal disease and diabetes mellitus, which tend to affect small artery beds preferentially. For those with BTK PAD with CLTI, the standard of care is revascularization. Early revascularization was performed using surgical bypass. However, endovascular techniques, starting with percutaneous transluminal angioplasty and expanding to the modern armamentarium of adjunctive devices and therapies, have become standard of care for most patients with CLTI due to BTK PAD. In this review, we will discuss the modern surgical and endovascular approaches to revascularization, as well as devices that are currently in development or preapproval study for the treatment of BTK PAD.

The Efficacy of Drug-Coated Balloons and Drug-Eluting Stents in Infrapopliteal Revascularization: A Meta-analysis

OBJECTIVE

The study aimed to compare the effectiveness of drug-coated balloon (DCB) and drug-eluting stents (DESs) to standard endovascular techniques like percutaneous transluminal angioplasty (PTA) and bare metal stent (BMS) for treating infrapopliteal artery disease.

METHODS

Including 8 DCB trials and 4 DES trials, this meta-analysis of 12 recent randomized controlled trials (RCTs) is comprehensive. We searched MEDLINE, EMBASE, Science of Web, Cochrane, and PubMed for this meta-analysis. We searched these databases for papers from their inception to February 2023. We also analyzed the references given in the listed studies and any future study that cited them. No language or publication date restrictions were applied to the 12 RCTs. The experimental group includes 8 DCB studies and 4 DES investigations, the DCB group is primarily concerned with the paclitaxel devices, whereas the DES group is preoccupied with the "-limus" devices. Key clinical outcomes in this study were primary patency and binary restenosis rates. This study's secondary outcomes are late lumen loss (LLL), clinically-driven target lesion revascularization (CD-TLR), limb amputation, and all-cause mortality. The evidence quality was assessed using Cochrane risk-of-bias. The PROSPERO registration number for this study is CRD42023462038.

FINDINGS

Only 108 of 1152 publications found satisfied qualifying criteria and contained data. All 13 RCTs have low to moderate bias. Drug-coated balloons and DESs were compared in the excluded study. The analysis comprised 2055 participants from 12 RCTs that met the inclusion criteria, including 1417 DCB patients and 638 DES patients. Drug-coated balloons outperform traditional methods in short-term monitoring of primary patency, binary restenosis, and CD-TLR. The benefits fade over time, and the 2 techniques had similar major amputation rates, mortality rates, and LLL. Drug-eluting stents outperform conventional procedures in primary patency, binary restenosis, and CD-TLR during medium-term to short-term follow-up. Comparing the 2 methods, major and minor amputations, death rate, and LLL were similar.

CONCLUSION

Comparison of DES and DCB with PTA or BMS shows that DES had better follow-up results. DCB has positive short-term results, but long-term effects differ, however, more research is needed to determine when DES and DCB should be used in medical procedures.

CLINICAL IMPACT

The provision of additional evidence to substantiate the advancement of drug-coated balloon (DCB) therapy in the treatment of lower limb arteriosclerosis obliterans, particularly in the below-the-knee area characterized by high calcium load and significant occlusion, is comparable in efficacy to conventional procedures. This finding is advantageous for the progress of interventional revascularization. The advancement and efficacy of DCB have resulted in improved treatment outcomes for medical practitioners in clinical settings. Our research incorporates the most recent randomized experiments.

Comparation of drug-eluting stents and control therapy for the treatment of infrapopliteal artery disease: a Bayesian analysis

BACKGROUND

Critical limb-threatening ischaemia is a life-threatening disease which often combines with infrapopliteal arterial disease. Percutaneous transluminal angioplasty (PTA) is recommended as the first-line treatment for infrapopliteal arterial disease. Drug-eluting stent (DES) is another widely used option; however, its long-term therapeutic effect is controversial. The effectiveness of different DES for infrapopliteal arterial disease needs further exploration.

METHODS AND RESULTS

The PubMed, EMBASE, Cochrane Library and Clinical trials were systematically searched from inception to 1 February 2023. Literatures were included if the study was original, peer-reviewed, published in English or Chinese, and contained patients diagnosed with simple infrapopliteal arterial disease or with properly treated combined inflow tract lesions before or during the study procedure. A total of 953 patients, 504 in the DES group and 449 in the PTA/bare-metal stenting (BMS) group, from 12 randomised controlled trials were included in the meta-analysis. The results showed that DES is superior to control group for improving clinical patency, reducing the restenosis rate, and reducing the amputation rate at 6 months, 1 year, and 3 years post-treatment [at 3 years, risk ratio (RR): 1.90, 95% CI 1.23-2.93; RR: 0.87, 95% CI 0.79-0.96; RR: 0.60, 95% CI 0.36-1.00, P =0.049]. In addition, subgroup analyses suggested that DES is superior to BMS and PTA in improving clinical patency and reducing target lesion revascularisation and restenosis rates at 6-month and 1-year post-treatment. The network meta-analysis indicated that sirolimus-eluting stent was superior for improving clinical patency (at 1 year, RR: 0.23, 95% CI 0.08-0.60) and reducing the restenosis rate (at 6 months, RR: 31.58, 95% CI 4.41-307.53, at 1 year, RR: 3.80, 95% CI 1.84-8.87) significantly. However, according to the cumulative rank probabilities test, everolimus-eluting stent may have the lowest target lesion revascularisation rates and amputation rates at 1-year post-treatment (the cumulative rank probability was 77% and 49%, respectively).

CONCLUSIONS

This systematic review and network meta-analysis showed that DES was associated with more clinical efficacy than PTA/BMS significantly. In addition, sirolimus-eluting stent and everolimus-eluting stent may have better clinical benefits.

Endovascular Interventions for Peripheral Artery Disease: A Contemporary Review

PURPOSE OF REVIEW

Peripheral artery disease (PAD) is an increasingly prevalent but frequently underdiagnosed condition that can be associated with high rates of morbidity and mortality. While an initial noninvasive approach is the cornerstone of management, revascularization is often pursued for patients with treatment-refractory claudication or chronic limb-threatening ischemia (CLTI). In this review, we discuss the current state of endovascular interventions for PAD and explore the many new emerging technologies.

