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)

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.