Endovaskuläre Therapie der pAVK – Therapieoptionen bei starker Verkalkung

Was ist neu?

Aktuelle Studiendaten Die randomisierte Disrupt-III-Studie verglich die intravaskuläre Lithotrypsie verkalkter Plaques zur Läsionsvorbereitung vor medikamentenbeschichteter Ballon-Angioplastie (DCB) mit einer Vordilatation mit einem herkömmlichen Ballon. Die einarmige REALITY-Studie untersuchte die direktionale Atherektomie zur Läsionsvorbereitung vor DCB-Angioplastie. Beide Studien zeigten, dass sich auch schwer verkalkte Stenosen und Verschlüsse der femoropoplitealen Arterie bis zu 30cm Länge erfolgreich mit einer geringen Stent-Implantationsrate behandeln lassen. Dies ist von besonderer Bedeutung, da sich in einer multivariaten Analyse eine Residualstenose > 30% nach DCB-Angioplastie als einziger unabhängiger Risikofaktor für eine Restenose erwiesen hat. Der potenzielle Nutzen der Lithotrypsie wurde auch in einer Studie an Zugangsarterien, die für die transfemorale Implantation von Aortenklappenprothesen benötigt werden, mit einer hohen Erfolgs- und niedrigen Komplikationsrate untersucht.

Technisches Verfahren zur Behandlung verkalkter Plaques: Intravaskuläre Lithotrypsie (IVL) Die intravaskuläre Lithotrypsie ist eine neue Katheter-Technologie. Dabei wird über einen in der Stenose inflatierten Ballon-Katheter durch die Emission pulsatiler akustischer Stoßwellen die verkalkte Plaque frakturiert. Ziel ist, kalkbedingtes Recoil und Dissektionen zu reduzieren. Dieses Therapiekonzept wird aktuell neben der femoropoplitealen Strombahn in anderen Gefäßprovinzen wie Unterschenkel- und Beckenarterien in klinischen Studien erprobt.

Atherektomie-Systeme sind bereits seit mehr als einer Dekade zur Therapie der pAVK etabliert, insbesondere die direktionale Atherektomie erlaubt es, exzentrische verkalkte Plaques gezielt zu entfernen. Klinische Studien untersuchen den möglicherweise additiven Effekt der Kombination einer mechanischen und biologischen Restenoseprophylaxe mittels DCB.

Abstract

Calcified lesions are a major limitation of endovascular therapy of peripheral artery disease. Recently published studies evaluating the impact of lithotripsy (Disrupt III) and directional atherectomy (REALITY) as vessel preparation devices for calcified femoro-popliteal lesions prior to the final treatment with drug-coated balloons (DCB). Disrupt III, a randomized controlled trial comparing lithotripsy and regular balloon angioplasty for vessel preparation prior to DCB, and REALITY, a single-arm study of directional atherectomy prior to DCB angioplasty resulted in low provisional stent and dissection rates. Moreover, lithotripsy did result in a better 2-year patency rate as compared to predilatation with a regular balloon. Importantly, both vessel preparation strategies resulted in a low rate of post-procedural residual stenosis of >30%, the major predictor for loss of patency following DCB angioplasty in long-term.

Lithotripsy is an emerging therapy concept for vessel preparation of calcified pelvic arteries prior to trans-femoral aortic valve implantation.

In summary, vessel preparation of calcified arterial lesions by improving vessel compliance or reducing the plaque load represent promising technical methods reducing provisional stent rates and improving longer-term outcomes.

Schlüsselwörter

Periphere arterielle Verschlusskrankheit - Lithotrypsie - Atherektomie - Verkalkung - Medikamentenbeschichteter Ballon

Keywords

Peripheral arterial disease - lithotripsy - atherectomy - calcification - drug-coated balloon

Publication History

Article published online:
31 May 2023

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