Mortality Assessment of Paclitaxel-Coated Balloons: Patient-Level Meta-Analysis of the ILLUMENATE Clinical Program at 3 Years

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.

Chronic Kidney Disease and Risk of Mortality and Major Adverse Limb Events After Femoral Artery Endovascular Revascularization for Peripheral Artery Disease: The Boston Femoral Artery Endovascular Revascularization Outcomes (Boston FAROUT) Study

BACKGROUND

Chronic kidney disease (CKD) is associated with worse outcomes in peripheral artery disease (PAD). The impact of the severity of CKD on mortality and major adverse limb events (MALE) after endovascular revascularization of the superficial femoral artery (SFA) is unknown.

AIMS

To assess the relationship of increasing severity of CKD on the risk of mortality and MALE in patients after endovascular revascularization of the SFA.

METHODS

We followed a cohort of 202 patients (253 limbs) with SFA endovascular revascularization for claudication or chronic limb-threatening ischemia in two academic centers between 2003 and 2011. Patients were categorized into four Kidney Disease Improving Global Outcomes (KDIGO) categories of increasingly worse CKD based on estimated glomerular filtration rate (eGFR). The primary outcome was all-cause death. Secondary outcomes included cardiovascular death, noncardiovascular death, and MALE. The relationship between CKD severity and outcomes was assessed by hazard ratios (HR) and 95% confidence intervals (95%CI) from cause-specific multivariable Cox proportional hazards models and Fine-Gray competing risks analyses.

RESULTS

During a median follow-up of 9.3 years, there was a graded and increasing risk of all-cause, cardiovascular, and noncardiovascular mortality with worse eGFR (all tests of trend p < 0.001). The lowest eGFR category (< 45 mL/min/1.73 m²) was associated with the highest risk of all-cause mortality (HR = 5.0, 95% CI = 2.4, 10), cardiovascular mortality (HR = 5.8, 95% CI = 1.8, 18), and noncardiovascular mortality (HR = 4.5, 95% CI = 1.9, 11). There was no significant association between CKD severity and MALE or minor revascularization events.

CONCLUSION

The risk of mortality risk after SFA endovascular revascularization incrementally increases with decreasing renal function. However, impaired renal function is not related to the risk of adverse limb events and supports femoral revascularization in these patients.

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.

Delivery of N-Cadherin Targeting Peptides to Vascular Tissues by Surface-Modified Polyurethane Nanoparticles via a Drug-Coated Balloon

Restenosis remains a long-standing limitation to effectively maintain functional blood flow after percutaneous transluminal angioplasty (PTA). While the use of drug-coated balloons (DCBs) containing antiproliferative drugs has improved patient outcomes, limited tissue transfer and poor therapeutic targeting capabilities contribute to off-target cytotoxicity, precluding adequate endothelial repair. In this work, a DCB system was designed and tested to achieve defined arterial delivery of an antirestenosis therapeutic candidate, cadherin-2 (N-cadherin) mimetic peptides (NCad), shown to selectively inhibit smooth muscle cell migration in vitro and limit intimal thickening in early animal PTA models. To enable successful tissue transfer in the current work, a nanoparticle excipient system previously demonstrated to be an effective carrier of NCad in vitro was integrated with customized DCB coating methodologies designed to prevent therapeutic loss during delivery. DCB design took into consideration four components: (1) the angioplasty balloon; (2) a poly(ethylene oxide) (PEO) monolayer acting as a hydrophilic spacer between the balloon surface and the nanoparticles to assist with improved nanoparticle release; (3) surface-modified degradable polar hydrophobic ionic polyurethane (D-PHI) nanoparticles loaded with NCad to facilitate the transport of the therapeutic peptide into vascular tissue; and (4) a PEO sacrificial coating applied over the nanoparticle excipient layer to prevent premature losses during transit to the artery. The nanoparticle-DCB platform successfully delivered NCad to rat carotid tissue, with superior efficacy and increased permeation within the vessel wall compared with soluble NCad infusion alone. Nanoscale technologies in conjunction with enhanced DCB design properties hold promise in advancing the localized delivery of preventive restenosis therapies in vascular disease.

Mortality, Safety, and Effectiveness of Paclitaxel-Containing Balloons and Stents in the Femoropopliteal Artery: Systematic Review and Meta-Analysis of Randomized Controlled Trials since 2018

PURPOSE

To provide an updated systematic review and meta-analysis of safety and effectiveness outcomes with paclitaxel-containing devices.

MATERIALS AND METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) investigating paclitaxel-containing balloons or stents in the treatment of femoropopliteal disease was performed. Pooled risk ratio (RR) was calculated using the inverse-variance, random-effects model in the assessment of primary patency, all-cause mortality, target limb major amputation, target lesion revascularization (TLR), and thrombosis.

RESULTS

In total, 19 RCTs were included comprising 4,284 participants. All-cause mortality rates did not differ significantly between the 2 arms at 12 months (RR, 1.06; 95% confidence interval [CI], 0.66-1.72; P = .80), 24 months (RR, 0.92; 95% CI, 0.56-1.50; P = .73), 36 months (RR, 1.21; 95% CI, 0.65-2.25; P = .55), or 48-60 months (RR, 0.95; 95% CI, 0.66-1.39; P = .81) after intervention. Primary patency was significantly higher at 12 months in the paclitaxel-containing arm: 80.92% (1,438/1,777) versus 57.48% (607/1,056) in the control arm (RR, 1.44; 95% CI, 1.30-1.59; P < .00001).

CONCLUSIONS

The present study demonstrates no statistically significant difference in all-cause mortality, target limb major amputation, or thrombosis with paclitaxel drug-eluting therapy to the femoropopliteal region. Additionally, improved and durable patency rates with a statistically significantly lower risk of clinically driven TLR with paclitaxel drug-eluting therapy have been demonstrated.

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.

Device regulation and surveillance in vascular care: Challenges and opportunities

Cardiovascular devices are essential for the treatment of cardiovascular diseases including cerebrovascular, coronary, valvular, congenital, peripheral vascular and arrhythmic diseases. The regulation and surveillance of vascular devices in real-world practice, however, presents challenges during each individual product's life cycle. Four examples illustrate recent challenges and questions regarding safety, appropriate use and efficacy arising from FDA approved devices used in real-world practice. We outline potential pathways wherein providers, regulators and payors could potentially provide high-quality cardiovascular care, identify safety signals, ensure equitable device access, and study potential issues with devices in real-world practice.

Comparative effectiveness of endovascular treatment modalities for de novo femoropopliteal lesions at long-term follow-up: A network meta-analysis of randomized controlled trials

PURPOSE

To evaluate the best endovascular treatment for de novo femoropopliteal lesions at long-term follow-up through network meta-analysis of randomized controlled trials.

METHODS

Medical databases were searched on September 17, 2023. 17 trials and 7 treatments were selected. Outcomes were primary patency, target lesion revascularization (TLR), major amputation and all-cause mortality at 3 and/or 5 years.

RESULTS

Regarding 3-year primary patency, drug-eluting stents (DES) was the best and better than balloon angioplasty (BA; odds ratio [OR], 4.96; 95% confidence interval [CI], 2.68-9.18), bare metal stents (BMS; OR, 2.81; 95% CI, 1.45-5.46), cryoplasty (OR, 6.75; 95% CI, 2.76-16.50), covered stents (CS; OR, 3.25; 95% CI, 1.19-8.87) and drug-coated balloons (DCB; OR, 2.04; 95% CI, 1.14-3.63). Regarding 5-year primary patency, DES was the best and better than BMS (OR, 2.34; 95% CI, 1.10-4.99). Regarding 3-year TLR, DES was the best and better than BA (OR, 0.24; 95% CI, 0.13-0.44). Regarding 5-year TLR, DES was the best and better than BA (OR, 0.20; 95% CI, 0.09-0.42) and balloon angioplasty with brachytherapy (OR, 0.21; 95% CI, 0.06-0.74). Regarding 3- and 5-year major amputation, DCB was the best. Regarding 3-year mortality, DES was the best and better than CS (OR, 0.09; 95% CI, 0.01-0.67).

CONCLUSIONS

DES was the best treatment regarding 3-year primary patency, TLR and mortality, and DCB was the best regarding major amputation. DES was the best treatment regarding 5-year TLR, and DCB was the best regarding primary patency and major amputation. DES and DCB should be given priority in treating femoropopliteal lesions.

Data sources and applied methods for paclitaxel safety signal discernment

Background

Following the identification of a late mortality signal, the Food and Drug Administration (FDA) convened an advisory panel that concluded that additional clinical study data are needed to comprehensively evaluate the late mortality signal observed with the use of drug-coated balloons (DCB) and drug-eluting stent (DES). The objective of this review is to (1) identify and summarize the existing clinical and cohort studies assessing paclitaxel-coated DCBs and DESs, (2) describe and determine the quality of the available data sources for the evaluation of these devices, and (3) present methodologies that can be leveraged for proper signal discernment within available data sources.

