Do not use balloon angioplasty to treat drug-eluting stent restenosis

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Raffaele Piccolo (Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy) and others report in The American Journal of Cardiology that, according to the findings of a network meta-analysis, both drug-eluting balloons and drug-eluting stents represent valid treatment options for patients with drug-eluting stent restenosis. However, they claim that balloon angioplasty is not an effective treatment option and should not be used.

The authors report that that the “optimal treatment for drug-eluting stent restenosis remains poorly defined” and that “direct evidence of head-to-head trials [of different treatment options] is still limited”. Therefore, they performed a network meta-analysis of randomised trials to assess the effectiveness of different treatment options for patients with drug-eluting stent restenosis. The treatments evaluated were balloon angioplasty, paclitaxel-eluting balloons, sirolimus-eluting stents, paclitaxel-eluting stents, and everolimus-eluting stents. Balloon angioplasty was used as the comparator and the primary endpoint was the diameter stenosis at follow-up angiography. Overall, Piccolo et al reviewed data from seven trials (a total of 1,586 patients with 1,728 restenotic lesions).


The authors report that although paclitaxel-eluting balloons, everolimus-eluting stents, paclitaxel-eluting stents, and sirolimus-eluting stents had similar reductions in diameter stenosis to balloon angioplasty at follow-up angioplasty, paclitaxel-eluting balloons (85%) and everolimus-eluting stents (68%) had the greatest probabilities for being the best treatment option for reducing diameter stenosis. Piccolo et al add: “Paclitaxel-eluting balloons had the greatest probability (85%) for being the best treatment option on reducing late lumen loss followed by paclitaxel-eluting stents (65%) and everolimus-eluting stents (54%).” Furthermore, compared with the other treatments, paclitaxel-eluting balloons had the greatest probability (85%) for being best treatment for reducing the incidence of angiographic restenosis.


Summarising the principal findings of the meta-analysis, Piccolo et al comment “Paclitaxel-eluting balloons and drug-eluting stents represent effective options for the treatment of drug-eluting stent restenosis” and add that the use of balloon angioplasty for the condition “should be discouraged”.


According to the authors, paclitaxel-eluting balloons have “potential advantages” over drug-eluting stents for the management of drug-eluting stent restenosis. These include the lack of additional stent layers, shorter duration of drug release limited to the time of the highest activity of the neointimal process following barotrauma, and uniform drug distribution. They add: “A further theoretical advantage of paclitaxel-eluting balloons may be the need for shorter duration of dual antiplatelet therapy.”

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