Device Effectiveness for Femoropopliteal Artery Disease Treatment: An Analysis of K-VIS ELLA Registry

Intravascular Ultrasound Predictors of 12-Month Patency Loss Following Drug-Coated Balloon Angioplasty for the Femoropopliteal Artery

Intravascular ultrasound (IVUS) has been shown to improve outcomes of drug-coated balloon (DCB) angioplasty for treatment of femoropopliteal artery (FPA) disease. However, the optimal IVUS criteria for achieving improved outcomes of DCB angioplasty for FPA disease remain uncertain. The study aimed to identify IVUS predictors for loss of patency at 12 months after DCB angioplasty for FPA disease. After excluding one patient due to insufficient IVUS imaging data, 98 patients in the IVUS-guidance group of the IVUS-DCB trial were included in the analysis. IVUS parameters predicting loss of patency at 12 months and their optimal cut-off values were investigated. Among the 98 patients who underwent IVUS-guided FPA intervention, 16 patients (16.3%) lost primary patency within 12 months. End-stage renal disease on hemodialysis and, bailout stenting, postprocedural dissection length >50% were independent procedural predictors for 12-month patency loss. Receiver operating characteristic (ROC) curve demonstrated that postprocedural minimal lumen area (MLA) ≥ 11.6 mm2 (area under the ROC curve: 0.685, 95% CI: 0.513 to 0.857) as the optimal cut-off value for sustained primary patency. In survival analysis, patients with MLA ≥ 11.6 mm2 had a hazard ratio of 0.27 (95% CI: 0.09 to 0.80, p-value = 0.019, risk difference: 19.8) for lower risk of patency loss. A postprocedural MLA ≥11.6 mm2 was an independent IVUS predictor for sustained primary patency after DCB angioplasty in patients with FPA disease. Our findings suggest that lesion optimization and achieving sufficient lumen area under IVUS guidance during DCB angioplasty are crucial for maintaining target vessel patency.

Association of Postprocedure Ankle-Brachial Index With Outcomes Following Drug-Coated Balloon Angioplasty in Femoropopliteal Artery Disease

Endovascular treatment of femoropopliteal artery (FPA) disease with drug-coated balloons (DCBs) may face complications such as arterial recoil, dissection, and residual stenosis. Angiography has limited accuracy for evaluating blood flow through revascularized target lesions. Thus, there is a need for postprocedure hemodynamic assessment in treated limbs. This study aims to explore how postprocedure ankle-brachial index (ABI) influences outcomes following DCB treatment for FPA disease. This study included patients in a multicenter registry (K-VIS ELLA) treated with DCB for FPA disease between January 2006 and August 2021. Optimal postprocedure ABI cutoff for predicting clinically driven target lesion revascularization (TLR) was determined using receiver operating characteristic curve analysis. Independent predictors of TLR were identified using multivariable Cox regression analysis. A total of 654 limbs (514 patients) treated with DCB for FPA were evaluated by ABI at 1-day (median, interquartile range, 1 to 2 days) postprocedure and followed up for a median of 370 days. The optimal immediate postprocedure ABI cutoff value for predicting TLR was 0.72 (area under the curve, 0.68). Significantly improved TLR-free and major adverse limb event-free survival rates were observed with a postprocedure ABI ≥ 0.72 (hazard ratio [HR] = 0.24, 95% confidence intervals [CI] = 0.16 to 0.37, p < 0.001; HR = 0.25, 95% CI = 0.16 to 0.38, p < 0.001, respectively). Independent predictors of TLR were postprocedure ABI < 0.72 (HR 3.76; 95% CI, 2.33 to 6.07; p < 0.001) and presence of anemia (HR 2.01; 95% CI, 1.03 to 3.92; p = 0.041). An immediate postprocedure ABI is a significant predictor of TLR risk following DCB treatment for FPA disease, underscoring the value of hemodynamic assessment in optimizing angioplasty outcomes.