Methods

Studies and data sources were identified through comprehensive searches. original research studies, clinical trials, comparative studies, multicenter studies, and observational cohort studies written in the English language and published from January 2007 to November 2021, with a follow-up longer than 36 months, were included in the review. Data quality of available data sources identified was assessed in three groupings. Moreover, accepted data-driven methodologies that may help circumvent the limitations of the extracted studies and data sources were extracted and described.

Results

There were 39 studies and data sources identified. This included 19 randomized clinical trials, nine single-arm studies, eight registries, three administrative claims, and electronic health records. Methodologies focusing on the use of existing premarket clinical data, the incorporation of all contributed patient time, the use of aggregated data, approaches for individual-level data, machine learning and artificial intelligence approaches, Bayesian approaches, and the combination of various datasets were summarized.

Conclusion

Despite the multitude of available studies over the course of eleven years following the first clinical trial, the FDA-convened advisory panel found them insufficient for comprehensively assessing the late-mortality signal. High-quality data sources with the capabilities of employing advanced statistical methodologies are needed to detect potential safety signals in a timely manner and allow regulatory bodies to act quickly when a safety signal is detected.

Risk of Mortality Related to Recurrent Limb Events After Endovascular Revascularization of the Superficial Femoral Artery for Peripheral Artery Disease: The Boston Femoral Artery Endovascular Revascularization Outcomes (Boston FAROUT) Study

Endovascular revascularization of the superficial femoral artery (SFA) may lead to recurrent ischemic syndromes, revascularization, or amputation. The impact of these events on mortality is unknown. We followed all patients having SFA endovascular revascularization for claudication or chronic limb-threatening ischemia in 2 cardiovascular (CV) divisions in Boston, Massachusetts. Any recurrent limb event after the initial SFA revascularization included recurrent claudication (67%), limb ulceration or gangrene (13%), repeat endovascular revascularization (61%), surgical revascularization (15%), or major (9%) or minor amputation (8%). We linked data to the National Death Index to ascertain cause of death grouped into CV mortality, or non-CV mortality. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) from Cox proportional hazards and sub-HRs from Fine-Gray competing risks analyses were clustered by patient. Overall, there were 202 patients with 253 index limb endovascular procedures. A recurrent limb event occurred in 123 limbs (49%) and 93 patients (46%). Patients with and without recurrent limb events had similar numbers of deaths over follow-up (76 [62%] vs 71 [55%], respectively). In multivariable models, recurrent limb event was not related to all-cause death (HR 0.92, 95% CI 0.64 to 1.33), CV death (HR 1.29, 95% CI 0.72 to 1.30), or non-CV death (HR 0.65, CI 0.39 to 1.07). Competing risk analyses suggested male gender and chronic limb-threatening ischemia were more strongly related to CV death, and chronic kidney more strongly related to disease to non-CV death. In conclusion, recurrent limb events, which contribute to patient morbidity, do not increase the risk of all-cause or cause-specific mortality, and should not discourage repeat revascularization to relieve symptoms or ischemia.

Five-Year Independent Patient-Level Mortality Analysis of the Pooled ILLUMENATE Pivotal and EU Randomized Controlled Trials

Background

There is a need to evaluate the latest information regarding a potential late safety signal in patients treated with paclitaxel-coated devices for peripheral artery disease. We evaluated the 5-year all-cause mortality rate of the Stellarex drug-coated balloon (DCB) compared with percutaneous transluminal angioplasty (PTA).

Methods

An independent third-party performed a patient-level meta-analysis of the pooled ILLUMENATE Pivotal and EU randomized controlled trials. The primary outcome was time to death. Kaplan-Meier estimates of all-cause mortality were compared with the log-rank test. Predictors of mortality were assessed with Cox proportional hazard modeling. A blinded clinical events committee adjudicated all serious adverse events (including death). The follow-up was 60 months.

Results

A total of 589 patients were followed for a median of 4.9 years (IQR, 4.8, 5.1 years); 419 were randomized to Stellarex DCB and 170 to PTA. Vital status was obtained for 93.8%. The 5-year Kaplan-Meier estimates of freedom from all-cause death were 80.4% (95% CI, 76.7%-84.3%) in the Stellarex DCB arm versus 80.4% (95% CI, 74.3%-86.5%) in the PTA arm (log-rank, P = .7754). There was no difference in all-cause mortality when stratified by paclitaxel dose terciles. Predictors of mortality included renal insufficiency, reference vessel diameter, age, and lesion length, but not paclitaxel dose nor paclitaxel exposure.

Conclusions

There was no difference in all-cause mortality between the Stellarex DCB and PTA through the final 5-year follow-up window of 2 ILLUMENATE randomized controlled trials. These long-term data build on the previously reported safety of the Stellarex DCB for treating symptomatic femoropopliteal peripheral artery disease.

Coronary Drug-Coated Balloons for De Novo and In-Stent Restenosis Indications

Drug-coated balloons are approved outside the United States, not only for the treatment of peripheral arteries but also for coronary arteries. This review describes the technological basics, the scenarios of clinical application, and the current available data from clinical trials for the different coronary indications.

Drug-Coated Balloon versus Drug-Eluting Stent: The Debate of Leave Nothing Behind

Endovascular techniques for peripheral artery disease have changed significantly in the past 10 years with advances in technology and data. Treatment of superficial femoral disease is complex secondary to the length, degree of calcification, high rate of chronic total occlusion, and areas of flexion within this vessel. Use of drug-coated devices has increased the interventionalist's toolbox with the objective to improve freedom from target lesion revascularization and primary patency. There remains debate as to which devices may reach these goals while also limiting overall morbidity and mortality. This article aims to highlight recent advances in the literature regarding the use of drug-coated devices.

Repetition of Paclitaxel-Coated Devices for the Treatment of Lower Extremity Artery Disease: Mortality Outcomes and Predictors

BACKGROUND

A recent meta-analysis reported late excess mortality in patients treated with paclitaxel-coated devices (PCDs) for symptomatic femoropopliteal disease. However, this finding is controversial.

OBJECTIVES

To investigate the impact on mortality and predictors of repeat exposure to PCDs in patients with lower extremity peripheral arterial disease (LE-PAD).

METHODS

We analyzed registry patient-level data from two centers. A total of 214 patients were enrolled, and stratified based on terciles of cumulative dose of paclitaxel. We treated 134 patients with a single PCD exposure and 80 with multiple PCD exposures. We used the follow-up index (FUI) in Kaplan-Meier survival estimates to minimize potential selection bias. We used Cox proportional hazard and splines models to determine the predictors of mortality and assess their relationships with mortality.

RESULTS

The mean cumulative dose of paclitaxel was significantly different among groups (6.40 mg vs. 15.06 mg vs. 38.57 mg, p < 0.001). The 5-year FUI (0.93 ± 0.19 vs. 0.94 ± 0.18 vs. 0.95 ± 0.15, p = 0.836) and survival rates were not different (65.4% vs. 51.9% vs. 72.0%, p = 0.148). There was no dose-response association between paclitaxel dosage and death (p = 0.297). The predictors of death were congestive heart failure, stroke, dialysis dependence, neutrophil-lymphocyte ratio (NLR) > 3, age > 71 years, and body mass index (BMI) < 20 kg/m2. Spline model analysis validated the non-linear associations between mortality, age, BMI, and NLR.

CONCLUSIONS

Repeated PCD exposure for LE-PAD did not result in excess late mortality. Predictors of mortality might change over time, and continuous variables had non-linear relationships with death.

Single-Center Study Evaluating Long-Term Major Adverse Outcomes with the Use of Paclitaxel-Coated Balloons in Treating Infrainguinal Arterial Disease

Paclitaxel drug-coated balloons (DCB) have been shown to reduce target lesion revascularization (TLR) rate, but recently an association between paclitaxel and an increase in mortality at 5-year was reported. We reviewed the 5-year mortality and freedom from TLR rates from a single center among patients that received DCB. Consecutive patients that received DCB from July 8, 2015 to November 27, 2019 with follow-up obtained from medical records and review of official death certificates were reviewed. The primary objective was total mortality and TLR rates with cumulative exposure to paclitaxel-coated balloons. Demographic, angiographic, clinical, and procedural variables were collected. Causes of mortality were classified according to death certificates. Descriptive analysis was performed on all variables. Kruskal-Wallis test was used to compare the total length of DCBs in those who were alive and those who died by the end of study. Kaplan-Meier (KM) was used to plot the freedom from mortality up to 5 years. A total of 91 symptomatic patients received the Lutonix balloon at index to treat femoropopliteal arterial disease and subsequently received either Lutonix or in.PACT during the follow-up phase for additional procedures. Age was 68.4 ± 10.8 years (56.0% males). Critical limb ischemia was present in 20.9%. There was no statistical difference in mortality between the median total number of balloons used among patients who were alive versus those who died (2.5 vs. 3.0, p -value = 0.89). Also, there was no statistical difference in the total length of DCB balloons used between those who were alive and those who died at the end of the study (p-value = 0.39). There were no in-hospital amputation or death. At 5-year follow-up KM freedom from TLR was 78.5%. A total of 13 patients died during follow-up. Of these 10 received only the Lutonix balloon and 3 did receive both Lutonix and In.PACT. The yearly KM freedom from mortality for the Lutonix only cohort were 92.7, 89.1, 85.5, 83.6, and 81.8% at 1, 2, 3, 4, and 5 years, respectively. Freedom from TLR and mortality at 5 years appears to be favorable with the use of DCB, predominantly Lutonix balloon in this cohort. This data needs to be supported prospectively by a larger number of patients.

