Physician-Initiated Trial Investigating the Efficacy of Endovascular Treatment of Femoropopliteal Arterial Stenotic Disease With the Biotronik Passeo-18 Lux Drug Releasing Balloon and the Biotronik Pulsar-18 Stent (Comparing With 4EVER Trial Results)
Overview
- Phase
- Phase 4
- Intervention
- Not specified
- Conditions
- Peripheral Vascular Disease
- Sponsor
- Flanders Medical Research Program
- Enrollment
- 120
- Locations
- 5
- Primary Endpoint
- Primary patency at 12 months
- Status
- Completed
- Last Updated
- 7 years ago
Overview
Brief Summary
The objective of this clinical investigation is to evaluate the short- and long-term (up to 24 months) outcome of treatment by means of dilation with the Passeo-18 Lux drug releasing balloon and by Pulsar-18 stent implantation in symptomatic (Rutherford 2-4) femoro-popliteal arterial stenotic or occlusive lesions.
Detailed Description
Ever since its introduction, one of the major limitations of endovascular therapy is the occurrence of restenosis after treatment. Factors contributing to loss of primary patency after percutaneous transluminal angioplasty (PTA) due to balloon injury are negative arterial remodeling, excessive neointimal proliferation and elastic recoil. In order to increase sustained vessel patency, systemic medication administration and brachytherapy have been proposed, but have not led to any success. With the introduction of stents, patency rates have been optimized also on longer term. However, neointimal hyperplasia after endovascular stent placement in infra-inguinal arteries remains a major limiting issue. Stents themselves contribute to this excessive intimal formation because of the vascular response to the metallic prosthesis. In order to find a solution to overcome this limitation, the possibilities of drug-eluting technologies are being examined. Current concepts include drug-eluting stents (DES), which provide sustained release of anti-proliferative medication into the vessel wall. The application of a drug coating on a stent surface inhibits the inflammatory response and smooth muscle cell proliferation in the vessel wall during a certain period and delays the process of intimal hyperplasia. Thus, DES technology was developed to prevent early restenosis and late luminal loss to potentially improve long-term patency rates. Because DES with active stent coatings have shown to be beneficial in the treatment of coronary artery disease, the technique of active stent coatings (sirolimus or paclitaxel) as commonly used in coronary interventions was transferred to the infrainguinal vascular bed. However, an active stent coating (sirolimus or paclitaxel) only inhibits the inflammatory response and smooth muscle cell proliferation in the vessel wall for a certain period; in fact, it merely delays the process of intimal hyperplasia as demonstrated by the 2-year results of the SIROCCO study. Another novel way of inhibiting restenosis after PTA is the use of drug-coated balloons (DCB), which inhibit restenosis by an immediate local release of medication during the intervention. The rationale behind the use of DCBs is based on the finding that sustained drug elution is not a necessary to obtain a sustained inhibition of restenosis. The concept of using a balloon with medication to treat vascular disease was introduced in 2003 by Scheller et al. One of the most commonly used drugs for arterial applications is the anti-proliferative paclitaxel (Taxol), which impedes cell division in the cell cycle. Paclitaxel has certain characteristics which make it a promising candidate for treatment of peripheral arterial disease. Because it is hydrophobic, paclitaxel does not require the use of a polymer to prevent wash-off during tracking or implantation. Adequate drug delivery to the vessel wall is possible because of its lipophilic characteristic, which enables paclitaxel to interact with the high concentrations of lipids present in the vessel wall and avoids the need for a polymer. Results of preclinical and clinical studies have shown that short-term exposure to Paclitaxel may suffice to obtain a sustained reduction in late lumen loss and avoid restenosis in both coronary and peripheral arteries: in contrast to stents, DCBs do not leave any residual material in the artery lumen that could trigger neointimal proliferation, thus making DCBs an attractive alternative to stents, especially in challenging arterial anatomies. Further investigation is warranted in order to obtain conclusive data. Furthermore, the benefit of treating in-stent restenosis (ISR) in the peripheral arteries with DCBs has yet to be investigated, although limited data is already available to date. The clinical value of these drug-eluting technologies has been proven repeatedly in the coronary arteries, and evidence of therapeutic applications to peripheral artery disease is starting to build. It is the intent of this prospective study to evaluate the treatment of a drug-coated balloon followed by stent implant and comparing this to the results of the 4EVER trial and results in the literature.
Investigators
Eligibility Criteria
Inclusion Criteria
- •General Inclusion Criteria:
- •De novo lesions located in the femoropopliteal arteries suitable for endovascular treatment
- •Patient presenting with a score from 2 to 4 according to the Rutherford classification
- •Patient is willing to comply with specified follow-up evaluations at the predefined time intervals time
- •Patients is \>18 years old
- •Patient understands the nature of the procedure and provides written informed consent, prior to enrollment in the study
- •Prior to enrollment, the target lesion was crossed with standard guidewire manipulation
- •Angiographic Inclusion Criteria:
- •The target lesions are located within the native SFA: distal point 3 cm above knee joint and 1 cm below the origin of the profunda femoralis
- •The target lesion has angiographic evidence of stenosis \>50% or occlusion
Exclusion Criteria
- •Presence of another stent in the target vessel that was placed during a previous procedure
- •Presence of an aortic thrombosis or significant common femoral ipsilateral stenosis
- •Previous bypass surgery in the same limb
- •Patients contraindicated for antiplatelet therapy, anticoagulants or thrombolytics
- •Patients who exhibit persistent acute intraluminal thrombus at the target lesion site
- •Perforation at the angioplasty site evidenced by extravasation of contrast medium
- •Patients with known hypersensitivity to nickel-titanium
- •Patients with uncorrected bleeding disorders
- •Female patient with child bearing potential not taking adequate contraceptives or currently breastfeeding
- •Life expectancy of less than 12 months
Outcomes
Primary Outcomes
Primary patency at 12 months
Time Frame: 12 months
Defined as freedom from \>50% restenosis as indicated by an independently verified duplex ultrasound peak systolic velocity ratio (PSVR) \<2.5 in the target vessel with no reintervention.
Secondary Outcomes
- Procedural success(1 day post-op)
- Compression time(1 day post-op)
- Primary patency rate at 1-month follow-up(1 month)
- Primary patency rate at 6- and 24-month follow-up(6 and 24 months)
- Clinical success at 1-, 6-, 12- and 24-months follow-up(1, 6, 12, 24 months)
- Number of puncture site complications(1 day post-op)
- Changes in ABI measurements at 1-, 6-, 12- and 24-months(1, 6, 12, 24 months)
- Technical success(1 day post-op)
- Serious Adverse Events(up to 24 months)
- Freedom from Target Lesion Revascularization (TLR) at at 1-, 6-, 12- and 24-months follow-up(1, 6, 12 and 24 months)