RECENT FINDINGS

The last decade has resulted in numerous advances in PAD interventions including the ongoing evolution of drug-coated devices, novel approaches to complex lesions, and contemporary evidence from large clinical trials for CLTI. Advances in endovascular management have allowed for increasingly complex lesions to be tackled percutaneously. Future directions for the field include the continued evolution in device technology, continued development of state-of-the-art techniques to revascularization of complex lesions, and increased collaboration between a largely multidisciplinary field.

A Bayesian network meta-analysis for acute thrombosis after lower extremity artery endovascular treatment

BACKGROUND

Various endovascular treatment devices have been widely used in the lower extremity arterial disease (LEAD). Their patency efficiency for target lesions has been well studied and reported. Comparison of the risk of acute thrombosis events between the different endovascular treatment devices is unclear.

AIMS

To rank the risk of acute thrombosis events when bare metal stents (BMSs), covered stents (CSs), drug-eluting stents (DESs), drug-coated balloons (DCBs), and conventional percutaneous transluminal balloon angioplasty (PTA) are used to treat LEAD through Bayesian network meta-analysis.

METHODS

We performed a network meta-analysis of randomized controlled trials comparing the risk of 1-year postoperative acute thrombosis between BMSs, CSs, DESs, DCBs, and PTA for treating LEAD. Bayesian random models were used for pooled endovascular treatment modality comparisons. We ranked these treatment modalities via the Bayesian method according to their surface under the cumulative ranking curve (SUCRA) and estimated probabilities.

RESULTS

Nineteen studies (38 study arms; 2758 patients) were included. The Bayesian network ranking of treatments indicated that DCB had the lowest risk of acute thrombosis, PTA had the second-lowest risk of thrombosis, and CS, BMS, and DES had the highest risk of thrombosis. Regarding the treatment efficacy, the OR values of the loss of primary patency were significantly lower for DCB (OR = 0.44, 95% CI: 0.30-0.62), DES (OR = 0.36, 95% CI: 0.14-0.94), and CS (OR = 0.31, 95% CI: 0.18,0.56) than for PTA. When BMS was used as a reference, only the OR for CS was significantly lower (OR = 0.41, 95% CI = 0.21-0.82). Correspondingly, the Bayesian ranking of treatments from better to worse target lesion primary patency was CS, DES, DCB, BMS, and PTA.

CONCLUSION

With the available research evidence and according to the network analysis ranking, DES appears to have the highest risk of acute thrombosis and DCB appears to have the lowest risk.

Advanced Endovascular Techniques for Limb Salvage

As the number of patients affected by peripheral arterial disease continues to increase, new technical approaches and devices have been developed to provide effective and durable treatment options that will lead to improved outcomes. While the mainstay of endovascular intervention remains mostly balloon-based, several innovative techniques and technologies are in development that may provide new solutions. This review highlights recent endovascular advancements in the management of chronic limb-threatening ischemia and additional adjunctive devices that are needed to improve lesion patency, reduce the need for reintervention, and lead to better patient-centered functional outcomes.

Peripheral Arterial Disease: A Narrative Review

Peripheral arterial disease (PAD) describes the partial or complete occlusion of blood flow in the distal arteries of the body. A decreased arterial patency may occur due to a reduction in the elasticity or diameter of the vessel. The goal of interventions is to decrease incidence and reduce complications by identifying and minimizing the primary causes. This paper discusses PAD affecting the aortoiliac, common femoral, and femoropopliteal arteries. In a significant portion of the population, PAD may lack usual symptoms such as limb pain, claudication, and diminished pulses. Imaging techniques become crucial to ensuring timely diagnosis, monitoring treatment effectiveness, and preventing recurrence. Duplex ultrasound (DUS) is a cheap and non-invasive preliminary technique to detect atherosclerotic plaques and grade arterial stenosis. Magnetic resonance angiography (MRA) provides the added advantage of minimizing artifacts. Digital subtraction angiography (DSA) remains the gold standard for grading the degree of stenosis but is only employed second-line to DUS or MRA due to the high dose of nephrotoxic contrast. Computed tomography angiography (CTA) is able to overcome the anatomical limitations of DUS and MRA and proves to be a suitable alternative to DSA in patients with renal disease. Preventative measures involve monitoring blood pressure, cholesterol levels, and tobacco usage. First-line treatment options include endovascular procedures as well as surgical interventions in cases of significant arterial involvement. Endovascular treatments involve the use of balloon angioplasty, drug-coated balloons, and drug-coated stents, to name a few, that serve as minimally invasive techniques to manage PAD. Surgical procedures, although more complex, are considered gold-standard treatment options for long and intricate lesions. Endovascular methods are generally preferred over surgical options as the complication risk is severely reduced and the rates of reintervention are comparable to surgical options.

Effectiveness and Safety of Atherectomy versus Plain Balloon Angioplasty for Limb Salvage in Tibioperoneal Arterial Disease

PURPOSE

To evaluate the effectiveness and safety of atherectomy versus plain balloon angioplasty (POBA) for treatment of critical limb ischemia (CLI) due to tibioperoneal arterial disease (TPAD).

MATERIALS AND METHODS

Patients enrolled in the Vascular Quality Initiative registry who had CLI (Rutherford Class 4-6) and underwent atherectomy versus POBA alone for isolated TPAD were retrospectively identified. Of eligible patients, a cohort of 2,908 patients was propensity matched 1:1 by clinical and angiographic characteristics. The atherectomy group comprised 1,454 patients with 2,183 arteries treated, and the POBA group comprised 1,454 patients with 2,141 arteries treated. The primary study endpoint was major ipsilateral limb amputation. Secondary endpoints were minor ipsilateral amputations, any ipsilateral amputation, primary patency, target vessel reintervention (TVR), and wound healing at 12 months.

RESULTS

The median follow-up period was 507 days, the mean patient age was 69 years ± 11.7, and the mean occluded length was 6.9 cm ± 6.5. There was a trend toward higher technical success rates with atherectomy than with POBA (92.9% vs 91.0%, respectively; P = .06). The rates of major adverse events during the procedure were not significantly different. The 12-month major amputation rate was similar in the atherectomy and POBA groups (4.5% vs 4.6%, respectively; P = .92; odds ratio, 0.97; 95% CI, 0.68-1.37). There was no difference in 12-month TVR (17.9% vs 17.8%; P = .97) or primary patency (56.4% vs 54.5%; P = .64) between the atherectomy and POBA groups.