The Use of Paclitaxel-Coated Devices in the Treatment of Peripheral Arterial Disease Is Not Associated with Increased Mortality or Amputations

INTRODUCTION AND OBJECTIVES

Strategies for the most effective treatment for peripheral arterial disease (PAD) remain controversial among clinicians. Several trials have shown improved primary patency of femoropopliteal interventions with the utilization of paclitaxel-coated balloons or stents (DCBS) compared to conventional balloons or stents. However, a 2018 meta-analysis suggested an increased mortality risk for patients receiving DCBS, resulting in an international pause in the use of DCBS. A 2021 meta-analysis by the same group suggested an increased risk of major amputation following DCBS use in peripheral arterial revascularization procedures. Here we report our long-term institutional outcomes comparing uncoated devices to DCBS.

METHODS

A retrospective review of all patients who underwent peripheral arterial angioplasty, stenting, atherectomy, or a combination between 2011 and 2020 within a regional healthcare system was performed. Univariate, multivariate and survival analyses were performed using standard statistical methods to assess the primary endpoints of overall survival, 5-year survival, and amputation-free survival.

RESULTS

A total of 2717 patients were identified, of whom 1965 were treated with conventional uncoated devices and 752 were treated with DCBS. Univariate analysis showed that patients treated with non-DCBS had higher rates of overall mortality, major amputations, as well as mortality at 1, 3 and 5 years. Multivariable analysis demonstrated that use of conventional devices, age, diabetes, chronic kidney disease, MI, TIA, warfarin use and atrial fibrillation all significantly increased the risk of 5-year mortality, overall mortality, and combined mortality and/or amputation.

CONCLUSIONS

DCBS are not associated with increased mortality or worse amputation-free survival in this real-world cohort of patients treated for PAD. Our data suggest that mortality is more closely linked with pre-existing patient comorbidities rather than device selection at the time of revascularization.

Systematic review and meta-analysis of the outcomes of drug eluting stent versus drug coated balloon angioplasty for lower extremity peripheral artery diseases

OBJECTIVES

Recent evidence raised the concern that paclitaxel-containing therapy was associated with increased risk of mortality in patients with peripheral artery diseases (PAD). However, it is unclear whether drug-eluting stent (DES) versus drug-coated balloon (DCB) have different effect on mortality of PAD patients. Our study aimed to systematically review current literature comparing clinical outcomes of patients treated with DES versus DCB for PAD.

METHODS

Medline and Embase were searched for eligible studies from January 2000 to December 31^st, 2020. Randomized controlled trials (RCT) or cohort studies that reported outcomes of DES versus DCB were included in our study. The primary outcome was 12-month all-cause mortality. Random-effect model was used to pool the odds ratios (OR) and related 95% confidence intervals (CI).

RESULTS

Our review included seven studies, involving two RCTs and five cohort studies. A total of 4237 patients with DES and 9234 patients with DCB were analyzed. All included cohort studies were high-quality with Newcastle-Ottawa scores from 7 to 8. No significant difference in 12-month all-cause mortality was found between DES and DCB without significant heterogeneity (OR 1.02, 95%CI 0.91-1.14, I²=0%). As for primary patency, no significant difference between treatments was observed (OR 1.27, 95%CI 0.75-2.15, I²=55%). Similar results were observed for freedom from target lesion revascularization (OR 0.94, 95%CI 0.64-1.40, I²=0%).

CONCLUSIONS

This systematic review and meta-analysis suggest that no significant difference in 12-month all-cause mortality was found between DES and DCB. Primary patency and freedom from target lesion revascularization of lower extremity PAD were also comparable between the two groups.

Efficacy and safety of drug-coated balloon versus non-drug-coated balloon combined with bare metal stent implantation in treatment of patients with occlusions of the superficial femoral artery: a retrospective study in clinical practice

OBJECTIVE

To assess the efficacy and safety of drug-coated balloon and non-drug-coated balloon combined with bare metal stent implantation for the treatment of patients with occlusions of the superficial femoral artery.

METHODS

In this retrospective study, 83 patients with occlusions of the superficial femoral artery were included. Among them, 41 patients received paclitaxel drug coated balloon treatment combined with bare metal stent implantation treatment (experimental group), the remaining 42 received non-drug-coated balloon treatment (control group). Patients were followed up at 1, 6, and 12 months after surgery. The primary clinical assessments, including ankle brachial index (ABI), RutherFord grade, Doppler ultrasound, or CT angiography (CTA), were used to observe the patency of target vessels, perioperative and postoperative complications.

RESULTS

All the diseased vessels were successfully opened. There were no serious intraoperative complications such as vascular rupture or acute thrombosis. There was no significant difference in ankle brachial index, RutherFord grade, and total score between the two groups at one month and six months after operation (P>0.05). There was no significant difference in mortality, amputation rate, or thrombosis between the two groups (P>0.05). Twelve months after the operation, the ankle brachial index, Rutherford grade and total score of the experimental group were better than those of the control group (P<0.05). There was no significant difference in mortality, amputation rate, or thrombosis between the two groups (P>0.05).

CONCLUSION

Paclitaxel coated balloon is safe and effective in the treatment of superficial femoral arteriosclerosis occlusion. It can significantly improve the ABI and Rutherford grades of patients, and it had a higher patency rate and lower reconstruction rate, but it may affect the healing ability of foot ulcer.

Progress in drug-delivery systems in cardiovascular applications: stents, balloons and nanoencapsulation

Drug-delivery systems in cardiovascular applications regularly include the use of drug-eluting stents and drug-coated balloons to ensure sufficient drug transfer and efficacy in the treatment of cardiovascular diseases. In addition to the delivery of antiproliferative drugs, the use of growth factors, genetic materials, hormones and signaling molecules has led to the development of different nanoencapsulation techniques for targeted drug delivery. The review will cover drug delivery and coating mechanisms in current drug-eluting stents and drug-coated balloons, novel innovations in drug-eluting stent technologies and drug encapsulation in nanocarriers for delivery in vascular diseases. Newer technologies and advances in nanoencapsulation techniques, such as the use of liposomes, nanogels and layer-by-layer coating to deliver therapeutics in the cardiovascular space, will be highlighted.

No Mortality Signal With Stellarex Low-Dose Paclitaxel DCB: ILLUMENATE Pivotal 4-Year Outcomes

BACKGROUND

Paclitaxel-coated balloons have shown safety and efficacy in the short- to intermediate-term; however, long-term data remain limited.

OBJECTIVES

To report late safety and efficacy outcomes for a low-dose paclitaxel drug-coated balloon (DCB) compared with percutaneous transluminal angioplasty (PTA) in femoropopliteal lesions from a large randomized controlled trial (RCT).

METHODS

ILLUMENATE Pivotal is a multicenter, single-blind RCT conducted across 43 US and EU centers to examine the safety and efficacy of the Stellarex DCB for the treatment of femoropopliteal disease. Assessments were recorded for all active patients at 36 and 48 months. Vital status of patients formally exited from the study was also collected.

RESULTS

Primary patency through 36 months for patients treated with DCB was significantly higher compared with PTA (p=0.016). The primary safety endpoint through 36 months was 77.4% and 72.4%, respectively (p=0.377). Kaplan-Meier analysis indicated that a higher proportion of DCB subjects were event-free compared with PTA at all study visits. The rate of major adverse event (MAE) through 48 months was 32.9% in the DCB group and 37.9% in the PTA group (p=0.428). No differences in the rate of mortality were evident through 48 months of follow-up with 15.6% in the DCB group and 15.2% in the PTA group (p=0.929).

CONCLUSIONS

Stellarex DCB was associated with significantly higher patency compared with PTA through 3 years with no mortality difference detected through 4 years. The data from the ILLUMENATE Pivotal RCT support the long-term safety and efficacy of the low-dose Stellarex DCB.

Comparative effectiveness of endovascular treatment modalities for de novo femoropopliteal lesions in intermittent claudication: A network meta-analysis of randomized controlled trials

PURPOSE

To evaluate the most effective endovascular treatment modalities for de novo femoropopliteal lesions in intermittent claudication (IC) in terms of technical success, primary patency, target lesion revascularization (TLR) and all-cause mortality through network meta-analysis of randomized controlled trials.

