Low-Dose vs High-Dose Paclitaxel-Coated Balloons for Femoropopliteal Lesions

Comparison of 2 Paclitaxel-Coated Balloons with Different Excipients for the Treatment of Femoropopliteal Artery Disease: A Randomized Prospective Trial

PURPOSE

To evaluate the effectiveness and safety of a novel drug-coated balloon (DCB), Genoss DCB (Genoss), using shellac plus vitamin E as an excipient, compared with a reference DCB using urea.

MATERIALS AND METHODS

Patients with femoropopliteal arterial disease under Rutherford Classes 2-5 were enrolled in this prospective, multicenter, noninferiority clinical trial and randomly assigned 1:1 to Genoss DCB and IN.PACT Admiral (Medtronic, Dublin, Ireland). The primary endpoint was late lumen loss at 6 months, which was evaluated using computed tomography (CT) angiography by an independent investigator blinded to the treatment assignment.

RESULTS

A total of 119 patients from 10 institutions in the Republic of Korea were assigned to the Genoss DCB (n = 59) and IN.PACT Admiral (n = 60) groups. The late lumen losses were -0.08 mm (SD ± 0.59) in the Genoss DCB group and 0.02 mm (SD ± 0.72) in the IN.PACT Admiral group (P = .469). The upper limit of the 1-sided 97.5% confidence interval for differences in late lumen loss was 0.17 mm, lower than the noninferiority limit of 0.50 mm, demonstrating the noninferiority of Genoss DCB compared with IN.PACT Admiral. In addition, the 2 groups showed no significant differences in clinically-driven target lesion revascularization, major amputation, and all-cause mortality.

CONCLUSIONS

The safety and 6-month late lumen loss of a new DCB using shellac plus vitamin E as excipients were noninferior compared with those of the reference DCB using urea as the excipient.

Comparing the Clinical Performance of High-Dose and Low-Dose Drug-Coated Balloons for Long Femoropopliteal Artery Disease: Results of the SATELLITE Study

BACKGROUND

Previous studies have shown comparable outcomes between first-generation high-dose drug-coated balloon (HD-DCB) and second-generation low-dose drug-coated balloon (LD-DCB) for femoropopliteal artery disease. However, data about the clinical performances of these DCBs for longer lesions in real-world clinical settings are limited.

METHODS

In this multicenter, retrospective study, the clinical performances of the HD-DCB (IN.PACT, Medtronic, MN, USA) and the LD-DCB (Ranger, Boston, MA, USA) were assessed in cases of femoropopliteal artery disease with lesion length ≥ 150 mm. From the database, 288 lesions in 288 patients were assigned to the HD-DCB group, and 88 lesions in 88 patients were assigned to the LD-DCB group. Propensity score-matching analysis was performed to adjust for baseline patient and lesion characteristics. The primary outcome was the 2-year primary patency rate of the two types of DCBs.

RESULTS

Propensity score matching was used to extract 76 pairs with no significant intergroup differences in baseline patient and lesion characteristics. The average lesion length was 257.5 and 255.7 mm in the HD and LD-DCB groups, respectively. The 2-year primary patency rates between the HD and LD-DCB groups were comparable (68.5% vs. 60.4%; p = 0.33). There were also no significant differences in clinically driven target lesion revascularization, acute limb ischemia, major amputation, or overall survival between the two types of DCBs.

CONCLUSION

The clinical outcomes between the HD and LD-DCBs did not significantly differ in real-world populations with severely complex lesions.

Femoropopliteal Endovascular Intervention: A Review of the Current Landscape

Superficial femoral artery disease poses significant challenges in patients with peripheral artery disease due to its unique anatomic and physiological characteristics. While conservative measures remain the initial approach for chronic, stable symptoms, endovascular therapies have gained prominence due to their minimally invasive nature, expedited recovery times, and preservation of future treatment options when performed correctly. Options for endovascular interventions include balloon angioplasty (percutaneous transluminal angioplasty [standard], drug-coated balloon), stenting (bare metal, drug-eluting, covered stents), with or without adjunct therapy (atherectomy or intravascular lithotripsy). Randomized controlled trials have demonstrated superior outcomes with drug-coated balloon and drug-eluting stent over bare metal stent or percutaneous transluminal angioplasty alone, particularly in long, heavily calcified lesions. However, challenges such as in-stent restenosis, stent fracture, and in-stent thrombosis persist, driving ongoing innovation in device technology and drug formulations on devices. Emerging therapies such as bioresorbable scaffolds and percutaneous bypass devices offer promising alternatives. Further research is needed to refine treatment strategies, minimize risks, and optimize outcomes.