Intravascular Ultrasound-Guided vs Angiography-Guided Drug-Coated Balloon Angioplasty in Patients With Complex Femoropopliteal Artery Disease

BACKGROUND

Intravascular ultrasound (IVUS) guidance has been shown to yield favorable outcomes for endovascular treatment of femoropopliteal artery (FPA) disease with drug-coated balloon (DCB) angioplasty. However, the specific benefits of IVUS for treatment of complex FPA lesions remain uncertain.

OBJECTIVES

In this study, the authors compared the clinical impact of IVUS-guided vs angiography-guided DCB angioplasty in patients with complex or noncomplex FPA lesions.

METHODS

This study was a prespecified, primary subgroup analysis of the randomized IVUS-DCB trial. Patients with FPA undergoing DCB angioplasty were randomized to receive the procedure under IVUS or angiography guidance. The primary endpoint was 12-month primary patency; secondary endpoints included clinically driven target lesion revascularization (CD-TLR), sustained clinical improvement, and hemodynamic improvement.

RESULTS

Among the 237 patients enrolled, 158 had complex FPA (Trans-Atlantic Inter-Society Consensus II [TASC II] type C/D), and 79 had noncomplex FPA (TASC II type A/B). In complex FPA, IVUS guidance was associated with significantly higher rates of primary patency (82.1% vs 60.3%; HR for loss of primary patency: 0.34; 95% CI: 0.16-0.70; P = 0.002), freedom from CD-TLR (90.0% vs 76.9%; HR: 0.31; 95% CI: 0.13-0.75; P = 0.01), and sustained clinical and hemodynamic improvement relative to angiography guidance. There was no significant difference in primary patency (87.5% vs 88.2%; HR: 1.84; 95% CI: 0.39-8.60; P = 0.44) or occurrence secondary endpoints between the IVUS-guidance and angiography-guidance groups for patients with noncomplex FPA.

CONCLUSIONS

In endovascular treatment of FPA using DCB, IVUS guidance was significantly associated with improved 12-month clinical outcomes, particularly in patients with complex FPA lesions. (Intravascular Ultrasound-Guided Drug-Coated Balloon Angioplasty for Femoropopliteal Artery Disease [IVUS-DCB] trial; NCT03517904).

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.

Treatment extent of femoropopliteal disease and clinical outcomes following endovascular therapy

BACKGROUND

Endovascular therapy (EVT) has become the preferred treatment modality for femoropopliteal disease. However, there is limited evidence regarding its procedural and clinical outcomes according to the affected area.

AIMS

The aim of this study is to investigate clinical outcomes and device effectiveness according to treatment extent in the superficial femoral artery (SFA), popliteal artery (PA), or both.

METHODS

In this study, we analysed EVT for SFA (2,404 limbs), PA (155 limbs), SFA/PA (383 limbs) using the population in the K-VIS ELLA (Korean Vascular Intervention Society Endovascular Therapy in Lower Limb Artery Diseases) registry. The primary endpoint was target lesion revascularisation (TLR) at 2 years.

RESULTS

The SFA/PA group exhibited a higher prevalence of anatomical complexity, characterised by long lesions, moderate to severe calcification, and total occlusion. The procedures were successful in 97.2% of SFA, 92.9% of PA, and 95.6% of SFA/PA EVTs. The 2-year TLR rates were 21.1%, 18.6%, and 32.7% in the SFA, PA, and SFA/PA groups, respectively. SFA/PA EVT was associated with a significantly increased risk for TLR compared to the SFA group (adjusted hazard ratio [HR] 1.48 [1.09-2.00]; p=0.008) and a trend towards an increased risk compared to the PA group (adjusted HR 1.80 [1.00-3.27]; p=0.052). After overlap weighting, the use of a drug-coated balloon (DCB) was shown to be beneficial, with the lowest TLR rate after SFA and SFA/PA EVT.