METHODS

Medical databases were searched on December 3, 2020. 16 studies (3265 patients) and 7 treatments were selected. Outcomes were technical success, primary patency, TLR and mortality at 6 and/or 12 months.

RESULTS

Regarding 6-month primary patency, drug-eluting stents (DES) was better than balloon angioplasty (BA; odds ratio [OR], 23.27; 95% confidence interval [CI], 12.57-43.06), drug-coated balloons (DCB; OR, 5.63; 95% CI, 2.26-14.03) and directional atherectomy (DA; OR, 31.52; 95% CI, 7.81-127.28), and bare nitinol stents (BNS) was better than BA (OR, 17.91; 95% CI, 7.22-44.48), DCB (OR, 4.33; 95% CI, 1.40-13.45) and DA (OR, 24.27; 95% CI, 5.16-114.11). Regarding 12-month primary patency, DES was better than BA (OR, 10.05; 95% CI, 4.56-22.16), DCB (OR, 3.70; 95% CI, 1.54-8.89) and DA (OR, 29.54; 95% CI, 7.26-120.26). DCB and combination of balloon and atherectomy were the most effective treatment regarding 12-month TLR and technical success (residual stenosis <30%), respectively. DES, BNS and DA with DCB (DA-DCB) were included in the best cluster in the clustered ranking plot combining 12-month primary patency and TLR.

CONCLUSIONS

Balloon and atherectomy may confer advantages over other treatments for technical success; DCB may for TLR. Stent technologies confer substantial advantages regarding primary patency. Stent technologies and DA-DCB should be given priority in treating femoropopliteal lesions in IC.

Drug-coated balloon angioplasty for failing haemodialysis access: meta-analysis of randomized clinical trials

BACKGROUND

Arteriovenous fistulas, a major treatment for end-stage kidney disease, frequently require endovascular reinterventions to maintain haemodialysis function. Drug-coated angioplasty balloons (DCBs) were developed with the intention of reducing reintervention rates. The aim of this study was to perform a systematic review and meta-analysis of DCBs in the treatment of failing haemodialysis access.

METHODS

Electronic databases were searched systematically to identify all relevant RCTs and any follow-up studies from RCTs. Pooled estimates of dichotomous outcomes were calculated using the odds ratio (OR) and 95 per cent confidence interval. Effect data are presented as summary hazard ratio and 95 per cent confidence interval.

RESULTS

Some 19 studies from 18 RCTs and comprising 1898 patients were included in the meta-analysis. Compared with plain balloon angioplasty (PBA), DCB use was associated with higher target-lesion primary patency (HR 0.60, 95 per cent c.i. 0.45 to 0.79), access-circuit primary patency (HR 0.67, 0.56 to 0.80), and less target-lesion revascularization (TLR) within 6 months (OR 0.33, 0.23 to 0.47). No difference was observed between DCB and PBA in 12-month TLR (OR 0.62, 0.28 to 1.37). Mortality after DCB use was similar to that associated with PBA use at 6 months (OR 1.20, 0.65 to 2.21) and 12 months (OR 0.99, 0.66 to 1.49), and was higher at 24 months (23.1 versus 16.6 per cent), although the difference was not statistically significant (OR 1.53, 0.92 to 2.53).

CONCLUSION

Drug-coated balloon angioplasty of haemodialysis fistulas is associated with higher patency rates and lower rates of reintervention in the short to mid term. Although mortality rates appeared to be higher with drug-coated angioplasty at 24 months, this did not reach statistical significance.

Safety and Effectiveness of Paclitaxel Drug-Coated Devices in Peripheral Artery Revascularization: Insights From VOYAGER PAD

BACKGROUND

Paclitaxel drug-coated devices (DCDs) were developed to improve lower extremity revascularization (LER) patency in peripheral artery disease (PAD) but have been associated with long-term mortality.

OBJECTIVES

This study assessed DCD safety and effectiveness in LER for PAD.

METHODS

VOYAGER PAD (Vascular Outcomes Study of ASA [acetylsalicylic acid] Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD) randomized patients with PAD who underwent LER to rivaroxaban or placebo. The primary VOYAGER PAD study efficacy and safety outcomes were composite cardiovascular and limb events and Thrombolysis In Myocardial Infarction major bleeding. For prespecified DCD analyses, primary safety and effectiveness outcomes were mortality and unplanned index limb revascularization (UILR). Major adverse limb events (MALE) were a secondary outcome. Inverse probability treatment weighting was used to account for each subject's propensity for DCD treatment. Effects of rivaroxaban were assessed with Cox proportional hazards models.

RESULTS

Among 4,316 patients who underwent LER, 3,478 (80.6%) were treated for claudication, and 1,342 (31.1%) received DCDs. Median follow-up was 31 months, vital status was ascertained in 99.6% of patients, and there were 394 deaths. After weighting, DCDs were not associated with mortality (HR: 0.95; 95% CI: 0.83-1.09) or MALE (HR: 1.08; 95% CI: 0.90-1.30) but were associated with reduced UILR (3-year Kaplan-Meier: 21.5% vs 24.6%; HR: 0.84; 95% CI: 0.76-0.92). Irrespective of DCD use, consistent benefit of rivaroxaban for composite cardiovascular and limb events (Pinteraction = 0.88) and safety of rivaroxaban with respect to bleeding (Pinteraction = 0.57) were observed.

CONCLUSIONS

In >4,000 patients with PAD who underwent LER, DCDs were not associated with mortality or MALE but were associated with persistent reduction in UILR. These findings provide insight into the safety and effectiveness of DCDs in PAD. (Vascular Outcomes Study of ASA [acetylsalicylic acid] Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD [VOYAGER PAD]; NCT02504216).

Revascularization Strategies for Acute and Chronic Limb Ischemia

Chronic limb-threatening ischemia requires aggressive risk factor management and a thoughtful approach to the complex decision of best strategy for revascularization. Patients often have multilevel disease amenable to endovascular, open surgical, or hybrid approaches. Limited high-quality evidence is available to support a specific strategy; randomized trials are ongoing. Acute limb ischemia is associated with a high risk of limb loss and mortality. Catheter-directed thrombolysis is mainstay of therapy in patients with marginally threatened limbs, whereas those immediately threatened with motor deficits require more rapid restoration of flow with open or endovascular techniques that can establish flow in single setting.

[Are there alternatives to dual antiplatelet therapy after stenting of peripheral arteries?]

It is estimated that more than 200 million people worldwide suffer peripheral artery disease and the rate of amputations remains at a high level. The basis of treatment is timely revascularization wherein the fraction of interventions performed endovascularly has steadily been growing both in Russia and abroad. Nevertheless, the parameters of long-term patency of endovascular reconstructions of the infrainguinal segment are still inferior to open interventions. In order to select an optimal method of revascularization and to predict the duration of patency of the reconstruction modern clinical guidelines suggest using the GLASS and WIfI scales, which may improve the remote results of the intervention. Moreover, modern paclitaxel-coated stents and balloons may help increase primary patency of the reconstruction after endovascular procedures. A not less important method of improving remote results of endovascular treatment of patients with peripheral artery disease is considered to be the use of contemporary regimens of antithrombotic therapy. The VOYAGER PAD trial showed that in patients with peripheral artery disease after endured revascularization of lower limbs rivaroxaban prescribed at a dose of 2.5 mg twice daily in a combination with conventional antithrombocytic therapy made it possible to decrease the risk of such ischaemic complications as acute limb ischaemia, major amputation, myocardial infarction, ischaemic stroke and death of cardiovascular causes.

Four-Year Patient-Level Pooled Mortality Analysis of the ILLUMENATE US Pivotal and EU Randomized Controlled Trials

OBJECTIVE

To perform a meta-analysis of two concordant randomized controlled trials (RCTs) examining the long-term, four-year safety profile of the Stellarex drug-coated balloon (DCB) versus percutaneous transluminal angioplasty (PTA) for the treatment of peripheral artery disease.

METHODS

An independent, third-party, meta-analysis of homogenous, patient-level data from the ILLUMENATE Pivotal and ILLUMENATE EU RCTs was performed to assess mortality (time to death) in patients treated for symptomatic femoropopliteal disease. Kaplan Meier (KM) methodology was used to estimate hazard rates of all-cause mortality and Cox proportional hazard modeling was used to assess predictors of mortality. All serious adverse events, including deaths, were adjudicated by an independent, blinded clinical events committee (CEC).