Clinical outcome of low-dose and high-dose drug-coated balloon angioplasty with intraplaque wiring for femoropopliteal chronic total occlusion lesions

Chronic total occlusion (CTO) lesions of the femoropopliteal artery have been shown to benefit from drug-coated balloon (DCB) angioplasty. However, because bailout stenting is often performed, the outcome of DCB angioplasty alone remains unknown, particularly the differences in outcomes between low-dose DCB (LD-DCB) and high-dose DCB (HD-DCB). To address these issues, we conducted a single-center, retrospective cohort study and enrolled 66 consecutive patients undergoing initial endovascular therapy with DCBs for femoropopliteal CTO lesions from June 2018 to February 2023. Of the 66 patients, 25 underwent LD-DCB angioplasty and 41 underwent HD-DCB angioplasty. In all lesions, no bailout stenting was performed and intraplaque wiring was confirmed by intravascular ultrasound. The primary outcome measure was 1-year primary patency and the secondary outcome measures were 1-year freedom from clinically driven target lesion revascularization (CD-TLR) and reocclusion. There were no significant differences between LD-DCB and HD-DCB angioplasty in patient and lesion characteristics, 1-year primary patency (76.4% vs. 85.9%, log-rank p = 0.51), CD-TLR (95.2% vs. 94.3%, log-rank p = 0.97), and reocclusion (95.0% vs. 94.3%, log-rank p = 0.99). Patients with two of the three risk factors for restenosis, i.e., minimum lumen area < 12.6 mm2, dissection angle > 63°, and calcification angle > 270°, had a significantly lower patency rate (no factor: 100% vs. 1 factor: 90.3% vs. 2 factors: 62.6%; log-rank p = 0.04). In patients undergoing DCB angioplasty for femoropopliteal CTO lesions, 1-year primary patency and freedom from CD-TLR were favorable, with no significant difference between LD-DCB and HD-DCB angioplasty.

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.

French multicentric registry on LUMINOR drug-eluting balloon for superficial femoral and popliteal arteries

BACKGROUND

Endovascular interventions using drug-coated balloons (DCBs) have shown promise in improving outcomes for femoropopliteal (FP) revascularizations. Luminor, a nanotechnology-based paclitaxel coated balloon, has demonstrated efficacy and safety in Effpac (Effectiveness of Paclitaxel-coated Luminor Balloon Catheter Versus Uncoated Balloon Catheter in the Arteria Femoralis Superficialis). The LUMIFOLLOW (European All-comers' Multicentric Prospective REGISTRY on LUMINOR Drug Eluting Balloon in the Superficial Femoral Artery and Popliteal Artery With 5 Years Follow-up) registry, a large-scale, prospective, multicenter study, aims to assess the real-world performance of Luminor in FP lesions.

METHODS

LUMIFOLLOW enrolled 542 patients with 580 lesions across 15 French centers. It included both de novo and restenotic lesions, with calcified and/or long occlusions. Primary end points were medical safety (defined as freedom from peri-procedural death, index limb amputation, and/or all-cause mortality) and efficacy (primary patency defined as freedom from target lesion revascularization and/or binary restenosis); secondary end points included acute device success, procedural and clinical success, major adverse events, and functional assessments.