CONCLUSIONS

In a large national registry, treatment of CLI from TPAD using atherectomy versus POBA showed no significant differences in procedural adverse events, major amputations, TVR, or vessel patency at 12 months.

Underutilization of Drug-Eluting Stents in Infrapopliteal Intervention for Chronic Limb-Threatening Ischemia

PURPOSE

Multiple randomized clinical trials have shown superiority of drug-eluting stents (DES) over bare-metal stents (BMS) for infrapopliteal disease. However, real-world data on DES utilization and outcomes in infrapopliteal chronic limb-threatening ischemia (CLTI) patients are unknown.

MATERIALS AND METHODS

We utilized the Nationwide Readmission Database (NRD) from 2016 to 2017 to extract patients undergoing infrapopliteal intervention with stents (BMS and DES) for CLTI using appropriate ICD-10 codes. Multilevel logistic regression with hospital ID as random effect was used to assess DES utilization. Primary outcome was the composite of target limb major amputation (TLmajA) and target limb revascularization (TLR). Multivariate Cox-proportional hazard regression was used to adjust for confounders.

RESULTS

Our study included a total of 1817 patients. Of these patients, 1056 patients (58.1%) received DES; DES utilization was stable (relative change: +2.5%, p-trend: 0.867) between 2016 and 2017 and was higher in teaching hospitals (adjusted odds ratio [aOR] = 1.28, 95% CI = 1.03-1.61, p=0.029] and medium (aOR = 3.13, 95% CI = 2.17-4.55, p≤0.001) and large (aOR = 1.56, 95% CI = 1.14-2.17, p=0.005) bed-sized hospitals. Inter-class correlation was 0.44 suggesting ~44% variation in DES utilization between any 2 random hospitals; DES was associated with lower rate of the primary composite outcome (aHR = 0.75, 95% CI = 0.62-0.92, p=0.004) compared with BMS.

CONCLUSION

In patients undergoing infrapopliteal intervention for CLTI, DES demonstrated significant underutilization despite supportive evidence of their superiority compared with BMS; DES was associated with improvement in the primary composite outcome compared with BMS.

The efficacy and safety of different endovascular modalities for infrapopliteal arteries lesions: A network meta-analysis of randomized controlled trials

BACKGROUND

Endovascular treatment has become the first-line therapy for infrapopliteal artery occlusive disease (IPOD), while the optimal endovascular method remains to be determined. We performed a network meta-analysis (NWM) of randomized controlled trials (RCTs) to simultaneously compare the outcomes of different endovascular modalities for IPOD.

METHODS AND RESULTS

The Pubmed, Embase, and Cochrane databases were used as data sources. The NWM approach used random-effects models based on the frequentist framework. In total, 22 eligible RCTs (44 study arms; 1,348 patients) involving nine endovascular modalities or combinations [balloon angioplasty (BA), drug-coated balloon (DCB), drug-eluting stent (DES), atherectomy device + BA (AD + BA), AD + DCB, balloon-expandable bare metal stent (BMS), self-expanding stent (SES), absorbable metal stents (AMS), and inorganics-coated stent (ICS)] were included. BA had a lower 12-month primary patency rate than DCB (RR 0.50, CI 0.27, 0.93) and AD + DCB (RR 0.34, CI 0.12, 0.93). AD + DCB decreased 6-month TLR compared with AMS (RR 0.15, CI 0.03, 0.90), and DES decreased it compared with BMS (RR 0.25, CI 0.09, 0.71). DCB had a lower 6-month TLR rate than AMS (RR 0.26, CI 0.08, 0.86) and BA (RR 0.51, CI 0.30, 0.89). BA had a higher 12-month TLR rate than DCB (RR 1.76, CI 1.07, 2.90). According to the value of the surface under the cumulative ranking curve (SUCRA), AD + DCB was considered the best treatment in terms of primary patency at 6 months (SUCRA = 87.5) and 12 months (SURCA = 91). AD + BA was considered the best treatment in terms of 6-month TLR (SUCRA = 83.1), 12-month TLR (SURCA = 75.8), and 12-month all-cause mortality (SUCRA = 92.5). In terms of 12-month major amputation, DES was considered the best treatment (SUCRA = 78.6), while AD + DCB was considered the worst treatment (SUCRA = 28.8). Moreover, AD + BA always ranks higher than AD + DCB in the comparison including these two combinations. Subgroup analyses of modalities without stenting did not significantly change the primary outcomes.

CONCLUSION

ADs showed noteworthy advantages in multiple terms for IPOD except for 12-month major amputation. AD + BA may be a better method for IPOD than AD + DCB. The efficacy and safety of ADs are worthy of further investigation.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022331626].

Paclitaxel-coated balloons versus percutaneous transluminal angioplasty for infrapopliteal chronic total occlusions: the IN.PACT BTK randomised trial

BACKGROUND

Data are mixed concerning the safety and effectiveness of drug-coated balloons (DCBs) for treating below-the-knee (BTK) lesions.

AIMS

The aim of this study was to assess the safety and effectiveness of the IN.PACT 014 paclitaxel-coated balloon catheter versus conventional percutaneous transluminal angioplasty (PTA) for infrapopliteal chronic total occlusions (CTOs) in patients with chronic limb-threatening ischaemia (CLTI).

METHODS

The IN.PACT BTK randomised study is a prospective, multicentre, randomised pilot study. Fifty CLTI participants (Rutherford clinical category 4-5) with BTK CTOs were randomised 1:1 to DCB (N=23) or PTA (N=27). The primary effectiveness endpoint was late lumen loss (LLL) at 9 months post procedure. Safety outcomes up to 9 months included all-cause mortality, major target limb amputation, and clinically driven target lesion revascularisation (CD-TLR).

