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Frontiers of Neurology and Neuroscience 2016The high rate of recurrent strokes in patients with intracranial atherosclerotic disease (ICAS) despite medical therapy prompted intracranial angioplasty and/or stenting... (Review)
Review
The high rate of recurrent strokes in patients with intracranial atherosclerotic disease (ICAS) despite medical therapy prompted intracranial angioplasty and/or stenting an adjunctive treatment option. The minute calibers of cerebral arteries, the relative paucity of supporting medial and adventitia layers, the presence of end-anastomosing perforator branches, and the vascular tortuosity from groin to head all demand specialized operative skills and dedicated tools. Since the stroke mechanism of ICAS is diverse, patient selection for endovascular treatment requires a sound understanding of the underlying pathophysiology. Patients with territorial cerebral hypo-perfusion associated with a high-grade steno-occlusive lesion may benefit most from endovascular revascularization. On the other hand, patients with atheromatous branch disease may stand a higher risk of perforator stroke from 'snow plowing' effect if angioplasty or stenting is inadvertently performed. A joint evaluation on the indication, procedural risks and benefits, and an individualized peri-operative care plan by a stroke neurologist and a neuro-interventionist is crucial prior to a procedure. Currently, the U.S. Food and Drug Administration approved Wingspan for patients who have developed two or more strokes despite aggressive medical management. The treatment indication will likely evolve in parallel with the advancement of endovascular techniques and our understanding of ICAS.
Topics: Angioplasty; Humans; Intracranial Arteriosclerosis; Stents; Stroke
PubMed: 27960179
DOI: 10.1159/000448311 -
The Cochrane Database of Systematic... Aug 2022Carotid patch angioplasty may reduce the risk of acute occlusion or long-term restenosis of the carotid artery and subsequent ischaemic stroke in people undergoing... (Review)
Review
BACKGROUND
Carotid patch angioplasty may reduce the risk of acute occlusion or long-term restenosis of the carotid artery and subsequent ischaemic stroke in people undergoing carotid endarterectomy (CEA). This is an update of a Cochrane Review originally published in 1995 and updated in 2008.
OBJECTIVES
To assess the safety and efficacy of routine or selective carotid patch angioplasty with either a venous patch or a synthetic patch compared with primary closure in people undergoing CEA. We wished to test the primary hypothesis that carotid patch angioplasty results in a lower rate of severe arterial restenosis and therefore fewer recurrent strokes and stroke-related deaths, without a considerable increase in perioperative complications.
SEARCH METHODS
We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and two trial registries in September 2021.
SELECTION CRITERIA
Randomised controlled trials and quasi-randomised trials comparing carotid patch angioplasty with primary closure in people undergoing CEA.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed eligibility and risk of bias; extracted data; and determined the certainty of evidence using the GRADE approach. Outcomes of interest included stroke, death, significant complications related to surgery, and artery restenosis or occlusion during the perioperative period (within 30 days of the operation) or during long-term follow-up.
MAIN RESULTS
We included 11 trials involving 2100 participants undergoing 2304 CEA operations. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Compared with primary closure, carotid patch angioplasty may make little or no difference to reduction in risk of any stroke during the perioperative period (odds ratio (OR) 0.57, 95% confidence interval (CI) 0.31 to 1.03; P = 0.063; 8 studies, 1769 participants; very low-certainty evidence), but may lower the risk of any stroke during long-term follow-up (OR 0.49, 95% CI 0.27 to 0.90; P = 0.022; 7 studies, 1332 participants; very low-certainty evidence). In the included studies, carotid patch angioplasty resulted in a lower risk of ipsilateral stroke during the perioperative period (OR 0.31, 95% CI 0.15 to 0.63; P = 0.001; 7 studies, 1201 participants; very low-certainty evidence), and during long-term follow-up (OR 0.32, 95% CI 0.16 to 0.63; P = 0.001; 6 studies, 1141 participants; very low-certainty evidence). The intervention was associated with a reduction in the risk of any stroke or death during long-term follow-up (OR 0.59, 95% CI 0.42 to 0.84; P = 0.003; 6 studies, 1019 participants; very low-certainty evidence). In addition, the included studies suggest that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion (OR 0.18, 95% CI 0.08 to 0.41; P < 0.0001; 7 studies, 1435 participants; low-certainty evidence), and may reduce the risk of restenosis during long-term follow-up (OR 0.24, 95% CI 0.17 to 0.34; P < 0.00001; 8 studies, 1719 participants; low-certainty evidence). The studies recorded very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation, with either patch or primary closure. We found no correlation between the use of patch angioplasty and the risk of either perioperative or long-term stroke-related death or all-cause death rates.