RESULTS

In total, 589 (419 DCB; 170 PTA) patients were included in the pooled analysis of the ILLUMENATE Pivotal and ILLUMENATE EU RCTs. The median follow-up was 1735 days (IQR 1434-1829), equivalent to 4.75 years. Vital status compliance was >95% in each RCT. The total number of deaths through four years was 81/589 (13.8%); 58/419 (13.8%) in the DCB arm and 23/170 (13.5%) in the PTA arm. The one-year KM estimate of all-cause mortality was 1.9% ± 0.7% (estimate ± SE) in those treated with DCB versus 1.2 ± 0.9% in those treated with PTA. At two, three, and four years, the respective KM estimates were 6.6 ± 1.2% versus 4.9 ± 1.7%, 9.3 ± 1.4% versus 9.9 ± 2.4%, and 14.0% ± 1.7% versus 14.4% ± 2.8% (P = 0.864). There were no significant differences in CEC-adjudicated deaths between the two cohorts. In multivariate analysis, predictors of four-year mortality were age (HR, 1.048; 95% CI, 1.026 - 1.071; P < 0.0001), renal insufficiency (HR, 2.440; 95% CI, 1.566 - 3.800; P < 0.0001), and lesion length (HR, 1.004; 95% CI, 1.000 - 1.008; P = 0.041). Neither paclitaxel exposure (DCB versus PTA; HR, 1.086; 95% CI, 0.709 - 1.664; P = 0.705) nor dose (mg; HR, 1.043; 95% CI, 0.971 - 1.119; P = 0.248) were predictors of all-cause mortality at four years.

CONCLUSIONS

This systematic meta-analysis of two concordant ILLUMENATE RCTs shows no difference in all-cause mortality through four-years between Stellarex DCB and PTA, confirming the acceptable, long-term safety profile of the Stellarex DCB.

Longitudinal Assessment of Safety of Femoropopliteal Endovascular Treatment With Paclitaxel-Coated Devices Among Medicare Beneficiaries: The SAFE-PAD Study

IMPORTANCE

Paclitaxel-coated peripheral devices have been associated with increased mortality, yet this harm signal has not been replicated outside of meta-analyses of small trials.

OBJECTIVE

To provide a longitudinal assessment of the safety of femoropopliteal endovascular treatment with peripheral drug-coated devices (DCDs) among Medicare beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

SAFE-PAD (Safety Assessment of Femoropopliteal Endovascular Treatment With Paclitaxel-Coated Devices) was a retrospective cohort study designed with the US Food and Drug Administration to evaluate the noninferiority of mortality between DCDs and non-drug-coated devices (NDCDs) for femoropopliteal revascularization performed in 2978 inpatient and outpatient facilities in the US from April 1, 2015, through December 31, 2018. Evaluation of the primary outcome was assessed through May 31, 2020. Participants were Medicare fee-for-service beneficiaries 66 years and older with 1 or more years of enrollment prior to femoropopliteal revascularization. Prespecified subgroups included low-risk cohorts, procedure location, disease severity, and device type. Inverse probability weighting was used to account for imbalances of observed characteristics. Sensitivity analyses were used to evaluate the potential influence of unmeasured confounding.

EXPOSURES

Treatment with DCDs vs NDCDs as determined by claims codes during the index procedure.

MAIN OUTCOMES AND MEASURES

The primary outcome was all-cause mortality. Secondary outcomes included repeated hospitalization, repeated lower extremity revascularization, and lower extremity amputation. Falsification end points were acute myocardial infarction, congestive heart failure, and pneumonia.

RESULTS

Of 168 553 patients, 70 584 (41.9%) were treated with a DCD. The mean (SD) age was 77.0 (7.6) years, 75 744 (44.9%) were female, 136 916 of 167 197 (81.9%) were White individuals, 85 880 of 168 553 (51.0%) had diabetes, 82 554 of 168 553 (49.0%) used tobacco, 78 665 of 168 553 (45.7%) had critical limb ischemia (CLI), and 13 296 of 168 553 (7.9%) had a prior amputation. Median follow-up was 2.72 years (interquartile range, 0.87-3.77; longest, 5.16 years). After weighting, the cumulative incidence of all-cause mortality was 53.8% with DCDs and 55.1% with NDCDs (hazard ratio [HR], 0.95; 95% CI, 0.94-0.97; noninferiority P < .001). Cox regression and instrumental variable analyses were consistent with the primary findings. No harm associated with DCDs was observed among subgroups, including those treated with stents (HR, 0.97; 95% CI, 0.95-1.00) or balloons (HR, 0.94; 95% CI, 0.92-0.96), with or without CLI (CLI: HR, 0.95; 95% CI, 0.93-0.97; non-CLI: HR, 0.97; 95% CI, 0.95-0.99), and those within the lowest quartile of total comorbidities (HR, 0.95; 95% CI, 0.92-0.99).

CONCLUSIONS AND RELEVANCE

In this initial report from the SAFE-PAD cohort study, DCDs were found to be noninferior to NCDCs in respect to mortality through a median follow-up of 2.72 years. This finding remained robust in sensitivity analyses and was consistent across prespecified subgroups.

Paclitaxel Exposure and Dosage of Drug-coated Devices for the Treatment of Femoropopliteal Peripheral Artery Disease

The role of paclitaxel in the treatment of femoropopliteal peripheral arterial disease is currently ambiguous. A summary-level meta-analysis of randomised trials published in 2018 demonstrated that paclitaxel-coated devices were associated with an increased all-cause mortality in those who underwent treatment at 2 years and 5 years. Further evaluation has been undertaken to establish whether there is a specific dose response, mechanism or reproducible signal. At this time, there has been no confirmation of dose response, as was initially asserted by the summary-level meta-analysis. No mechanism of harm has been identified. Although an association with increased mortality has been confirmed by patient-level meta-analysis, the strength of the signal has been inconsistent. The information suggests there is only an association between paclitaxel-coated devices and increased all-cause mortality, not causation. The authors encourage additional studies designed to follow long-term results after treatment with paclitaxel-coated devices, using real patient data, before a conclusion can be made.

One-year outcomes of drug-coated balloon treatment for long femoropopliteal lesions: a multicentre cohort and real-world study

Background

Drug-coated balloons (DCBs) have shown superiority in the endovascular treatment of short femoropopliteal artery disease. Few studies have focused on outcomes in long lesions. This study aimed to evaluate the safety and effectiveness of Orchid^® DCBs in long lesions over 1 year of follow-up.

Methods

This study is a multicentre cohort and real-world study. The patients had lesions longer than or equal to 150 mm of the femoropopliteal artery and were revascularized with DCBs. The primary endpoints were primary patency, freedom from clinically driven target lesion revascularization (TLR) at 12 months and major adverse events (all-cause death and major target limb amputation). The secondary endpoints were the changes in Rutherford classification and the ankle brachial index (ABI).

Results

One hundred fifteen lesions in 109 patients (mean age 67 ± 11 years, male proportion 71.6%) were included in this study. The mean lesion length was 252.3 ± 55.4 mm, and 78.3% of the lesions were chronic total occlusion (CTO). Primary patency by Kaplan–Meier estimation was 98.1% at 6 months and 82.1% at 12 months. The rate of freedom from TLR by Kaplan–Meier estimation was 88.4% through 12 months. There were no procedure- or device-related deaths through 12 months. The rate of all-cause death was 2.8%. Cox regression analysis suggested that renal failure and critical limb ischaemia (CLI) were statistically significant predictors of the primary patency endpoint.

Conclusion

In our real-world study, DCBs were safe and effective when used in long femoropopliteal lesions, and the primary patency rate at 12 months by Kaplan–Meier estimation was 82.1%.

Programmed death-1 mediates venous neointimal hyperplasia in humans and rats

Venous neointimal hyperplasia can be a problem after vein interventions. We hypothesized that inhibiting programmed death-1 (PD-1) can decrease venous neointimal hyperplasia in a rat inferior vena cava (IVC) patch venoplasty model. The rats were divided into four groups: the control group was only decellularized without other special treatment; the PD-1 group was injected with a single dose of humanized PD-1 antibody (4 mg/kg); the PD-1 antibody coated patches group; the BMS-1 (a PD-1 small molecular inhibitor) coated patches group (PD-1 inhibitor-1). Patches were implanted to the rat IVC and harvested on day 14 and analyzed. Immunohistochemical analysis showed PD-1-positive cells in the neointima in the human samples. There was high protein expression of PD-1 in the neointima in the rat IVC venoplasty model. PD-1 antibody injection can significantly decrease neointimal thickness (p < 0.0001). PD-1 antibody or BMS-1 was successfully conjugated to the decellularized rat thoracic artery patch by hyaluronic acid with altered morphology and reduced the water contact angle (WCA). Patches coated with humanized PD-1 antibody or BMS-1 both can also decrease neointimal hyperplasia and inflammatory cells infiltration. PD-1-positive cells are present in venous neointima in both human and rat samples. Inhibition of the PD-1 pathway may be a promising therapeutic strategy to inhibit venous neointimal hyperplasia.

Results of drug-eluting stent in significant restenosis of the hemodialysis access: An initial study

BACKGROUND

This study aimed to report the 12-month results of drug-eluting stent (DES) for the treatment of significant restenosis of the hemodialysis access.

MATERIALS AND METHODS

A total of 14 patients (seven men and seven women; median age 70 years; range of 50-83 years) with significant restenosis of hemodialysis accesses were enrolled from January 2017 to December 2018. A total of 10 arteriovenous graft (AVG) and four arteriovenous fistulae were treated with DES. Study outcomes included primary patency of the target lesion and circuit.