RESULTS

Mean lesion length was 215.41±83.81 mm in the DCB group and 218.19±80.43 mm for PTA (p=0.806). The 9-month angiographic LLL was 0.892±0.774 mm for the DCB group and 1.312±0.720 mm for the PTA group (p=0.070) in a classic analysis, and 0.592±0.944 mm for DCB and 1.260±0.810 mm for PTA (p=0.017) in a subsegmental analysis. The Kaplan-Meier estimated freedom from CD-TLR up to 9 months was 91.1% for DCB and 91.8% for PTA (log-rank p=0.942). At 9 months, 1 patient died in the DCB group and 2 in the PTA group (p=1.000); there were no major target limb amputations in either arm.

CONCLUSIONS

The 9-month subsegmental LLL was lower after treatment with the IN.PACT 014 DCB compared with PTA with no differences in safety or revascularisation events in a small complex population of patients with BTK CTOs.

CLINICALTRIALS

gov: NCT02963649.

Drug-Eluting Stents Versus Conventional Endovascular Therapies in Symptomatic Infrapopliteal Peripheral Artery Disease: A Meta-analysis

Background

Balloon angioplasty is the standard endovascular treatment for symptomatic infrapopliteal peripheral artery disease (PAD). However, recent trials have studied the effectiveness of drug-eluting stents (DES) for infrapopliteal PAD.

Objective

This study investigated the use of DES compared with standard endovascular techniques for treatment of infrapopliteal artery disease.

Methods

This is a comprehensive systematic review and meta-analysis of 9 recent randomized controlled trials. The primary clinical outcome assessed was primary patency. The secondary outcomes were target lesion revascularization (TLR), major limb amputation, and all-cause mortality.

Results

A total of 945 patients met the inclusion criteria. Patients treated with DES were found to have increased primary patency than control at maximum follow-up (hazard ratio [HR] 2.17, 95% confidence interval [CI] 1.58-2.97, P < .0001, I2 = 62%). A similar result was seen in the subgroup of patients with critical limb ischemia (HR 2.58, 95% CI 1.49-4.49, P = .0008, I2 = 75%). DES were associated with significantly lower rates of TLR than control at maximum follow-up (HR 0.48, 95% CI 0.33-0.68, P < .0001; I2 = 11%). There was no statistical difference between DES versus control in rates of major limb amputation and mortality.

Conclusions

DES have superior primary patency and TLR rates with no difference in amputation and all-cause mortality rates compared with conventional endovascular therapies in patients with infrapopliteal PAD.

VOLume flow assistance for optimizing outcomes of dysfunctional autologous arteriovenous fistula Angioplasty: the VOLA Pilot Study

OBJECTIVES

To investigate the feasibility of VF-assisted angioplasty (VFA) in dysfunctional AVF using sequential intraprocedural duplex ultrasound (DUS), to utilize intraprocedural VF as a quantifiable, functional endpoint in endovascular treatment.

METHODS

This prospective study included 20 consecutive patients (23 lesions; 16 men; mean age 67 ± 16 years) with dysfunctional AVF undergoing fluoroscopically guided balloon angioplasty between June 2019 and May 2020. Primary endpoints were quantification of outcome using sequential DUS VF analysis following each dilation, 6-month target lesion re-intervention (TLR)-free rate, standard technical success, procedural success (achievement of a postprocedural VF value equal (or 10% less) or superior to the baseline steady-state access), and correlation between procedural success and TLR-free rate. Secondary endpoints included 6-month lesion late lumen loss (LLL), correlation between balloon diameter used and intraprocedural VF values, and correlation between VF and LLL at 6 months follow-up.

RESULTS

Mean VF increase was 168.5% ± 102.5% (range: 24.24-493.33%). Procedural success was 80% (16/20 cases). VFA improved procedural success by 20% (4/20 cases) compared to standard assessment (< 30% residual stenosis and palpable thrill). TLR-free rate was 78.3% and 67.3% at 6 and 12 months. Significantly less TLR was noted in cases of procedural success (82.4% vs. 66.7% 6 months; p = 0.041). Unweighted linear regression showed a significant positive relationship between diameter of balloon and VF (146.9 ± 42.3 mL/min VF gain per mm of balloon diameter; p = 0.001, R2 = 0.23) and a significant negative relationship between LLL and VF decline at follow-up (102.0 ± 34.6 mL/min loss per mm of LLL; p = 0.01, R2 = 0.35). Optimal VF cutoff value and percentile increase to predict access failure were 720 mL/min (sensitivity 58.3%, specificity 71.4%) and 153% (sensitivity 66.7%, specificity 85.7%), respectively.

CONCLUSION

Intraprocedural VF assessment could be used to optimize AVF angioplasty.

KEY POINTS

• A newly proposed functional endpoint of angioplasty in dysfunctional dialysis fistula was evaluated and angioplasty outcome was quantified using volume flow (VF) assessment with sequential intraprocedural DUS. • Intraprocedural VF assessment improved immediate procedural success; increased balloon diameter was correlated with VF gain and late lumen loss with VF decline. • Intraprocedural VF values ≥ to baseline steady-state values were correlated with less re-interventions.

Implementation of innovative medical technologies in German inpatient care: patterns of utilization and evidence development

BACKGROUND

Innovative medical technologies are commonly associated with positive expectations. At the time of their introduction into care, there is often little evidence available regarding their benefits and harms. Accordingly, some innovative medical technologies with a lack of evidence are used widely until or even though findings of adverse events emerge, while others with study results supporting their safety and effectiveness remain underused. This study aims at examining the diffusion patterns of innovative medical technologies in German inpatient care between 2005 and 2017 while simultaneously considering evidence development.

METHODS

Based on a qualitatively derived typology and a quantitative clustering of the adoption curves, a representative sample of 21 technologies was selected for further evaluation. Published scientific evidence on efficacy/effectiveness and safety of the technologies was identified and extracted in a systematic approach. Derived from a two-dimensional classification according to the degree of utilization and availability of supportive evidence, the diffusion patterns were then assigned to the categories "Success" (widespread/positive), "Hazard" (widespread/negative), "Overadoption" (widespread/limited or none), "Underadoption" (cautious/positive), "Vigilance" (cautious/negative), and "Prudence" (cautious/limited or none).

RESULTS

Overall, we found limited evidence on the examined technologies regarding both the quantity and quality of published randomized controlled trials. Thus, the categories "Prudence" and "Overadoption" together account for nearly three-quarters of the years evaluated, followed by "Success" with 17%. Even when evidence is available, the transfer of knowledge into practice appears to be inhibited.