RESULTS

The mean patient age was 71.2 years, with 67.2% male patients. Prevalent comorbidities included diabetes (n = 231/542 [42.6%]), hypertension (n = 391/542 [72.1%]), hyperlipidemia (n = 305/542 [56.3%]), and current smoking (n = 147/540 [27.2%]); 23.8% were classified as Rutherford category 2 (n = 129/542), 43.2% as Rutherford category 3 (n = 234/542), 16.8% as Rutherford category 4 (n = 91/542), and 16.2% as Rutherford category 5 (n = 88/542). Lesions were located in the superficial femoral artery (n = 329/572 [57.5%]) and could extend to the popliteal artery (n = 243/572 [42.5%]), with 43.6% classified as Trans-Atlantic Inter-Society Consensus II C or D; 24.2% were restenosis (n = 139/575) with a 44.3% rate of total occlusions (n = 255/576). The mean lesion length was 140.55 ± 99.42 mm. Provisional stenting was required in 43.1% of patients (n = 249/580), with a mean stent length shorter than the initial lesion length at 87.21 ± 42.30 mm. The acute procedural success rate was 99.4% (n = 536/539), with two in-hospital deaths and one thrombosis of target lesion. Acute clinical success was achieved in 93.5% (n = 504/539). The 12-month composite safety end point was 82.7% (5.7% all-cause mortality, 0.7% index limb major amputation) and the estimated primary patency was 87.4% (95% confidence interval [CI], 84.1%-90.1%), with freedom from target lesion revascularization at 96.2% (95% CI, 93.9%-97.6%) and from target vessel revascularization at 94.9% (95% CI, 92.5%-96.6%). The EQ-5D-5L questionnaire indicated significant improvements in quality of life at 12 months, with 67.4% improved mobility, 63.5% reduced pain and discomfort, and 47.8% enhanced usual activities. Walking Impairment Questionnaire scores increased significantly in walking distance, speed, and stair-climbing ability (from 31.4 ± 24.7 to 62.5 ± 31.0; P < .001).

CONCLUSIONS

The LUMIFOLLOW registry demonstrates that Luminor DCBs are effective and safe for FP interventions. The significant improvement in quality of life and walking ability, along with high primary patency and low complication rates, underscore the benefits of Luminor DCBs in real-world settings. However, the high rate of provisional stenting underscores the need for these devices to be used alongside other endovascular techniques in challenging lesions.

Editor's Choice - Results of SurVeil Versus IN.PACT Admiral Paclitaxel Coated Balloons in Femoropopliteal Arteries: 24 Month Outcomes of the Randomised TRANSCEND Study

OBJECTIVE

The aim of the TRANSCEND study was to compare the safety and efficacy of the next generation SurVeil PCB with the IN.PACT Admiral PCB in patients with femoropopliteal arterial disease. SurVeil is a lower dose PCB (2.0 μg/mm2vs. 3.5 μg/mm2 for IN.PACT Admiral) with a uniform microcrystalline coating intending to enhance durability and maximise drug delivery.

METHODS

TRANSCEND is a prospective, single blind, randomised controlled, multicentre, non-inferiority clinical study. Patients with femoropopliteal artery disease in Rutherford stages 2 - 4 were randomised 1:1 to the SurVeil or the IN.PACT Admiral PCB. A sample size of 446 patients was calculated to prove non-inferiority of the SurVeil compared with the IN.PACT Admiral PCB for primary safety and efficacy endpoints at twelve months. Primary safety was defined as a composite of freedom from device and procedure related death through 30 days, and freedom from major target limb amputation and clinically driven (CD) target vessel revascularisation at twelve months. Primary efficacy was defined as primary patency at twelve months as a composite of freedom from binary re-stenosis and freedom from CD target lesion revascularisation. Secondary outcomes were reported up to twenty four months.

RESULTS

A total of 446 subjects were randomised, 222 to the SurVeil and 224 to the IN.PACT Admiral PCB. Primary safety was 91.8% for the SurVeil vs. 89.8% for the IN.PACT Admiral PCB (pnon-inferiority < .001), and primary efficacy was 82.2% vs. 85.9% (pnon-inferiority = .003). Primary patency through twenty four months was 65.4% with the SurVeil and 66.9% with the IN.PACT Admiral PCB (pnon-inferiority = .005).

CONCLUSION

The next generation low dose SurVeil PCB demonstrated excellent safety and efficacy up to twenty four months and was non-inferior to the IN.PACT Admiral PCB. (ClinicalTrials registration ID: NCT03241459).

Duplex Ultrasound Surveillance After Femoropopliteal Endovascular Treatment for Peripheral Arterial Disease: A Systematic Review and Narrative Synthesis

BACKGROUND

To review the current literature and establish a consensual recommendation on duplex ultrasound (DUS) surveillance after endovascular treatment of the femoropopliteal tract.

METHODS

This systematic review conducted literature searches on DUS surveillance after endovascular treatment of the femoropopliteal tract, and event rates. The primary end point was primary assisted patency. Secondary end points were primary patency, secondary patency, and limb salvage for double-armed studies, and sensitivity and specificity of DUS compared with other surveillance methods for single-armed studies. PubMed, Embase, and the Cochrane Library were searched. A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Articles were eligible if they compared DUS surveillance others surveillance methods. Prospective, large cohort studies reporting on long-term events after endovascular treatment were also included.