RESULTS

Venous anastomosis of the AVG was the most common target lesion for DES insertion (nine hemodialysis accesses). The range of follow-up time was 12-36 months. Primary patency rates of target lesion before DES (patency for last conventional balloon angioplasty [CBA]) versus target lesion after DES at 6 and 12 months were 29% versus 100% and 7% versus 86% (p < 0.001). Primary patency rates of pre-DES circuit (patency for last CBA) versus post-DES circuit at 6 and 12 months were 29% versus 64% and 7% versus 29%, respectively (p = 0.058).

CONCLUSION

DES might improve the patency rate of target lesion in patients with significant restenosis of the hemodialysis access.

Mortality Rates After Paclitaxel-Coated Device Use in Patients With Occlusive Femoropopliteal Disease: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

A late increased mortality risk has been reported in a summary level meta-analysis of patients with femoropopliteal artery occlusive disease treated with paclitaxel-coated angioplasty balloons and stents. However, at the longer follow up timepoints that analysis was limited by small trial numbers and few participants. The aim of this study was to report an updated summary level risk of all-cause mortality after treatment with paclitaxel-coated devices in that same patient group.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis of randomized controlled trials to investigate the mortality outcomes associated with paclitaxel-coated devices used to treat patients with occlusive disease of femoropopliteal arteries (last search date December 10, 2020). The single primary endpoint was all-cause mortality.

RESULTS

We identified 34 randomized controlled trials (7654 patients; 84% intermittent claudication). There were 622 deaths among 4147 (15.0%) subjects in the paclitaxel device group and 475 deaths among 3507 (13.5%) subjects in the noncoated control group [relative risk ratio (RR) 1.07, 95% confidence interval (CI) 0.96 to 1.20, p=0.20, I²=0%). All-cause mortality was similar between groups at 12 months (34 studies, 7654 patients; RR 0.99, 95% CI 0.81 to 1.22, p=0.94, I²=0%), 24 months (20 studies, 3799 patients; RR 1.16, 95% CI 0.87 to 1.55, p=0.31, I²=0%), and 60 months (9 studies, 2288 patients; RR 1.19, 95% CI 0.98 to 1.45, p=0.08, I²=0%).

CONCLUSION

This updated meta-analysis with included additional trials and larger patient numbers shows no evidence of increased risk of all-cause mortality in patients treated with paclitaxel-coated devices, compared with uncoated devices for femoropopliteal disease at all time points to 60 months. There is therefore no justification to limit their use, or alter regulatory body follow-up recommendations in this patient population.

SYSTEMATIC REVIEW REGISTRATION

CRD42020216140.

COMPARE: prospective, randomized, non-inferiority trial of high- vs. low-dose paclitaxel drug-coated balloons for femoropopliteal interventions

Aims

Drug-coated balloons (DCBs) for femoropopliteal interventions have not been tested against each other. We aimed to directly compare efficacy and safety of a high-dose (In.Pact™) vs. low-dose (Ranger™) DCB with nominal paclitaxel densities of 3.5 vs. 2.0 μg/mm².

Methods and results

Within a prospective, multicentre, non-inferiority, clinical trial 414 patients with symptomatic femoropopliteal lesions (Rutherford classification 2–4) were randomly assigned in a 1:1 ratio to endovascular treatment with either high- or low-dose DCB after stratification for lesion length. Primary efficacy and safety endpoints comprised primary patency and freedom from major adverse events (i.e. device and procedure-related deaths through 1 month, major amputations, and clinically driven target lesion revascularization through 12 months). We set a non-inferiority margin of −10% at 12 months. Total occlusions were observed frequently (>40%) and provisional stenting was performed in every fourth intervention. Non-inferiority was determined for both primary efficacy and safety endpoints at 12 months. Primary patency was 81.5% in the high-dose and 83.0% in low-dose DCB group {difference: 1.5% [lower bound of the 90% two-sided confidence interval (CI) −5.2%]; P  _{non-inferiority} < 0.01}. Freedom from major adverse events was determined in 92.6% in high-dose and in 91.0% in low-dose DCB group [difference −1.6% (lower bound of the 90% two-sided CI −6.5%); P  _{non-inferiority} < 0.01]. Overall death rate was low (2.0%) and no major amputation occurred.

Conclusion

Two DCBs with different coating characteristics exhibited comparable results with excellent effectiveness and safety through 12 months for femoropopliteal interventions including a wide range of lesion lengths.

Clinical trial registration

The trial is registered with ClinicalTrials.gov (NCT02701543).

1-Year Results From the RANGER II SFA Randomized Trial of the Ranger Drug-Coated Balloon

OBJECTIVES

This study sought to evaluate the safety and effectiveness of the Ranger drug-coated balloon (DCB) (paclitaxel dose density 2 μg/mm²) for treating superficial femoral artery or proximal popliteal artery lesions.

BACKGROUND

Paclitaxel-coated balloon treatment prevents reinterventions, but dose and coating characteristics differ among balloons and necessitate discrete confirmation of safety and effectiveness.

METHODS

Patients with symptomatic lower limb ischemia (Rutherford classification 2 to 4) were randomized 3:1 to treatment with the Ranger DCB or standard percutaneous transluminal angioplasty (PTA). Twelve-month primary target lesion patency, freedom from major adverse events (i.e., target lesion revascularization, major amputations, death within 1 month of the index procedure), and patient outcomes were analyzed.

RESULTS

Mean lesion length was 82.5 ± 48.9 mm for the Ranger DCB group (n = 278) and 79.9 ± 49.3 mm for the control group (n = 98). Ranger DCB was superior to PTA (82.9% [n = 194 of 234] vs. 66.3% [n = 57 of 86]) with observed 12-month primary patency rates yielding a difference of 16.6% (95% confidence interval: 5.5% to 27.7%; p = 0.0013). Noninferior freedom from major adverse events (94.1% [n = 241 of 256] vs. 83.5% [n = 76 of 91]) was demonstrated with a difference of 10.6% (95% confidence interval: 2.5% to 18.8%; noninferiority p < 0.0001). Primary patency rate curves showed significant separation by Kaplan-Meier analysis (log-rank p = 0.0005), with rates of 89.8% and 74.0% estimated at day 365 for the Ranger DCB and PTA cohorts, respectively.

CONCLUSIONS

The low-dose Ranger DCB demonstrated significantly better effectiveness than standard PTA through 1 year and a good safety profile. (Ranger™ Paclitaxel Coated Balloon vs Standard Balloon Angioplasty [RANGER II SFA]; NCT03064126).

Twenty-Four-Month Outcomes of Drug-Coated Balloon in Diabetic Patients in the BIOLUX P-III Registry: A Subgroup Analysis

OBJECTIVES

This study aims to assess the use of drug-coated balloon (DCB) in a large patient population under real-world conditions and, specifically, analyse the impact of diabetes mellitus on long term outcomes following DCB utilisation.

METHODS

BIOLUX P-III is a prospective, international, multicentre, registry that was conducted at 41 centres. The present study is a 24-month subgroup analysis of patients with diabetes mellitus having infrainguinal lesions treated with the Passeo-18 Lux DCB. The primary endpoints were freedom from major adverse events (MAEs) within 6 months of intervention and freedom from clinically driven target lesion revascularisation (CD-TLR) within 12 months of intervention.

RESULTS

Of the 882 patients in the registry, 418 had diabetes (516 lesions). Most diabetics had concomitant hypertension (88.8%) and hyperlipidaemia (70.3%). Insulin dependence was observed in 48.8% of diabetics. Moreover, smoking (62.2%) and chronic renal insufficiency (41.9%) were also found to be common in this cohort. Chronic limb threatening ischemia (Rutherford class ≥4) was present in 53.1% of all patients. 22.9% of lesions were infrapopliteal, while 22.5% of lesions were treated for in-stent restenosis. The mean target lesion length was 85.6 ± 73.2 mm, and 79.4% of lesions were calcified (of which 17.9% were heavily calcified). Overall, device success was 99.7%. Freedom from MAEs was 90.5% (95% confidence interval (95% CI): 87.2-93.0) at 6 months, 85.4% (95% CI: 81.5-88.6) at 12 months and 80% (95% CI: 75.5-83.8) at 24 months. Freedom from CD-TLR was 95.9% (95% CI: 93.8-97.4), 91.6% (95% CI: 88.7-93.8), and 87.1% (95% CI: 83.5-89.9) at 6, 12, and 24 months, respectively. All-cause mortality at 24 months in diabetics was 16.0% (95% CI: 12.6-20.2), and major target limb amputation was 6.1% (95% CI: 4.1-8.9), which was significantly higher than in non-diabetics (8.4% (95% CI: 6.0-11.6), P = 0.0005 and 1.2% (95% CI: 0.5-2.9), P <0.0001, respectively). At 24 months, 82.0% of patients had improved by ≥1 Rutherford class.