CONCLUSIONS

The successful implementation of safe and effective innovative medical technologies into practice requires substantial further efforts by policymakers to strengthen systematic knowledge generation and translation. Creating an environment that encourages the conduct of rigorous studies, promotes knowledge translation, and rewards innovative medical technologies according to their added value is a prerequisite for the diffusion of valuable health care.

Comprehensive Assessment of Current Management Strategies for Patients With Diabetes and Chronic Limb-Threatening Ischemia

Chronic limb-threatening ischemia (CLTI) is the most severe form of peripheral artery disease. It is estimated that 60% of all nontraumatic lower-extremity amputations performed annually in the United States are in patients with diabetes and CLTI. The consequences of this condition are extraordinary, with substantial patient morbidity and mortality and high socioeconomic costs. Strategies that optimize the success of arterial revascularization in this unique patient population can have a substantial public health impact and improve patient outcomes. This article provides an up-to-date comprehensive assessment of management strategies for patients afflicted by both diabetes and CLTI.

[Use of endovascular drug-coated devices in lesions of femoropopliteoltibial arteries]

Endovascular intervention is one of the main methods of treatment in atherosclerotic lesions of the infrainguinal segment in patients with chronic lower limb ischaemia. Recent years have witnessed active use of drug-eluting techniques, significantly improving the long-term outcomes of peripheral reconstructions. This article is a review of publications on the results of using modern drug-eluting balloon catheters and stents in the femoropopliteoltibial position. The accumulated data will help solve the main problems of the classic balloon angioplasty, reducing the incidence of restenosis, improving primary patency, and decreasing the need for repeat interventions in the remote period of follow-up.

Atherectomy and Drug-Coated Balloon Angioplasty for the Treatment of Long Infrapopliteal Lesions: A Randomized Controlled Trial

[Figure: see text].

Benefits with drug-coated balloon as compared to a conventional revascularization strategy for the treatment of coronary and non-coronary arterial disease: a comprehensive meta-analysis of 45 randomized trials

BACKGROUND

Drug-coated balloons (DCB) have shown promising results for the percutaneous treatment of de novo and restenotic lesions, involving both the coronary and femoropopliteal district. However, clinical outcomes data associated with the use of this devices are still unclear, with potential warnings on increased mortality being raised from initial studies. We aimed at performing an updated and comprehensive meta-analysis comparing DCB with conventional percutaneous revascularization strategies for the treatment of coronary (CAD) or peripheral artery disease (PAD).

METHODS

Literature and main scientific session abstracts were searched for studies comparing DCB vs a standard percutaneous revascularization strategy, with or without stenting, for the treatment of CAD and PAD. The primary efficacy endpoint was mortality. Secondary endpoints were recurrent acute ischemic events (myocardial infarction or amputation) or target lesion revascularization (TLR).

RESULTS

We included 45 randomized trials, (CAD: 27 studies, PAD: 18 studies) with an overall population of 7718 patients, (56.4%) randomized to a DCB strategy. At a mean follow-up of19.3 ± 15.2 months, death occurred in 5.8% of the patients, with no significant difference between DCB or conventionally treated patients (5.9% vs 5.7%, OR[95%CI] = 0.89[0.71,1.11], p = 0.31; phet = 0.43). We observed a non-significant reduction in recurrent acute ischemic events, whereas the use of DCB significantly reduced the rate of TLR, with larger benefits observed in patients with PAD and respect to balloon-only angioplasty, while being lower in comparison with stent implantation. No significant interaction was observed with de novo lesions or in-stent restenosis.

CONCLUSIONS

Based on the current meta-analysis, the use of drug-coated balloons for the percutaneous treatment of CAD and PAD is associated to a comparable risk of mortality and recurrent acute ischemic events as compared to a conventional revascularization strategy, although offering larger benefits in terms of TLR, especially when compared with balloon-only angioplasty and in femoropopliteal disease.

Factors associated with long-term graft patency after lower extremity arterial bypasses

Purpose

This study was conducted to determine factors associated with long-term graft patency after lower extremity arterial bypass (LEAB).

Methods

Database of LEABs for patients with chronic arterial occlusive disease (CAOD) at a single institution was retrospectively reviewed. To determine the factors we compared demographic, clinical, and procedural variables between 2 patient groups; group I (graft patency < 2 years) and group II (graft patency ≥ 5 years after LEAB) using univariable and multivariable analyses.

Results

Among 957 LEABs, 259 limbs (group I, 125 limbs and group II, 134 limbs) in 213 patients were included for the analysis. On a univariable analysis, younger age (69 years vs. 66 years, P = 0.024), hypertension (60.8% vs. 74.6%, P = 0.017), claudication (51.2% vs. 70.9%, P = 0.001), absence of prior intervention (50.4% vs. 73.9%, P < 0.001), common femoral artery based bypass (57.6% vs. 70.1%, P = 0.035), above-the knee bypass (36.8% vs. 64.2%, P < 0.001), postoperative graft salvage procedure (3.2% vs. 14.8%, P = 0.001), and statin use (75.2% vs. 88.8, P = 0.004) were associated with long-term patency. On a multivariate analysis hypertension (odds ratio [OR], 1.91; P = 0.038), claudication (OR, 2.08; P = 0.032), no prior intervention (OR, 2.48; P = 0.001), vein graft (OR, 4.36; P = 0.001), above-the knee bypass (OR, 4.68; P < 0.001), and graft salvage procedures (OR, 7.70; P < 0.001) were identified as independent factors.

Conclusion

These factors can be considered in decision making before treatment of patients with CAOD.