CONCLUSIONS

In this large real-world registry, SFA/PA EVT was associated with an increased risk for TLR at 2 years compared to the SFA or PA EVT groups, with favourable outcomes when using a DCB or drug-eluting stent in the SFA/PA EVT group.

Drug-coated balloon versus drug-eluting stent for femoropopliteal total occlusions: intraluminal versus subintimal approaches

Because there is a lack of comparative studies assessing drug-coated balloon (DCB) and drug-eluting stent (DES) outcomes with respect to intraluminal (IL) and subintimal (SI) approaches in femoropopliteal (FP) total occlusive lesions, we compared the outcomes between DCB (including bailout stenting) and DES treatments for this lesion. A total of 487 limbs (434 patients) were divided into the IL (n = 344, DCB: n = 268, DES: n = 76) and SI (n = 143, DCB: n = 83, DES: n = 60) approach groups. The primary outcome was a major adverse limb event (MALE), defined as above-ankle amputation or repeat revascularization of the index limb. Secondary outcomes included clinically driven target lesion revascularization (TLR), loss of clinical patency, and all-cause death. After adjustment, in each IL and SI approach, the 2-year rates of MALE (p = 0.180 and p = 0.236, respectively), TLR, loss of clinical patency, and all-cause death were similar between the DCB and DES groups. In the DCB and DES groups, both primary and secondary outcomes were similar between the IL and SI approaches. DCB and DES strategies for patients presenting with FP total occlusive lesions demonstrated similar outcomes regardless of the IL or SI approach.Clinical Trial Registration: NCT02748226.

Intravascular ultrasound-guided drug-coated balloon angioplasty for femoropopliteal artery disease: a clinical trial

BACKGROUND AND AIMS

Drug-coated balloons (DCBs) have demonstrated favourable outcomes following endovascular therapy for femoropopliteal artery (FPA) disease. However, uncertainty remains whether the use of intravascular ultrasound (IVUS) can improve the outcomes of DCBs.

METHODS

This prospective, multicentre, randomized trial, conducted at seven centres in South Korea, compared the outcomes of IVUS-guided vs. angiography-guided angioplasty for treating FPA disease with DCBs. Patients were assigned to receive IVUS-guided (n = 119) or angiography-guided (n = 118) angioplasty using DCBs. The primary endpoint was 12-month primary patency.

RESULTS

Between May 2016 and August 2022, 237 patients were enrolled and 204 (86.0%) completed the trial (median follow-up; 363 days). The IVUS guidance group showed significantly higher primary patency [83.8% vs. 70.1%; cumulative difference 19.6% (95% confidence interval 6.8 to 32.3); P = .01] and increased freedom from clinically driven target lesion revascularization [92.4% vs. 83.0%; difference 11.6% (95% confidence interval 3.1 to 20.1); P = .02], sustained clinical improvement (89.1% vs. 76.3%, P = .01), and haemodynamic improvement (82.4% vs. 66.9%, P = .01) at 12 months compared with the angiography guidance group. The IVUS group utilized larger balloon diameters and pressures for pre-dilation, more frequent post-dilation, and higher pressures for post-dilation, resulting in a greater post-procedural minimum lumen diameter (3.90 ± 0.59 vs. 3.71 ± 0.73 mm, P = .03).

CONCLUSIONS

Intravascular ultrasound guidance significantly improved the outcomes of DCBs for FPA disease in terms of primary patency, freedom from clinically driven target lesion revascularization, and sustained clinical and haemodynamic improvement at 12 months. These benefits may be attributed to IVUS-guided optimization of the lesion before and after DCB treatment.

Efficacy of Drug-Coated Balloon Angioplasty in Pulmonary Vein Stenosis or Total Occlusion

BACKGROUND

Current therapies for pulmonary vein stenosis (PVS) or pulmonary vein total occlusion (PVTO) involving angioplasty and stenting are hindered by high rates of restenosis.