CONCLUSION

Treatment of a real-world diabetic patient population with the Passeo-18 Lux DCB resulted in high efficacy and low complication rates, despite the fact that diabetic patients usually suffer from a multitude of concomitant comorbidities.

CLINICAL TRIAL REGISTRATION

NCT02276313.

Survival and Causes of Death Among Veterans With Lower Extremity Revascularization With Paclitaxel-Coated Devices: Insights From the Veterans Health Administration

BACKGROUND The long-term safety of paclitaxel-coated devices (PCDs; drug-coated balloon or drug-eluting stent) for peripheral endovascular intervention is uncertain. We used data from the Veterans Health Administration to evaluate the association between PCDs, long-term mortality, and cause of death. METHODS AND RESULTS Using the Veterans Administration Corporate Data Warehouse in conjunction with International Classification of Diseases, Tenth Revision (ICD-10) Procedure Coding System, Current Procedural Terminology, and Healthcare Common Procedure Coding System codes, we identified patients with peripheral artery disease treated within the Veterans Administration for femoropopliteal artery revascularization between October 1, 2015, and June 30, 2019. An adjusted Cox regression, using stabilized inverse probability-weighted estimates, was used to evaluate the association between PCDs and long-term survival. Cause of death data were obtained using the National Death Index. In total, 10 505 patients underwent femoropopliteal peripheral endovascular intervention; 2265 (21.6%) with a PCD and 8240 (78.4%) with a non-PCD (percutaneous angioplasty balloon and/or bare metal stent). Survival rates at 2 years (77.4% versus 79.7%) and 3 years (70.7% versus 71.8%) were similar between PCD and non-PCD groups, respectively. The adjusted hazard for all-cause mortality for patients treated with a PCD versus non-PCD was 1.06 (95% CI, 0.95-1.18, P=0.3013). Among patients who died between October 1, 2015, and December 31, 2017, the cause of death according to treatment group, PCD versus non-PCD, was similar. CONCLUSIONS Among patients undergoing femoropopliteal peripheral endovascular intervention within the Veterans Administration Health Administration, there was no increased risk of long-term, all-cause mortality associated with PCD use. Cause-specific mortality rates were similar between treatment groups.

Mortality risk after use of a paclitaxel-coated stent in femoropopliteal peripheral artery disease

Although paclitaxel-based devices which demonstrated improved outcomes in the treatment of lower-extremity peripheral artery disease (PAD) have been used worldwide, Katsanos et al. reported a systematic review and summary-level meta-analysis of RCTs in which application of paclitaxel-based devices in the femoropopliteal artery was associated with an increased mortality risk. The purpose of this study was to describe the safety of endovascular therapy (EVT) using paclitaxel-coated stents for femoropopliteal disease by evaluating the mortality risk compared with patients treated with paclitaxel-free devices. A retrospective, multicenter, non-randomized study examined 481 de-novo symptomatic PAD patients treated in 13 Japanese medical centers from January 2011 to December 2015. The risk of all-cause mortality was analyzed between the 65 patients treated with a paclitaxel-coated stent (PTX-coated group) and 416 patients treated with an uncoated balloon or bare nitinol stent (PTX-free group). Overall survival of the PTX-coated group and the PTX-free group were compared after propensity score matching. The 2-year overall survival estimates were 87.7% in the PTX-coated group vs 88.7% in the PTX-free group. There were no significant differences in the mortality risk between the groups through a full follow-up of 2 years (p = 0.80). The multivariate cox proportional hazards model identified three significant predictors of mortality; age (HR, 1.08; 95% CI, 1.03-1.13; p = 0.002), hemodialysis (HR, 3.16; 95% CI, 1.34-7.42; p = 0.008), and albumin (g/dl) (HR, 0.46; 95% CI, 0.25-0.85; p = 0.01).

Update on paclitaxel for femoral-popliteal occlusive disease in the 15 months following a summary level meta-analysis demonstrated increased risk of late mortality and dose response to paclitaxel

BACKGROUND

Peripheral vascular devices (stents and balloons) coated with paclitaxel were developed to address suboptimal outcomes associated with percutaneous revascularization procedures of the femoral-popliteal arteries. In randomized controlled trials (RCT), paclitaxel-coated devices (PCD) provided increased long-term patency and a decreased need for repeat revascularization procedures compared with uncoated devices. This finding resulted in the adoption of their use for endovascular lower extremity revascularization procedures. However, in late 2018 a study-level meta-analysis showed increased all-cause mortality at 2 years or more after the procedure in patients treated with PCDs. This review examines the subsequent data evaluation following the publication of the meta-analysis.

METHODS

We review the published responses of physicians, regulatory agencies, and patient advocates during 15-month period after the meta-analysis. We present the additional data gathered from RCTs that comprised the meta-analysis and safety outcomes from large insurance databases in both the United States and Europe.

RESULTS

Immediately after the publication of the meta-analysis, concern for patient safety resulted in less PCD use, the suspension of large RCTs evaluating their use, and the publication of a letter from the U.S. Food and Drug Administration informing physicians that there was uncertainty in the benefit-risk profile of these devices for indicated patients and that the potential risk should be assessed before the use of PCDs. Review of the meta-analysis found that a mortality signal was present, but criticisms included that the evaluation was performed on study-level, not patient-level data, and the studies in the analysis were heterogenous in device type, paclitaxel doses, and patient characteristics. Further, the studies were not designed to be pooled nor were they powered for evaluating long-term safety. Clinical characteristics associated with a drug effect or causal relationship were also absent. Specifically, there was no dose response, no clustering of causes of death, and a lack of signal consistency across geographic regions. As more long-term data became available in the RCTs the strength of the mortality signal diminished and analysis of real-world use in large insurance databases, showed that there was no significant increase in all-cause mortality associated with PCD use.

CONCLUSIONS

The available data do not provide definitive proof for increased mortality with PCD use. A key observation is that trial design improvements will be necessary to better evaluate the risk-benefit profile of PCDs.

Long-Term Follow-Up of Percutaneous Coronary Intervention With Paclitaxel-Eluting Balloon Catheter

Drug-eluting balloons currently constitute a therapeutic tool used in percutaneous coronary interventions (PCI). Long-term results remain unknown. We evaluated the prognosis of PCI using a second generation paclitaxel-eluting balloon (PEB) in real-world patients. We included all PCI with PEB in de novo or in-stent restenosis coronary lesions performed in our unit from March 2009 to March 2019. We assessed the composite of major adverse cardiovascular events (MACE) rate after a median follow-up of 42 months. Consecutive patients (n = 320) with 386 lesions were included; 46.9% presented with stable angina and 53.1% acute coronary syndromes; 52.6% of the lesions were in-stent restenosis and 47.3% de novo lesions with a mean diameter of 2.4 ± 0.5 mm. A bare metal stent was implanted in 6.7% and a drug-eluting stent in 8.5% of patients. The MACE rate was 8%: 10 (2.6%) cardiovascular deaths, 13 (3.4%) myocardial infarctions, and 16 (4.1%) target lesion revascularization. The all-cause death rate was 5.2%. No cases of thrombosis were recorded. In conclusion, PEB was a safe and effective tool to treat in-stent restenosis and de novo coronary lesions, especially small vessel disease, during long-term follow-up.

The characteristics and risk factors of in-stent restenosis in patients with percutaneous coronary intervention: what can we do

BACKGROUND

Percutaneous coronary intervention (PCI) is a common treatment for patients with coronary heart disease, and intra-stent restenosis (ISR) is a serious complication after PCI. It's necessary to identify the potential risk factors to provide evidence for the prevention of ISR.

METHODS

The patients who underwent coronary angiography 1 year after PCI in our hospital from January 2017 to May 2019 were selected. The characteristics and results of clinical examination of ISR and no-ISR patients were compared, Multivariate logistic regression analyses were performed to identify the risk factors.

RESULTS

A total of 209 patients were included, the incidence of ISR after PCI was 30.62%. There were significant differences on the hypertension, diabetes, number of coronary artery lesions, reasons for stent implantation, the diameter of stent, the length of stent and stent position between ISR group and no-ISR patients (all p < 0.05). The LDL-C in ISR groups was significantly higher than that of no-ISR group (p = 0.048), there were no significant differences between two groups in FPG, TG, TC, HDL-C, Apo A1, Apo B, LP-a and glycated haemoglobin (all p > 0.05). The hypertension (OR 4.30, 95% CI 1.12-9.34), diabetes (OR 5.29, 95% CI 1.25-9.01), number of coronary artery lesions ≥ 2 (OR 4.84, 95% CI 1.21-9.55), LDL-C ≥ 1.9 mmol/L (OR 5.93, 95% CI 2.29-10.01), unstable angina (OR 2.92, 95% CI 1.20-4.55), left anterior descending artery (OR 4.01, 95% CI 1.73-7.58), diameter of stent ≥ 3 mm (OR 5.42, 95% CI 1.24-10.84), the length of stent > 20 mm (OR 3.06, 95% CI 1.19-5.22) were the independent risk factor for ISR (all p < 0.05).