Outcomes of endovascular treatment for infrapopliteal peripheral artery disease based on the updated TASC II classification

We retrospectively analyzed all endovascular procedures of infrapopliteal arterial lesions (n = 383) performed in 270 patients at our institution between December 2008 and January 2018. The overall technical success rate was 97% and yielded 98% for stenoses (n = 214) and 95% for occlusions (n = 169). Trans-Atlantic Inter-Society Consensus (TASC II) classification had no impact on success rates (TASC A + B vs C + D; 96.5% vs 96.9%, p = 0.837). Freedom from clinically driven target lesion revascularization (TLR) after 6 and 12 months was 88.3% and 77.2%. TLR was comparable for TASC A to C lesions and no difference was observed comparing groups of moderately complex TASC A/B lesions and more complex TASC C/D lesions (TASC A + B vs C + D; 78.5% vs 74.2%, p = 0.457). Freedom from TLR was significantly lower in very complex TASC D lesions (TASC A + B + C vs D; 79.7% vs 42.5%, p < 0.001). Multivariate analysis identified TASC D lesions (hazard ratio D/A: 1.5; overall p = 0.002), Fontaine class III and IV (hazard ratio III or IV/IIa or IIb: 2.4; p = 0.041), and occlusive lesions (hazard ratio occlusion/stenosis: 2.4; p = 0.026) as predictors for TLR. In conclusion, endovascular therapy for infrapopliteal artery disease was safe and accompanied with a promising long-term outcome.

Drug-eluting balloon treatment in femoropopliteal in-stent restenosis of different lengths

Background

In this study, we present one-year results of drugeluting balloon treatment of femoropopliteal in-stent restenosis.

Methods

A total of 62 patients (48 males, 14 females; mean age 64.2±9.1 years; range, 54 to 81 years) who underwent drugeluting balloon stenting for femoropopliteal in-stent restenosis between August 2013 and October 2017 were included in the study. The patients were classified into three groups based on the narrowing length of stenosis in the stents. Group/Class 1 (n=17): narrowing <1/2 of the stent length; Group/Class 2 (n=22): narrowing >1/2 of the stent length, not totally occluded; and Group/Class 3 (n=23): totally occluded. In-stent restenosis was treated with drug-eluting balloon treatment.

Results

There was a significant difference among all classes in terms of in-stent restenosis. The length of stenosis was a predictor for in-stent restenosis. The mean stent length was 107.7±24.6 mm in Group 1, 164.6±17.9 mm in Group 2, and 180±19.3 mm in Group 3. For non-occluded in-stent restenosis, restenosis rate at one year after balloon angioplasty was 47.1% in Group 1, 86.4% in Group 2, and 95.7% in Group 3. Femoropopliteal bypass was performed in five patients in whom treatment failed. None of the patients required amputation.

Conclusion

The length of in-stent restenosis in the femoropopliteal arterial stents is an important predictor for recurrent stenosis, when re-flow is achieved with drug-eluting balloons.

Intravascular Ultrasound-Guided Interventions for Below-the-Knee Disease in Patients With Chronic Limb-Threatening Ischemia

Purpose: To assess the utility of intravascular ultrasound (IVUS) during below-the-knee (BTK) interventions for patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: This retrospective single-center study included 216 symptomatic patients (mean age 74.2±9.5 years; 167 men) with CLTI and BTK steno-occlusive disease who underwent successful balloon angioplasty between January 2016 and August 2018. Data from 88 vessels (58 patients) treated with IVUS-guided procedures were compared with corresponding values from 242 vessels (158 patients) treated with angiography-guided procedures. The primary outcomes included procedure-related variables of balloon size, contrast dose, and complication rates, as well as changes in ankle-brachial index (ABI) and skin perfusion pressure (SPP). Secondary outcomes included IVUS determination of vessel size, wire route, and calcification severity, as well as technical success and clinically-driven target lesion revascularization (TLR), limb salvage, and wound healing rates in the Rutherford category 5/6 patients as evaluated by propensity score matching analysis. Results: The patient and lesion characteristics were similar in both groups. The mean balloon size for IVUS-guided procedures was significantly larger (2.45±0.4 mm) compared with that for angiography-guided procedures (2.23±0.4 mm; p<0.001). The technical success (p=0.56) and complication rates (p=0.16) were similar between the groups. The postprocedure dorsal and plantar SPP and change in dorsal SPP improved more in the IVUS-guided group (p<0.001, p=0.015, and p=0.02, respectively). The IVUS-guided group had a significantly better wound healing rate than the angiography-guided group (p=0.006), although the freedom from TLR and limb salvage rates were similar between the groups (p=0.16 and p>0.99, respectively). Conclusion: IVUS-guided interventions for BTK lesions were safe and effective in accurately assessing the lesions. The results suggest that IVUS guidance of endovascular procedures has the potential to influence better clinical outcomes than angiography-guided angioplasty.

Balloon Angioplasty of Infrapopliteal Arteries: A Systematic Review and Proposed Algorithm for Optimal Endovascular Therapy

Endovascular revascularization has been increasingly utilized to treat patients with chronic limb-threatening ischemia (CLTI), particularly atherosclerotic disease in the infrapopliteal arteries. Lesions of the infrapopliteal arteries are the result of 2 different etiologies: medial calcification and intimal atheromatous plaque. Although several devices are available for endovascular treatment of infrapopliteal lesions, balloon angioplasty still comprises the mainstay of therapy due to a lack of purpose-built devices. The mechanism of balloon angioplasty consists of adventitial stretching, medial necrosis, and dissection or plaque fracture. In many cases, the diffuse nature of infrapopliteal disease and plaque complexity may lead to dissection, recoil, and early restenosis. Optimal balloon angioplasty requires careful attention to assessment of vessel calcification, appropriate vessel sizing, and the use of long balloons with prolonged inflation times, as outlined in a treatment algorithm based on this systematic review. Further development of specific devices for this arterial segment are warranted, including devices for preventing recoil (eg, dedicated atherectomy devices), treating dissections (eg, tacks, stents), and preventing neointimal hyperplasia (eg, novel drug delivery techniques and drug-eluting stents). Further understanding of infrapopliteal disease, along with the development of new technologies, will help optimize the durability of endovascular interventions and ultimately improve the limb-related outcomes of patients with CLTI.

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee

BACKGROUND

Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD.

OBJECTIVES

The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD.

METHODOLOGY

A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique.

RESULTS

A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.

Mortality in patients undergoing revascularization with paclitaxel eluting devices for infrainguinal peripheral artery disease: Insights from a network meta-analysis of randomized trials

OBJECTIVES

We aimed to evaluate whether paclitaxel eluting devices increased the risk of death in patients undergoing revascularization for infrainguinal peripheral artery disease using network meta-analyses.

