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

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.

Clinical Comparison of High- and Low-Dose Drug-Coated Balloons for De Novo Chronic Total Occlusive Femoropopliteal Lesions

BACKGROUND

Endovascular therapy (EVT) with a drug-coated balloon (DCB) is an established treatment for patients with atherosclerotic lesions in the femoropopliteal (FP) artery, including complex lesions. Currently, 3 types of DCBs are available, but the most effective DCB for FP chronic total occlusive (CTO) lesions is unknown.

METHODS AND RESULTS

In this retrospective, single-center study, we enrolled 539 consecutive patients (562 FP lesions) treated with EVT between January 2018 and December 2022. Of these patients, 161 with FP CTO lesions who underwent EVT with DCBs were included. Propensity-score matching was performed to compare the clinical outcomes of the high-dose (HD) and low-dose (LD) DCB groups, resulting in the analysis of 56 matched pairs. Primary patency and freedom from target lesion revascularization were significantly higher with HD-DCB than with LD-DCB (89.9% vs. 70.8%, respectively P=0.03; and 93.6% vs. 79.7%, respectively, P=0.046). Multivariate analysis showed that a larger minimum lumen area and the use of HD-DCB (vs. LD-DCB) were favorable predictors of primary patency at 1 year, while a small vessel diameter (≤4.5 mm) was an unfavorable predictor.

CONCLUSIONS

For FP CTO lesions, EVT performed with HD-DCB is superior to that with LD-DCB.

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.

Catch Up with the Latest Trend in Vascular Intervention-Chronic Limb-threatening Ischemia Up to Date

Endovascular treatment for patients with lower extremity artery disease is conducted worldwide due to its efficacy. Many studies have shown durability for patients with intermittent claudication, and various guidelines have shifted to the use of endovascular treatment. However, clinical outcomes in patients with chronic limb-threatening ischemia who undergo endovascular treatment have not been fully investigated. Generally, chronic limb-threatening ischemia cases have complex lesions such as small vessels, severe calcification, poor runoff vessels, chronic total occlusion, and long lesions, which result in poor outcomes. Thus, endovascular treatment for chronic limb-threatening ischemia cases remains challenging, despite the many technical and device advances. In 2019, the Global Vascular Guidelines were proposed for the treatment of patients with chronic limb-threatening ischemia. Here, we review previous guidelines and reports of patients with lower extremity artery disease who underwent endovascular treatment.

Recurrence patterns and clinical outcomes following paclitaxel-coated balloon angioplasty in femoropopliteal artery disease: Results of the CRESCENT study

BACKGROUND

Paclitaxel-coated balloons (PCBs) are widely used for femoropopliteal artery (FPA) diseases. However, data on recurrence and recurrence patterns after PCB angioplasty are limited. This study investigated the association between recurrence patterns, baseline characteristics, and clinical outcomes in the cases following PCB angioplasty.

METHODS

This multicenter, retrospective study included 1159 limbs in 1031 patients treated for de novo FPA lesions using PCBs. Patients were classified into three groups (patency, restenosis, and reocclusion) according to patency or recurrence patterns within 2 years after the index PCB angioplasty. The primary outcome was the incidence of target lesion revascularization (TLR), and the secondary outcome was the pattern of re-recurrence within 2 years following TLR using PCBs.

RESULTS

When comparing the three groups, reocclusive cases were characterized by more complex lesions, including chronic total occlusion, at baseline. Following the index PCB angioplasty, approximately 70% of recurrent cases underwent TLR, which was performed more frequently in reocclusive than in restenotic cases (82.1% vs 63.7%). Conversely, a higher percentage of restenotic cases did not require TLR compared to reocclusive cases (10.3% vs 27.8%). In cases where TLR was performed using PCBs, the rate of re-recurrence with occlusive morphology was significantly higher in reocclusive than in restenotic cases (52.3% vs 24.3%).

CONCLUSIONS

After PCB angioplasty for FPA lesions, symptomatic recurrence and requirement for TLR were more frequent in reocclusive cases. Even after TLR using PCBs, reocclusive cases tend to recur with occlusion.

Effects of statin therapy in patients treated with drug-eluting and drug-coated stents for femoropopliteal lesions

OBJECTIVE

The effects of statins on drug-eluting and drug-coated stents for femoropopliteal lesions are not well known. Therefore, this multicenter retrospective study evaluated the impact of statins on the patency of drug-eluting and drug-coated stents.

METHODS

Between January 2018 and December 2021, a total of 449 patients were treated with drug-eluting and drug-coated stents at eight cardiovascular centers in Japan (LEADers femoropopliteal lesion registry). These lesions were divided into statin-treated and non-statin-treated arms. After propensity-score matching, the effects of statins on drug-eluting and drug-coated stents were evaluated. The primary outcome was the 2-year primary patency in the statin and nonstatin groups. The secondary outcomes included secondary patency, freedom from clinically driven target lesion revascularization, and freedom from all-cause mortality at 2 years.

RESULTS

After propensity-score matching, the baseline characteristics did not differ significantly between the 134 patient pairs in the statin and nonstatin groups. The primary patency at 2 years was significantly better in the statin group than in the nonstatin group (87.3% vs 75.8%, P = .043). In terms of secondary outcomes, the statin group tended to have better secondary patency than the nonstatin group (94.4% vs 87.5%, P = .064). There was no significant difference between the groups in freedom from clinically driven target lesion revascularization and freedom from all-cause mortality (90.8% vs 84.7%, P = .15; 75.8% vs 70.7%, P = .31, respectively).

CONCLUSIONS

The results of this study demonstrated that the statin group had superior primary patency to that of the nonstatin group at 2 years. These findings suggest that statins improve the patency of implanted drug-eluting or drug-coated stents for femoropopliteal 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).

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.

High- Versus Low-Dose Paclitaxel-Coated Balloons for Femoropopliteal Disease: A systematic review and meta-analysis

To evaluate the comparative effectiveness of high- and low doses of paclitaxel in endovascular revascularization procedures for patients with femoropopliteal disease. The databases (Embase, PubMed, Scopus, and Web of Science) were searched for studies that had compared outcomes of high-dose and low-dose paclitaxel-coated balloons (PCBs) in the treatment of patients with femoropopliteal disease. Randomized controlled trials and nonrandomized comparative studies (eg, cohort studies and case-control studies) were eligible for inclusion. The primary outcomes of interest were patency rates, risk of restenosis, and clinically-driven target lesion revascularization (CD-TLR). Pooled effect sizes were reported as relative risk (RR) with 95% confidence intervals (CI). The analysis included 7 studies. High-dose PCB use was associated with higher patency (RR, 1.10; 95% CI, 1.00-1.21), reduced risk of restenosis (RR, 0.60; 95% CI, 0.46-0.79), and reduced need for CT-TLR (RR, 0.57; 95% CI, 0.41-0.79) compared to low-dose PCB. Rates of limb salvage (RR, 1.01; 95% CI, 0.99-1.04), freedom from major adverse limb events (RR, 1.39; 95% CI, 0.79-2.42), and overall survival (RR, 1.02; 95% CI, 0.99-1.05) were comparable in the 2 groups. There was no evidence of publication bias. High-dose PCB correlates with superior outcomes in patients with femoropopliteal disease, particularly in terms of better vascular patency, reduced restenosis risk, and lower need for target lesion revascularization, compared to low-dose PCB.