RESULTS

The initial search resulted in 5 studies. Only one double-armed nonrandomized study compared DUS surveillance with ankle-brachial index (ABI) follow-up after femoropopliteal stenting. The DUS group demonstrated improved primary assisted patency (84% vs. 76% at 12 months and 68% vs. 38% at 36 months, P = 0.008) and limb salvage (97% vs. 83% at 12 months and 90% vs. 50% at 36 months, P < 0.001) compared with ABI follow-up. In one single-armed study, DUS surveillance showed a high sensitivity (91%) and specificity (100%) in detecting restenosis. ABI and clinical follow-up demonstrated a low sensitivity (55-67% and 52-64%, respectively) but reasonable specificity (80-85% and 82-88%, respectively) in detecting restenosis.

CONCLUSIONS

The scarce available evidence suggests a clinical benefit of DUS surveillance after endovascular treatment of the femoropopliteal tract.

Comparison of safety and efficacy of femoropopliteal arterial disease using different dose drug-coated balloons: Systematic review and meta-analysis

BACKGROUND

Endovascular therapy with balloon percutaneous angioplasty (PTA) in the femoro-popliteal segment is frequently performed, however, long-term favorable outcomes and patency remain challenging, with restenosis rates reaching 60% post-standard balloon angioplasty. Drug-coated balloons (DCBs) have shown promise in improving these outcomes; Paclitaxel, used in DCBs, inhibits hyperplasia and smooth muscle cell proliferation, reducing restenosis; however, the optimal dose of Paclitaxel remains unclear, with high-dose (HD-DCB [>3 mg/mm2]) and low-dose (LD-DCB [<2.0 mg/mm2]) options available. This meta-analysis aims to compare the efficacy and safety of HD-DCB and LD-DCB in treating femoropopliteal arterial disease.

METHODS

We followed PRISMA guidelines and conducted a comprehensive search of PubMed, EMBASE, Cochrane, Scopus, and Mendeley up to May 27, 2024. We included randomized controlled trials and cohort studies comparing HD-DCB and LD-DCB in patients with femoropopliteal arterial disease. Data were extracted on baseline characteristics, outcomes, and study quality. The Newcastle-Ottawa Scale and ROB2 tool were used for bias assessment. Outcomes included overall survival (OS), limb salvage (LS), freedom from clinically driven target lesion revascularization (CD-TLR), and major amputation.

RESULTS

Six studies comprising 2563 patients were included. HD-DCB showed a significant benefit in limb salvage at 6 months (RR = 0.38, 95% CI = 0.18-0.78, p = .009) but not at 12 months (RR = 3.08, 95% CI = 0.14-67.13, p = .47). No significant difference was observed in overall survival between HD-DCB and LD-DCB at either 6 months (RR = 1.53, 95% CI = 0.25-9.57, p = .65) or 12 months (RR = 1.21, 95% CI = 0.17-8.84, p = .85). HD-DCB was associated with an increased risk of perioperative complications (RR = 1.90, 95% CI = 1.14-3.17, p = .01) and a higher, though not statistically significant, risk of major amputation (RR = 4.73, 95% CI = 0.54-41.52, p = .16).

CONCLUSION

HD-DCB may offer advantages in limb salvage over LD-DCB in the short term, but this comes with an increased risk of perioperative complications. These findings underscore the need for careful patient selection when considering HD-DCB for femoropopliteal artery disease.

Clinical Outcomes Following Low-Dose Second-Generation "Ranger" Drug-Coated Balloon Angioplasty for Femoropopliteal Artery Disease

PURPOSE

To reveal the rate of 1-year freedom from restenosis and to determine the factors associated with the restenosis risk in femoropopliteal (FP) lesions treated with a Ranger drug-coated balloon (DCB) in real-world clinical settings.

METHODS

This multicenter, prospective observational study enrolled 1131 patients and 1453 de novo or restenotic FP lesions (mean age=75±9 years; female=35.3%, mean lesion length=19.2±16.0 cm; chronic total occlusion [CTO]=33.7%; severe calcification=33.7%) that underwent successful Ranger DCB angioplatsy between March 2021 and December 2022.