AUTHORS' CONCLUSIONS
Compared with primary closure, carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and long-term restenosis of the operated artery. It would appear to reduce the risk of ipsilateral stroke during the perioperative and long-term period and reduce the risk of any stroke in the long-term when compared with primary closure. However, the evidence is uncertain due to the limited quality of included trials.
Topics: Angioplasty; Endarterectomy, Carotid; Humans; Randomized Controlled Trials as Topic; Stroke
PubMed: 35920689
DOI: 10.1002/14651858.CD000160.pub4 -
Cardiovascular Revascularization... Mar 2021
Topics: Angioplasty; Angioplasty, Balloon; Humans
PubMed: 33495048
DOI: 10.1016/j.carrev.2020.12.008 -
Circulation Feb 2015Drug-coated balloons (DCBs) have shown promise in improving the outcomes for patients with peripheral artery disease. We compared a paclitaxel-coated balloon with... (Randomized Controlled Trial)
Randomized Controlled Trial
Drug-coated balloon versus standard percutaneous transluminal angioplasty for the treatment of superficial femoral and popliteal peripheral artery disease: 12-month results from the IN.PACT SFA randomized trial.
BACKGROUND
Drug-coated balloons (DCBs) have shown promise in improving the outcomes for patients with peripheral artery disease. We compared a paclitaxel-coated balloon with percutaneous transluminal angioplasty (PTA) for the treatment of symptomatic superficial femoral and popliteal artery disease.
METHODS AND RESULTS
The IN.PACT SFA Trial is a prospective, multicenter, single-blinded, randomized trial in which 331 patients with intermittent claudication or ischemic rest pain attributable to superficial femoral and popliteal peripheral artery disease were randomly assigned in a 2:1 ratio to treatment with DCB or PTA. The primary efficacy end point was primary patency, defined as freedom from restenosis or clinically driven target lesion revascularization at 12 months. Baseline characteristics were similar between the 2 groups. Mean lesion length and the percentage of total occlusions for the DCB and PTA arms were 8.94 ± 4.89 and 8.81 ± 5.12 cm (P=0.82) and 25.8% and 19.5% (P=0.22), respectively. DCB resulted in higher primary patency versus PTA (82.2% versus 52.4%; P<0.001). The rate of clinically driven target lesion revascularization was 2.4% in the DCB arm in comparison with 20.6% in the PTA arm (P<0.001). There was a low rate of vessel thrombosis in both arms (1.4% after DCB and 3.7% after PTA [P=0.10]). There were no device- or procedure-related deaths and no major amputations.
CONCLUSIONS
In this prospective, multicenter, randomized trial, DCB was superior to PTA and had a favorable safety profile for the treatment of patients with symptomatic femoropopliteal peripheral artery disease.
CLINICAL TRIAL REGISTRATION URL
http://www.clinicaltrials.gov. Unique Identifiers: NCT01175850 and NCT01566461.