METHODS

PUBMED and EMBASE were searched through April 2020 for randomized trials in patients with infrainguinal peripheral artery disease who underwent revascularization with or without a paclitaxel eluting device (balloon/stent). Short-term mortality defined as death at 6-12 months, and long-term mortality defined as death at >12 months after revascularization.

RESULTS

Our search identified 57 eligible randomized controlled studies enrolling a total of 9,362 patients comparing seven revascularization strategies (balloon angioplasty vs. bare metal stent vs. covered stent vs. paclitaxel eluting stent vs. other drug eluting stent vs. paclitaxel-coated balloon vs. bypass surgery). Overall, paclitaxel eluting stent and paclitaxel-coated balloons did not increase short-term mortality (eg, vs. balloon angioplasty: paclitaxel-coated balloon OR [95% CI] 1.21 [0.88-1.66], p = .24; paclitaxel eluting stent OR [95%CI] 1.01 [0.63-1.63], p = .97, respectively). In addition, paclitaxel eluting stent did not show significant increase in long-term mortality (eg, vs. balloon angioplasty: OR [95%CI] 1.06 [0.70-1.59], p = .79). However, paclitaxel-coated balloon showed significant increase in long-term mortality compared to balloon angioplasty and bypass (vs. balloon angioplasty: OR [95% CI] 1.48 [1.06-2.07], p = .021; vs. bypass: OR [95%CI] 1.73 [1.05-2.84], p = .031, respectively).

CONCLUSIONS

In this meta-analysis of randomized trials, there was no significant increase in mortality with paclitaxel eluting stent, but there was increased risk of long-term mortality in paclitaxel-coated balloon for the treatment of infrainguinal peripheral artery disease.

Current developments in endovascular therapy of peripheral vascular disease

More than 200 million people worldwide have peripheral artery disease (PAD) or its most severe manifestation, critical limb ischemia (CLI). While endovascular treatment has become first line therapy in most cases, a number of challenges remain for optimal treatment of femoropopliteal (FP) or infrapopliteal (IP) disease, especially when these lesions are severely calcified, chronic total occlusions (CTOs) or in-stent restenosis (ISR). Continued evolution of technologies has significantly improved the outcomes for endovascular treatment. A number of new devices are in the pipeline right now, including new paclitaxel eluting stents and balloons, intravascular lithotripsy to treat severely calcified lesions, adventitial delivery of anti-restenotic agents to limit restenosis rates, and percutaneous femoro-popliteal bypass.

Diagnostic and Therapeutic Approaches in the Management of Infrapopliteal Arterial Disease

Chronic limb-threatening ischemia represents end-stage peripheral artery disease. It is underdiagnosed; it relies on clinical symptoms and traditional noninvasive tests, which significantly underestimate the severity of disease. Innovative techniques, approaches, technologies, and risk-assessment tools have significantly improved our ability to treat these patients and to better understand their complex disease process. For patients with chronic limb-threatening ischemia considered without options, the reengineering of deep venous arterialization procedures has shown promising results. Finally, the creation of interactive and multidisciplinary teams in centers of excellence is of paramount importance to significantly improve the care and outcomes of these patients.

A universal drug delivery catheter for the treatment of infrapopliteal arterial disease using liquid therapy

OBJECTIVE

The objective of this study was to investigate the safety and feasibility of treating infrapopliteal lesions using a novel drug delivery catheter locally delivering liquid paclitaxel.

BACKGROUND

Balloon angioplasty is currently the Gold Standard to treat below-the-knee disease; however, restenosis continues to be a great challenge following these percutaneous revascularization procedures.

METHODS

The Occlusion Perfusion Catheter for Optimal Delivery of Paclitaxel for the Prevention of Endovascular Restenosis (COPPER-A) study-Below-the-Knee Cohort was a prospective, nonrandomized, multicenter, feasibility, and safety study that enrolled 35 patients at 11 participating sites. The safety endpoints at 1, 3, and 6 months were freedom from thrombosis, major amputation in the target limb and target limb related death. The efficacy endpoints were primary patency and freedom from clinically driven target lesion revascularization at 6 months.

RESULTS

All patients tolerated the procedure well with no reports of adverse procedural events. Thirty-five patients were treated with a mean lesion length of 112 ± 81.2 mm with the lesion length range of 20-286 mm. At 6-month follow-up, primary patency was 89.3% and freedom from clinically driven target lesion revascularization was 96.4%. No patients demonstrated thrombosis, major amputation in the target limb and target limb related death at the 1-, 3- and 6-months follow-up intervals.

CONCLUSIONS

The results of this multi-center study demonstrated that infrapopliteal arteries can be safely and effectively treated with liquid paclitaxel using the occlusion perfusion catheter.

Efficacy and Safety of TurboHawk Plaque Rotation Combined With Drug-coated Balloon in Treating Diabetic Patients With Lower Extremity Arterial Disease

To evaluate the efficacy and safety of TurboHawk plaque rotation system combined with drug-coated balloon in treating lower extremity arterial disease (LEAD) of diabetes patients, a total of 145 diabetic patients with LEAD from March 2015 to September 2016 were recruited in our study. Lower extremity arterial disease was diagnosed by ultrasound and CT angiography (CTA). According to the surgical method, 65 cases underwent TurboHawk plaque rotation combined with drug-coated balloon (group A), 80 cases underwent simple drug-coated balloon expansion (group B). The characteristics of lesion, function test, ankle-brachial index (ABI), and postoperative complications were analyzed. All the patients were followed up at 1, 3, 6, 12, and 24 months after operation. At baseline, there was no difference in all the characteristics between the 2 groups. The early postoperation minimum lumen diameter (MLD), lumen stenosis rate, and ABI in 2 groups both improved. As the follow-up time increased, patients in group A had significantly higher MLD and ABL value, as well as lower level of lumen stenosis rate, restenosis rate, late lumen loss, and target lesion revascularization (all P < .05). Accordingly, functional testing revealed the 6-minute walk distance, 6-minute claudication distance, resting ABI, and post-exercise ABI in group A were significantly higher than those in group B (all P < .05). Besides, major graft reintervention (4.62% vs 11.25%) and major adverse limb events (6.15% vs 12.5%) in group A occurred less frequently than group B (all P < .05). In conclusion, the long-term effect of the combined approach was better than only drug-coated balloon in LEAD in Chinese diabetes patients.