OBJECTIVES

This study compares a novel approach of drug-coated balloon (DCB) angioplasty and stenting with the current standard of care in PVS or PVTO due to pulmonary vein isolation (PVI).

METHODS

A retrospective single-center study analyzed patients with PVS or PVTO due to PVI who underwent either angioplasty and stenting (NoDCB group; December 2012-December 2016) or DCB angioplasty and stenting (DCB group; January 2018-January 2021). Multivariable Andersen-Gill regression analysis assessed the risk of restenosis and target lesion revascularization (TLR).

RESULTS

The NoDCB group comprised 58 patients and 89 veins, with a longer median follow-up of 35 months, whereas the DCB group included 26 patients and 33 veins, with a median follow-up of 11 months. The DCB group exhibited more PVTO (NoDCB: 12.3%; DCB: 42.4%; P = 0.0001), with a smaller reference vessel size (NoDCB: 10.2 mm; DCB: 8.4 mm; P = 0.0004). Follow-up computed tomography was performed in 82% of NoDCB and 85% of DCB, revealing lower unadjusted rates of restenosis (NoDCB: 26%; DCB: 14.3%) and TLR (NoDCB: 34.2%; DCB: 10.7%) in the DCB group. DCB use was associated with a significantly lower risk of restenosis and TLR (HR: 0.003: CI: 0.00009-0.118; P = 0.002).

CONCLUSIONS

The novel approach of DCB angioplasty followed by stenting is effective and safe and significantly reduces the risk of restenosis and reintervention compared with the standard of care in PVS or PVTO due to PVI.

Repeat drug-coated balloon angioplasty for femoropopliteal lesions: 12-month results from a retrospective observational study

BACKGROUND

The clinical implications of restenosis after drug-coated balloon (DCB) treatment remain unclear. We compared the clinical outcomes between DCB angioplasty for restenosis and de novo femoropopliteal artery lesions. This single-center retrospective study included 571 patients (737 limbs) who underwent either repeat (54 patients, 64 limbs) or de novo DCB (517 patients, 673 limbs) without bailout stenting. After propensity score matching, 49 matched pairs were analyzed. The primary endpoint was the 1-year primary patency, with secondary endpoints including the freedom from target lesion revascularization (TLR), major adverse limb events (MALE), and early restenosis. Predictors of restenosis were identified using multivariable Cox regression analysis.

RESULTS

The repeat-DCB group displayed significantly lower rates of 1-year primary patency and freedom from TLR compared to those of the de novo-DCB group (50.1% vs. 77.4%, p = 0.029 and 54.9% vs. 83.6%, p = 0.0.44, respectively). No significant differences were observed in early restenosis or MALE (10.7% vs. 5.9%, p = 0.455 and 48.3% vs. 73.4%, p = 0.055, respectively). Restenosis after DCB angioplasty was associated with repeat DCB (hazard ratio [HR], 5.13; 95% confidence interval [CI], 1.43-18.4; p = 0.012) and small vessel size of < 4.5 mm (HR, 6.25; 95% CI, 1.17-33.4; p = 0.032). Furthermore, restenosis after repeat DCB angioplasty was associated with the Peripheral Artery Calcification Scoring System (PACSS) grade 4 (HR, 4.20; 95% CI, 1.08-16.3; p = 0.038), small vessel size of < 4.5 mm (HR, 9.44; 95% CI, 1.21-73.7; p = 0.032), and intravascular ultrasound (IVUS) use (HR, 0.05; 95% CI, 0.01-0.44; p = 0.007).

CONCLUSIONS

The 1-year primary patency rate following repeat DCB angioplasty for femoropopliteal lesions was notably lower than that of DCB treatment for de novo lesions. Repeat DCB strategy was associated with an increased risk of patency loss. Regarding repeat restenosis after DCB treatments, PACSS grade 4 calcification and small vessel diameter of < 4.5 mm were associated with an increased risk of restenosis, whereas IVUS use correlated with a decreased risk of restenosis.