Topics: Aged; Angioplasty; Angioplasty, Balloon; Female; Femoral Artery; Humans; Internationality; Male; Middle Aged; Peripheral Arterial Disease; Popliteal Artery; Prospective Studies; Single-Blind Method; Time Factors; Treatment Outcome; Vascular Access Devices
PubMed: 25472980
DOI: 10.1161/CIRCULATIONAHA.114.011004 -
Lasers in Surgery and Medicine 1994With the widespread growth of percutaneous transluminal coronary angioplasty (PTCA), the realization of limitations of balloon angioplasty stimulated the development of... (Review)
Review
With the widespread growth of percutaneous transluminal coronary angioplasty (PTCA), the realization of limitations of balloon angioplasty stimulated the development of alternative revascularization approaches such as laser angioplasty. PTCA is best suited for the treatment of discrete atherosclerotic stenoses, with lower success rates and more difficult application in patients with diffuse atherosclerotic disease or total occlusions [1-3]. Moreover, despite an initially high primary success rate, coronary angioplasty is still plagued by a restenosis rate as high as 57% [4]. The potential advantages of laser angioplasty address the limitations of PTCA. In contrast to balloon angioplasty where the plaque material is compressed or displaced, laser angioplasty ablates the plaque material [5]. This bulk removal of plaque material could improve acute procedural success rates, decrease complication rates, treat "untreatable" lesions, and decrease restenosis rates. Because laser energy can vaporize atherosclerotic plaque, there may be no requirement for a preexisting channel, and therefore laser angioplasty may have a high success rate for the treatment of coronary occlusions. In its best embodiment, laser angioplasty offers the potential for passing a fiberoptic catheter through the entire length of the coronary circulation to vaporize all atherosclerotic plaque along the arterial wall. This applicability for the treatment of diffuse atherosclerotic disease would offer treatment opportunities currently unavailable with conventional bypass surgery or angioplasty.
Topics: Angioplasty, Balloon, Coronary; Angioplasty, Balloon, Laser-Assisted; Angioplasty, Laser; Coronary Artery Disease; Humans; Recurrence
PubMed: 8183044
DOI: 10.1002/1096-9101(1994)14:2<101::aid-lsm1900140202>3.0.co;2-l -
The British Journal of Surgery May 1993
Comparative Study Review
Topics: Angioplasty, Balloon; Angioplasty, Laser; Arterial Occlusive Diseases; Humans; Safety
PubMed: 8518888
DOI: 10.1002/bjs.1800800504 -
The Cochrane Database of Systematic... May 2015Atherosclerosis of the iliac artery may result in a stenosis or occlusion, which is defined as iliac artery occlusive disease. A range of surgical and endovascular... (Review)
Review
BACKGROUND
Atherosclerosis of the iliac artery may result in a stenosis or occlusion, which is defined as iliac artery occlusive disease. A range of surgical and endovascular treatment options are available. Open surgical procedures have excellent patency rates but at the cost of substantial morbidity and mortality. Endovascular treatment has good safety and short-term efficacy with decreased morbidity, complications and costs compared with open surgical procedures. Both percutaneous transluminal angioplasty (PTA) and stenting are commonly used endovascular treatment options for iliac artery occlusive disease. A stenotic or occlusive lesion of the iliac artery can be treated successfully by PTA alone. If PTA alone is technically unsuccessful, additional stent placement is indicated. Alternatively, a stent could be placed primarily to treat an iliac artery stenosis or occlusion (primary stenting, PS). However, there is limited evidence to prove which endovascular treatment strategy is superior for stenotic and occlusive lesions of the iliac arteries.
OBJECTIVES
To assess the effects of percutaneous transluminal angioplasty versus primary stenting for stenotic and occlusive lesions of the iliac artery.
SEARCH METHODS
The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and Cochrane Register of Studies (CRS) (2015, Issue 3). The TSC searched trial databases for details of ongoing and unpublished studies.
SELECTION CRITERIA
We included all randomised controlled trials (RCTs) comparing percutaneous transluminal angioplasty and primary stenting for iliac artery occlusive disease. We excluded quasi-randomised trials, case reports, case-control or cohort studies. We excluded no studies based on the language of publication.
DATA COLLECTION AND ANALYSIS
Two authors (JB, NA) independently selected suitable trials. JB and HJ independently performed data extraction and trial quality assessment. When there was disagreement, consensus would be reached first by discussion among both authors and, if still no consensus could be reached, through consultation with BF.