RESULTS

The primary endpoint was 1-year freedom from restenosis and its associated factors. Bail-out stenting was performed in 5.3%. During the follow-up, restenosis was detected in 249 cases. Freedom from restenosis by the Kaplan-Meier analysis was estimated to be 85.2% and 81.0% at 12 and 14 months, whereas freedom from target lesion revascularization (TLR) was 91.7% and 90.0% at 12 and 14 months. The patterns of restenosis were focal (39.2%), tandem (12.3%), diffuse (17.2%), and occlusive (31.3%). Independent risk factors of restenosis were female sex, diabetes mellitus, no runoff, history of revascularization, lesion length ≥25 cm, and CTO.

CONCLUSIONS

Our study demonstrated that 1-year freedom from restenosis after Ranger DCB for FP lesions in a real-world clinical setting was acceptable. Independent predictors of restenosis were female gender, diabetes mellitus, no runoff, history of revascularization, lesion length ≥25 cm, and CTO.

CLINICAL IMPACT

Our study demonstrated the true performance of Ranger DCB in real-world practice, with a very low rate of bail-out stenting and no use of atherectomy devices. In addition, it also elucidated morphologies associated with restenosis and the risk factors for restenosis after DCB. Freedom from re-stenosis and TLR at 1-year after Range DCB angioplasty was 84.5% and 91.5%. Two thirds of restenosis had a non-occlusive pattern, and independent predictors of restenosis were female gender, diabetes mellitus, no runoff, history of revascularization, lesion length ≥25 cm, and CTO.

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.

Benefits and Challenges of Drug-Coated Balloons in Peripheral Artery Disease: From Molecular Mechanisms to Clinical Practice

Multiple clinical trials have reported favorable outcomes after drug-coated balloon therapy for peripheral artery disease in above-the-knee and below-the-knee lesions and in both de novo and in-stent restenosis. However, there are still insufficient data to identify and tackle the risk factors associated with a higher risk of restenosis, which is the primary concern for patients who are treated with an endovascular approach. A modern armamentarium, which includes improved lesion preparation techniques such as plaque modification balloons, mechanical atherectomy, intravascular lithotripsy, and imaging, is crucial for obtaining better long-term clinical outcomes. Moreover, a better understanding of the molecular properties of drug-coated balloons has led to improved devices that could tackle the shortcomings of previous generations. This comprehensive review focuses on drug-coated balloon technology as a tool to treat peripheral artery disease and the effects of the molecular mechanisms involved in preventing vascular restenosis.

Impact of a Less Than 50% Residual Stenosis Following Vessel Preparation in Femoropopliteal Drug-Coated Balloon Angioplasty

PURPOSE

Drug-coated balloon (DCB) has been established as first-line therapy in femoropopliteal (FP) intervention, and successful vessel preparation (VP) is considered a key element. However, the clinical impact of successful VP remains unknown. This retrospective study examined the clinical impact of successful VP in DCB FP intervention.

METHODS

In total, 268 patients (308 limbs) who underwent successful FP intervention using DCB without atherectomy devices for symptomatic lower extremity artery disease between March 2018 and December 2019 were included in this study (high-dose DCB: 69.8%; low-dose DCB: 30.2%). Successful VP was defined as <50% residual stenosis and

RESULTS

The median follow-up period was 2.1 (interquartile range=1.1-2.7) years. Successful VP was achieved in 163 patients (60.8%). Primary patency and freedom from clinically-driven target lesion revascularization (CD-TLR) were significantly higher in the successful VP group than in the nonsuccessful VP group (54.2% vs 33.0%, p<0.001; 69.9% vs 57.7%, p=0.047). In the successful VP group, high-dose DCB and low-dose DCB were comparable in primary patency and freedom from CD-TLR (53.2% vs 53.6%, p=0.48; 68.7% vs 70.9%, p=0.69). In nonsuccessful VP group, high-dose DCB demonstrated numerically higher primary patency but not statistically significant than low-dose DCB (44.5% vs 16.0%, p=0.06), whereas no significant difference in freedom from CD-TLR was observed (56.0% vs 58.9%, p=0.29). On multivariate analysis, successful VP and preballoon size to reference vessel diameter ratio were significantly associated with primary patency.

CONCLUSIONS

Achieving successful VP before DCB was independently associated with primary patency in DCB FP intervention.

CLINICAL IMPACT

This study revealed that the successful vessel preparation (VP) before DCB and preballoonsize to reference vessel diameter ratio were independently associated with primary patency in DCB femoropopliteal intervention. When successful VP was achieved only before DCB treatment, the clinical outcomes were comparable between high-dose DCB and low-dose DCB at midterm follow-up.To maximized DCB efficacy, successful VP is very important in daily clinical practice.