Cost-Effectiveness of Drug-Eluting Stents for Infrapopliteal Lesions in Patients with Critical Limb Ischemia: The PADI Trial

PURPOSE

Drug-eluting stents (DES) improve clinical and morphological long-term results compared to percutaneous transluminal angioplasty (PTA) with bailout bare metal stenting (BMS) in patients with critical limb ischemia (CLI) and infrapopliteal lesions (PADI trial). We performed a cost-effectiveness analysis of DES compared to PTA ± BMS in cooperation with Dutch health insurance company VGZ, using data from the PADI trial.

MATERIALS AND METHODS

In the PADI trial, adults with CLI (Rutherford category ≥ 4) and infrapopliteal lesions were randomized to receive DES with paclitaxel or PTA ± BMS. Seventy-four limbs (73 patients) were treated with DES and 66 limbs (64 patients) with PTA ± BMS. The costs were calculated by using the mean costs per stent multiplied by the mean number of stents used per patient (€750 × 1.8 for DES vs €250 × 0.3 for PTA ± BMS). These costs were compared with the costs of major amputation (€16.000) and rehabilitation (first year €15.750, second year €7.375 and third year €3.600).

RESULTS

The 5-year major amputation rate was lower in the DES group (19.3% vs 34.0% for PTA ± BMS; p = 0.091). In addition, the 5-year amputation-free survival and event-free survival were significantly higher in the DES group (31.8% vs 20.4%, p=0.043; and 26.2% vs 15.3%, p=0.041, respectively). After 1 year, the cost difference per patient between DES and PTA ± BMS is €1.679 in favor of DES and €2.694 after 3 years.

CONCLUSION

In our analysis, DES are cost-effective due to the higher hospital costs of amputation and rehabilitation in the PTA ± BMS group.

LEVEL OF EVIDENCE

Level 1b, analysis based on clinically sensible costs and randomized controlled trial.

A Network Meta-analysis of Randomized Controlled Trials Comparing Treatment Modalities for Infrapopliteal Lesions in Critical Limb Ischemia

BACKGROUND

We aimed to conduct a network meta-analysis of randomized controlled trials comparing treatment modalities for infrapopliteal lesions in critical limb ischemia.

METHODS

Five treatments for infrapopliteal lesions in critical limb ischemia were recognized. We compared primary patency, target lesion revascularization (TLR), major amputation at the 12-month follow-up, and technical success rate of the treatment modalities.

RESULTS

Altogether, 11 studies (22 study arms; 1,330 patients) were considered eligible. The drug-eluting balloon (DEB) significantly increased primary patency compared with balloon angioplasty (BA; odds ratio [OR] 9.02, 95% confidence interval [CI] 3.18-25.55), the bare metal stent (BMS; OR 14.39, 95% CI 4.33-47.87), and the drug-eluting stent (DES; OR 3.70, 95% CI 1.20-11.11). The DES significantly increased primary patency compared with BA (OR 2.42, 95% CI 1.57-3.74) and BMS (OR 3.86, 95% CI 2.24-6.65). DES significantly increased the technical success rate compared with BA (OR 11.78, 95% CI 1.42-97.59). According to the value of the surface under the cumulative ranking curve (SUCRA), DEB was considered the best treatment in terms of primary patency (SUCRA = 99.7) and TLR (SUCRA = 70.7), and DES was considered the best treatment in terms of technical success rate (SUCRA = 90.6) and major amputation (SUCRA = 85.9).

CONCLUSIONS

DEB has shown encouraging results in terms of primary patency for infrapopliteal lesions in critical limb ischemia; furthermore, DEB may be better than other treatments in terms of TLR. DES may be better than other treatments in terms of technical success and major amputation. In contrast, BA and BMS seem to be less effective treatment options.

Endovascular Revascularization Incorporating Infrapopliteal Coronary Drug-Eluting Stents Improves Clinical Outcomes in Patients with Critical Limb Ischemia and Tissue Loss

BACKGROUND

Critical limb ischemia (CLI) involving infrapopliteal arterial atherosclerosis and tissue loss remains a formidable clinical scenario with significant morbidity and mortality. Despite level IA evidence, tibial revascularization with coronary drug-eluting stents (DES) remains a seldom-used technique in the United States due, in part, to lack of a Food and Drug Administration-approved indication and dedicated stent technology for infrapopliteal application. Furthermore, follow-up data beyond 1 year remain scarce, and further evidence for improvement in clinical outcomes using this technique is needed. Herein, we present our multi-institutional experience with endovascular revascularization of patients with CLI and tissue loss using coronary DES for infrapopliteal lesions of appropriate dimensions and the Wound, Ischemia, and foot Infection (WIfI) score as supportive evidence for improvement in clinical outcomes.

METHODS

In this retrospective study, 40 sequential tibial revascularization procedures performed in 32 patients with CLI were reviewed. Outcomes including changes in WIfI scores, patency rates, freedom from major amputation, target lesion recurrence, and all-cause mortality were analyzed. Average follow-up duration was 19.3 months (interquartile range: 7-27.1 months).

RESULTS

Freedom from major amputation was 88.6%. One-year primary patency was 90.3%. Mean ankle-brachial indices increased after revascularization (0.57 ± 0.26 to 0.97 ± 0.26; P = 0.03). All components of the WIfI score significantly improved after revascularization (W: 1.9 to 1.1, P = 0.03; I: 2.0 to 0.6, P = 0.001; and fI: 1.5 to 0.8, P = 0.01). WIfI risk of major amputation score before revascularization was 3.58 ± 0.75 (high risk), which was reduced to 2.04 ± 1.31 (low risk; P < 0.001). One-year survival rate was 90.6%.

CONCLUSIONS

Coronary DES continue to demonstrate promising primary patency and limb salvage rates in appropriately selected patients undergoing multilevel endovascular revascularization for CLI and tissue loss. In addition to its value as a predictor for major amputation and revascularization benefit, the WIfI score can also serve as a multicomponent tool for objective assessment of outcomes after revascularization.