MAIN RESULTS
We identified two RCTs with a combined total of 397 participants as meeting the selection criteria. One study included mostly stenotic lesions (95%), whereas the second study included only iliac artery occlusions. Both studies were of moderate methodological quality with some risk of bias relating to selective reporting and non-blinding of participants and personnel. The overall quality of evidence was low due to the small number of included studies, the differences in study populations and definitions of the outcome variables. Due to the heterogeneity among these two studies it was not possible to pool the data. Percutaneous transluminal angioplasty (PTA) with selective stenting and primary stenting (PS) resulted in similar improvement in the stage of peripheral arterial occlusive disease according to Rutherford's criteria, resolution of symptoms and signs, improvement of quality of life, technical success of the procedure and patency of the treated vessel. Improvement in walking distance as reported by the patient, measured claudication distance, ulcer healing, major amputation-free survival and delayed complications (> 72 hours) were not reported in either of the studies. In one trial, PTA of iliac artery occlusions resulted in a significantly higher rate of major complications, especially distal embolisation. The other trial showed a significantly higher mean ankle brachial index (ABI) at two years in the PTA group (1.0) compared to the mean ABI in the PS group (0.91); mean difference (MD) 0.09 (95% confidence interval (CI) 0.04 to 0.14; P value = 0.001, analysis performed by review authors). However, at other time points there was no difference. We consider it unlikely that this difference is attributable to the study procedure, and also believe this difference may not be clinically relevant.
AUTHORS' CONCLUSIONS
There is insufficient evidence to assess the effects of PTA versus PS for stenotic and occlusive lesions of the iliac artery. From one study it appears that PS in iliac artery occlusions may result in lower distal embolisation rates. More studies are required to come to a firm conclusion.
Topics: Angioplasty; Constriction, Pathologic; Humans; Iliac Artery; Peripheral Arterial Disease; Randomized Controlled Trials as Topic; Retreatment; Stents; Treatment Outcome
PubMed: 26023746
DOI: 10.1002/14651858.CD007561.pub2 -
Cardiovascular Revascularization... Jun 2018
Topics: Angioplasty, Balloon; Angioplasty, Balloon, Coronary; Humans; Stents; Vascular Diseases
PubMed: 29941179
DOI: 10.1016/j.carrev.2018.06.011 -
Cardiovascular and Interventional... 1987Of 768 angioplasties performed in our institute, 42 procedures (5%) in 39 patients were performed by a radiologist in the operating room in combination with vascular...
Of 768 angioplasties performed in our institute, 42 procedures (5%) in 39 patients were performed by a radiologist in the operating room in combination with vascular surgery; 15 ilial, 20 femoral, 5 tibial, 1 renal, and 1 brachiocephalic artery stenoses were treated. Immediate and late successes, as well as the complication rates, were comparable to those of the percutaneous approach. The main reasons for the intraoperative approach were absence of arterial pulsations, ulcerative lesions at the puncture site with risk of peripheral embolisation, and the opportunity of a surgical arteriotomy offering access to an otherwise unreachable stenotic artery. The advantages of intraoperative dilatation in combination with surgery over simple operation are the reduction of operative morbidity and mortality, shortening of the operative time, and improved results by reassuring the in- or outflow of the operated territory. The main disadvantages are the limited fluoroscopic field and the limited mobility of the fluoroscopy device.
Topics: Angioplasty, Balloon; Arterial Occlusive Diseases; Femoral Artery; Humans; Iliac Artery; Intraoperative Period; Surgical Procedures, Operative
PubMed: 2949843
DOI: 10.1007/BF02583298 -
The Cochrane Database of Systematic... Dec 2020Atherosclerosis of the iliac artery may result in a stenosis or occlusion, which is defined as iliac artery occlusive disease. A range of surgical and endovascular...
BACKGROUND
Atherosclerosis of the iliac artery may result in a stenosis or occlusion, which is defined as iliac artery occlusive disease. A range of surgical and endovascular treatment options are available. Open surgical procedures have excellent patency rates but at the cost of substantial morbidity and mortality. Endovascular treatment has good safety and short-term efficacy with decreased morbidity, complications and costs compared with open surgical procedures. Both percutaneous transluminal angioplasty (PTA) and stenting are commonly used endovascular treatment options for iliac artery occlusive disease. A stenotic or occlusive lesion of the iliac artery can be treated successfully by PTA alone. If PTA alone is technically unsuccessful, additional stent placement is indicated. Alternatively, a stent could be placed primarily to treat an iliac artery stenosis or occlusion (primary stenting, PS). However, there is limited evidence to prove which endovascular treatment strategy is superior for stenotic and occlusive lesions of the iliac arteries. This is an update of the review first published in 2015.