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Key Words

• drug-coated balloon
• peripheral artery disease
• vessel preparation

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Affiliation(s)

Yusuke Tomoi Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
Yoshimitsu Soga Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
Kazuaki Imada Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
Nobuaki Sakai Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
Tomonori Katsuki Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
Kenji Ando Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan

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Low-Dose vs High-Dose Drug-Coated Balloon for Symptomatic Femoropopliteal Artery Disease: The PROSPECT MONSTER Study Outcomes

BACKGROUND

Randomized trials have shown comparable outcomes between second-generation low-dose drug-coated balloons (LD-DCBs) and first-generation high-dose drug-coated balloons (HD-DCBs); but the trial patients had low clinical complexity, and there were no comparisons in medically complex populations.

OBJECTIVES

The aim of this study was to compare outcomes between an LD-DCB (Ranger; 2.0 μg/mm2) and an HD-DCB (IN.PACT; 3.5 μg/mm2) in patients with symptomatic femoropopliteal artery disease.

METHODS

PROSPECT MONSTER (Prospective Comparison of Second-Generation Low-Dose Drug-Coated Balloon With High-Dose Drug-Coated Balloon) was a prospective, multicenter, nonrandomized trial that prospectively collected data from 581 patients who underwent endovascular therapy with the LD-DCB (n = 370) or the HD-DCB (n = 211) for symptomatic femoropopliteal artery disease (Rutherford classes 2-5). The primary outcome was the 1-year primary patency of the LD-DCB in comparison with that of the HD-DCB, as evaluated using propensity score matching. The incidence of impaired flow after drug-coated balloon application was also evaluated.

RESULTS

Propensity score matching extracted 163 pairs (358 and 163 patients in the LD-DCB and HD-DCB groups, respectively), with no significant intergroup difference in baseline characteristics. The 1-year primary patency rates in the matched population were similar between the LD-DCB and HD-DCB groups (87.0% [95% CI: 82.5%-91.7%] vs 81.3% [95% CI: 74.8%-88.5%]; HR: 0.93; 95% CI: 0.55-1.59; P = 0.79), as was the incidence of impaired flow (13.6% vs 9.8%; OR: 1.46; 95% CI: 0.78-2.73; P = 0.24). No baseline characteristics had any significant interaction effects on the association of the LD-DCB vs the HD-DCB and 1-year restenosis risk.

CONCLUSIONS

LD-DCBs demonstrate efficacy and safety comparable with HD-DCBs in patients with complex clinical backgrounds, suggesting that drug-coated balloon treatment using a lower dose may be possible.

Application of first-generation high- and low-dose drug-coated balloons to the femoropopliteal artery disease: a sub-analysis of the POPCORN registry

BACKGROUND

Drug-coated balloons (DCBs) have significantly changed endovascular therapy (EVT) for femoropopliteal artery (FPA) disease, in terms of the expansion of indications for EVT for symptomatic lower extremity arterial disease (LEAD). However, whether there is a difference in the performance among individual DCBs has not yet been fully discussed. The present sub-analysis of real-world data from a prospective trial of first-generation DCBs compared the clinical outcomes between high- and low-dose DCBs using propensity score matching methods. The primary endpoint was the restenosis-free and revascularization-free rates at 1 year.

RESULTS

We compared 592 pairs matched for patient and lesion characteristics using propensity score matching among a total of 2,507 cases with first-generation DCBs (592 and 1,808 cases in the Lutonix low-dose and In.PACT Admiral high-dose DCB groups, respectively). There were no differences in patient/lesion characteristics, procedural success rates, or complications between the two groups. First-generation low-dose DCB had significantly lower patency (73.3% [95% confidence interval, 69.6%-77.3%] in the low-dose DCB group versus 86.2% [84.1%-88.3%] in the high-dose DCB group; P < 0.001) and revascularization-free (84.9% [81.9%-88.1%] versus 92.5% [90.8%-94.1%]; P < 0.001) rates. Chronic kidney disease on dialysis, cilostazol use, anticoagulant use, and severe calcification had a significant interaction effect in the association (all P < 0.05).

CONCLUSIONS

EVT to FPA with first-generation DCBs had inferior low-dose patency outcomes as compared with high-dose outcomes in the present cohort.

LEVEL OF EVIDENCE

Sub analysis of a prospective multicenter study.