Meta-Analysis of Drug-Eluting Balloon Angioplasty and Drug-Eluting Stent placement shows Superior Outcomes compared to PTA and BMS

A multi-institutional team recently published a met-analysis of RCTs of DEB and DES for infrainguinal peripheral arterial disease. Baerlocher et al identified 8 RCTs for DEB (763 unique patients) and 12 RCTs for DES (1,228 unique patients). Individual study bias was assessed by using the Cochrane risk for bias tool and the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) methodology was used to rate the confidence in each reported outcome as high, moderate, low, or very low. The results were expressed as averages of the given outcome per individual patient, effect sizes were expressed by Hedges g, and ORs were calculated in cases in which proportions or rates were used. The results indicate a statistically significant benefit of DEB angioplasty and DES placement in the treatment of femoral-popliteal and/or infrapopliteal arterial disease restenosis and target lesion revascularization. There was no benefit in major amputation or mortality.

Comment:

While the present study yielded similar results to other meta-analyses covering the same topic, the study is noteworthy for its inclusion of the most recent literature, use of the GRADE methodology, and data inclusion methods. Further, the study evaluated a larger vascular territory when compared with previous studies. However, while a reflection of the RCTs included in the meta-analysis, there remains a significant amount of heterogeneity within the lesions treated (eg length, amount of calcification, location, etc). Further, long-term follow-up data, cost/benefit analysis, and a defined lesion-based treatment algorithm remain areas for future research.


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Risk of bias across studies assessing DEB angioplasty outcomes. The x axis represents percentage of studies.

Risk of bias across studies assessing DES placement outcomes. The x axis represents percentage of studies.


Citation: Baerlocher, M. O. et al. Meta-Analysis of Drug-Eluting Balloon Angioplasty and Drug-Eluting Stent Placement for Infrainguinal Peripheral Arterial Disease. Journal of Vascular and Interventional Radiology 26, 459–473.e4 (2015).


Post author: Luke Wilkins, MD

Bariatric Embolization for the Treatment of Obesity: A Review

Bariatric embolization has been discussed as a possible treatment for obesity since first early pre-clinical studies were done by Arepally et al in 2007. While much work in this field has been done, there remain many challenges prior to full clinical implementation. The current state of BAE was recently reviewed in JVIR by researchers from Johns Hopkins. Weiss et al. provide a thorough review of the physiologic and anatomic basis along with a review of the preclinical and clinical data. If successful, BAE will represent a minimally invasive solution to obesity offered by interventional radiologists.

Comment:

This manuscript does an excellent job reviewing the topic of BAE. The physiologic and anatomic basis for the procedure along with the current preclinical and clinical data are reviewed well. Clearly there are many challenges to mainstream implementation of this procedure. Many questions remain unanswered. What is the ideal embolic agent? What is the long-term outcome and will this procedure result in sustained weight loss? What is the best method of targeting the appropriate vascular bed? As more robust clinical trials provide answers to these questions, we will be closer to understanding the role this procedure may have in the treatment of this prevalent disease process.


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Angiogram of the left gastric artery. Fundal (solid arrows) and esophageal (dashed arrow) branches are identified. This LGA shows a large anastomosis (arrowheads) with the right gastric artery along the lesser curvature.

Hormonal changes during the fasting versus fed states. Several hormones are released from the GI tract. The “hunger hormone” ghrelin is secreted from X/A cells in the gastric fundus, whereas PYY and GLP-1 are secreted from L cells, primarily from the ileum and colon. Leptin is primarily produced in adipocytes. During fasting, decreased food intake suppresses the release of PYY, GLP-1, and CCK from the gut while stimulating the secretion of ghrelin by the stomach. Fasting also decreases serum leptin levels. These changes are detected by the brain, leading to hunger. Dieting results in a gut hormone profile that mimics the fasted state. During and after regular feeding, there is a reduction in the production of ghrelin by the stomach. In contrast, production of PYY, GLP-1, and CCK from the gut is increased, and serum leptin levels also increase. These changes, which are detected by the brain, result in decreased appetite and a feeling of satiety.


Citation: Weiss, C. R. et al. Bariatric Embolization of the Gastric Arteries for the Treatment of Obesity. Journal of Vascular and Interventional Radiology (2015). doi:10.1016/j.jvir.2015.01.017


Post author: Luke Wilkins, MD