OBJECTIVES
To assess the effects of percutaneous transluminal angioplasty versus primary stenting for stenotic and occlusive lesions of the iliac artery.
SEARCH METHODS
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 24 September 2019. We also undertook reference checking and citation searching to identify additional studies.
SELECTION CRITERIA
We included all randomised controlled trials (RCTs) comparing percutaneous transluminal angioplasty and primary stenting for iliac artery occlusive disease. We excluded quasi-randomised trials, case reports, case-control or cohort studies. We did not exclude studies based on the language of publication.
DATA COLLECTION AND ANALYSIS
Two authors independently selected suitable trials, extracted data, assessed trial quality and performed data analyses. When there was disagreement, consensus would be reached first by discussion between the two authors and, if needed, through consultation with a third author. We used GRADE criteria to assess the certainty of the evidence and presented the main results in a 'Summary of findings' table. The main outcomes of interest were technical success, complications, symptomatic improvement of peripheral arterial disease (PAD), patency, reinterventions, resolutions of symptoms and signs, and improvement in walking distance as reported by the patient.
MAIN RESULTS
We identified no new studies for this update. Previously, we identified two RCTs, with a combined total of 397 participants, as meeting the selection criteria. One study included mostly stenotic lesions (95%), whereas the second study included only iliac artery occlusions. Heterogeneity between these two studies meant it was not possible to pool the data. Both studies were of moderate methodological quality with some risk of bias relating to selective reporting and non-blinding of participants and personnel. Both studies occurred in the 1990s and techniques have since evolved. We assessed the overall certainty of the evidence to be low. We downgraded by two levels: one for risk of bias concerns and one for imprecision and indirectness. There was no evidence of a difference following percutaneous transluminal angioplasty (PTA) with selective stenting compared to primary stenting (PS) in technical success rates in either the study involving stenotic lesions (odds ratio (OR) 1.51, 95% confidence interval (CI) 0.77 to 2.99; 279 participants; low certainty evidence); or the study involving iliac artery occlusions (OR 2.95, 95% CI 0.12 to 73.90; 112 participants; low certainty evidence). In one trial, PTA of iliac artery occlusions resulted in a higher rate of major complications, especially distal embolisation (OR 4.50 95% CI 1.18 to 17.14; 1 study, 112 participants; low certainty evidence). Immediate complications were similar in the second study (OR 1.81, 95% CI 0.64 to 5.13; 1 study, 279 participants; low certainty evidence). Neither study reported on delayed complications. No evidence of a difference was seen in symptomatic improvement (OR 1.03, 95% CI 0.47 to 2.27; 1 study, 157 participants; low certainty evidence). The second study did not provide data but reported no differences. For the outcome of patency, no evidence of a difference was seen in the study involving iliac occlusion at two years (OR 1.60, 95% CI 0.34 to 7.44; 1 study, 57 participants; low certainty evidence); or the study involving stenotic lesions at two years (71.3% in the PS group versus 69.9% in the PTA group). Only one study reported on reintervention (six to eight years, OR 1.22, 95% CI 0.67 to 2.23; 1 study, 279 participants; low certainty evidence); and resolution of symptoms and signs (12 months, OR 1.14, 95% CI 0.65 to 2.00; 1 study, 219 participants; low certainty evidence), with no evidence of a difference detected in either outcome. Neither study reported on improvement in walking distance as reported by the patient.
AUTHORS' CONCLUSIONS
There is insufficient evidence to make general conclusions about the effects of percutaneous transluminal angioplasty versus primary stenting for stenotic and occlusive lesions of the iliac artery. Data from one study indicate that primary stenting in iliac artery occlusions may result in lower distal embolisation rates (low certainty evidence). The evidence in this review, based on two studies, was assessed as low certainty, with downgrading decisions based on limitations in risk of bias, imprecision and indirectness. More studies are required to strengthen our confidence in the results.
Topics: Angioplasty; Arterial Occlusive Diseases; Constriction, Pathologic; Humans; Iliac Artery; Randomized Controlled Trials as Topic; Retreatment; Stents; Treatment Outcome
PubMed: 33258499
DOI: 10.1002/14651858.CD007561.pub3