CONCLUSION

It is necessary to take preventive measures against these risk factors to reduce ISR, and studies with larger sample size and longer follow-up on this issue are needed in the future.

Safety and efficacy of paclitaxel drug-coated balloon treatment of femoropopliteal claudicants: Data and analytic methods matter

Claudicants with femoropopliteal disease average 25% higher primary patency and reduced target lesion revascularization long term with crystalline paclitaxel eluting stent and balloon treatment compared to uncoated devices. In animal models, local and downstream tissues have detectable paclitaxel for greater than 180 days. Aggregate data meta-analyses of 28 randomized trials suggested 50-100% higher all-cause mortality with paclitaxel device treatment. In contrast, more complete ascertainment of follow-up and pooled individual patient data analyses do not find significantly increased mortality, a dose-mortality relationship, or an unexpected cause of death pattern with paclitaxel eluting device treatment in femoropopliteal claudicants.

Paclitaxel exposure: Long-term safety and effectiveness of a drug-coated balloon for claudication in pooled randomized trials

BACKGROUND

Paclitaxel drug-coated balloons (DCB) prevent recurrent claudication after angioplasty, yet data from randomized trials with incomplete follow-up have raised uncertainty regarding long-term mortality.

OBJECTIVES

To evaluate the effect of paclitaxel exposure on the long-term safety and efficacy of angioplasty of femoropopliteal artery lesions in the combined IN.PACT randomized trials.

METHODS

The IN.PACT randomized trials (SFA, N = 331 and Japan, N = 100) each compared the DCB with standard percutaneous transluminal angioplasty (PTA) for claudication, and consented patients for 5 and 3 years, respectively. To address long-term safety, sites were requested to obtain vital status follow-up. In the pooled, updated data set, we examined the association between randomized treatment and mortality by cumulative incidence and hazard ratio (HR), and freedom from clinically driven target lesion revascularization (CD-TLR). Multivariable Cox regression with adjustment for baseline characteristics was used to evaluate the dose effect. Causes of death were adjudicated by a blinded clinical events committee that included oncologists with paclitaxel expertise.

RESULTS

The rate of long-term vital status ascertainment increased from 81% to 97% for DCB and from 85% to 97% for PTA in the IN.PACT SFA trial. The cumulative incidence of mortality was 14.7% DCB versus 12.0% PTA at 5 years, HR 1.39, log-rank p = .286. Paclitaxel dose (mg) was not an independent predictor of mortality (HR 1.02, p = .381), but was an independent predictor of reduced risk of CD-TLR (HR 0.79; p < .001). Causes of death did not differ by treatment arm.

CONCLUSIONS

In pooled randomized trial data with updated vital status ascertainment, paclitaxel was associated with improved efficacy but was not associated with increased mortality.

Scoring Balloon Reduces the Severity of Dissection and Stent Implantation Rate in Superficial Femoral Artery Angioplasty Compared to Plain Balloon

PURPOSE

The knowledge regarding the benefits of the scoring balloon (SB) in comparison to the plain balloon (PB) is limited. This study aims to elucidate the difference in efficacy between SB and PB as pre-balloon in superficial femoral artery angioplasty.

METHODS

We retrospectively analyzed angiographic images of 113 lesions in 98 patients treated with endovascular surgery. 37 lesions were prepared by SB and 76 lesions by PB. Lesions without significant residual stenosis nor a flow-limiting dissection were treated by drug-coated balloon and the others by drug-eluting stent. Severity of dissection was evaluated by Kobayashi dissection grade and NHLBI classification. The rate of stent implantation was compared between the 2 groups. Kaplan-Meier analysis estimated freedom from target lesion revascularization (TLR) rate at 12 months.

RESULTS

Severe dissections (>1/3 of lumen) occurred less frequently in the SB group (SB 40.5% vs. PB 75.0%, P = 0.001). Overall stent implantation rate was lower in the SB group (SB 27.0% vs. PB 55.3%, P = 0.005). In subgroup analysis for the complex lesions, the SB group had lower rate of severe dissection(>1/3 of lumen) in patients with long lesions(>15 cm) (SB 51.7% vs. PB 76.9%, P = 0.020) and lesions of calcium grade ≥2 (SB 43.8% vs. PB 72.5%, P = 0.009). SB group had lower stent implantation rate in patients with long lesions (SB 34.5% vs. PB 59.6%, P = 0.030), lesions of calcium grade ≥2 (SB 31.3% vs. PB 56.9%, P = 0.023), and total occlusion (SB 30.8% vs. PB 80.0%, P = 0.002). There were no procedure-related complications in either group except 1 case of puncture-site hematoma. There was no significant difference in TLR rate between both groups at 12 months (P = 0.509).

CONCLUSION

SB reduces the incidence of severe dissection (>1/3 of lumen) and rate of overall stent implantation in comparison with PB. The use of SB is a safe and effective method of lesion preparation in SFA angioplasty.

Safety, effectiveness and mid-term follow-up in 136 consecutive patients with moderate to severely calcified lesions undergoing phoenix atherectomy

To investigate the safety and effectiveness of the Phoenix atherectomy device for the treatment of complex and calcified lesions in patients with peripheral artery disease (PAD). 136 consecutive all-comer patients with chronic PAD underwent Phoenix atherectomy. Safety in terms of vessel injury and embolism, efficacy and clinical success in terms of ≥ 1Rutherford class (RF) improvement during follow-up were systematically analyzed. Lesion calcification was categorized by the Peripheral Arterial Calcium Scoring System (PACSS), whereas lesion complexity was classified by the Transatlantic Inter-Society Consensus (TASC). 151 lesions were treated in 136 consecutive patients. Clinical follow-up was available at 10.3 ± 4.2 months in 132 (97%) patients. 55 patients (40%) had intermittent claudication, 16 (12%) rest pain and 65 (48%) had ischemic ulcerations (mean RF class = 4.2 ± 1.1). 15 (11%) patients had TASC B lesions, whereas the majority 72 (53%) and 49 (36%) exhibited TASC C and D lesions, respectively. Mean PACSS score was 3.3 ± 0.9. Mean lesion length was 106 ± 92 mm. Atherectomy was combined with drug-coated balloon (DCB) in 129 (95%) patients. Nine (6.6%) patients with infra-inguinal lesions received stents. Technical and procedural success were recorded in 102 (75%) and 135 (99%), respectively. Perforation was noticed in 2 (1%), whereas asymptomatic embolism occurred in 6 (4%) patients. Clinical success was present in 54 (100%) patients with claudication and in 65 of 78 (83%) patients with critical limb ischemia (CLI). Atherectomy in combination with DCB angioplasty can be safely performed in patients with complex, calcified peripheral lesions with a relatively low rate of bail-out stenting and promising clinical mid-term results.German Clinical Trials Register: DRKS00016708.

JetStream Atherectomy for the Treatment of In-Stent Restenosis of the Femoropopliteal Segment: One-Year Results of the JET-ISR Study

PURPOSE

To report the results of a study evaluating JetStream atherectomy for the treatment of in-stent restenosis (ISR).

MATERIALS AND METHODS

The JetStream XC atherectomy device, a rotational cutter with aspiration capacity, was evaluated in a prospective, multicenter study (JET-ISR) of 60 patients (mean age 70.2±10.8 years; 40 men) with femoropopliteal ISR (ClinicalTrials.gov identifier NCT02730234). Lesion length was 19.9±13.5 cm; 33 (55%) were chronic total occlusions and 26 (45%) were TransAtlantic Inter-Society Consensus class D. No drug-bearing device was allowed, and stenting was performed only for bailout. Lesion characteristics and stent integrity were evaluated by an independent core laboratory. The primary endpoint was target lesion revascularization (TLR) at 6 months with bailout stenting considered as TLR. Secondary endpoints included TLR (without bailout stenting) and clinical patency (no restenosis or TLR) at 1 year. The Kaplan-Meier method was employed to evaluate time-to-event endpoints; estimates are given with 95% confidence interval (CI).

RESULTS

Bailout stenting was required in 6 of 60 limbs (10%). There were no stent fractures or deformities after atherectomy + adjunctive angioplasty reported by the core laboratory. Kaplan-Meier estimates of freedom from TLR at 6 months and 1 year were 79.3% (95% CI 68.9% to 89.8%) and 60.7% (95% CI 47.8% to 73.6%), respectively. When bailout stenting at the index procedure was not considered a TLR event, freedom from TLR estimates at 6 months and 1 year were 89.3% (95% CI 81.2% to 97.4%) and 66.8% (95% CI 54.3% to 74.2%), respectively. Clinical patency rates at 6 months and 1 year were 77.5% (31/40) and 51.7% (15/29), respectively.

CONCLUSION

JetStream atherectomy using the XC device and no drug-eluting devices is feasible, with good clinical patency and 1-year freedom from TLR.