Peripheral Arterial Disease Clinical Trial
Official title:
Local Paclitaxel Delivery to Prevent Restenosis Using the TAPAS Catheter After Endovascular Revascularization in Patients With Previous Femoropopliteal Intervention
The purpose of this study is to determine if the addition of a catheter-based local delivery of paclitaxel into the peripheral arterial vessels in patients with peripheral arterial disease (PAD) and subsequent restenosis of the femoropopliteal region would benefit from this type of investigational intervention with a known antiproliferative agent.
Peripheral arterial disease (PAD) of the lower extremities is an extremely prevalent, and
often times, disabling disorder reaching roughly 8 million people in the United States, and
up to 20 percent of the population over the age of 60 to 70. Atherosclerosis commonly occurs
in the superficial femoral artery (SFA) and the popliteal artery limiting blood flow to the
affected vessels, as well as, the distal lower extremities. PAD of this type causes
claudication in up to 35% of patients which may progress to critical limb ischemia in up to
2%.
Endovascular treatment options have significantly improved over the past decade, allowing a
multitude of treatment alternatives. In the US, the number of endovascular treatments now
exceed bypass surgery. Procedural success rates of greater than 90 percent can be achieved by
stenting, atherectomy, and percutaneous transluminal angioplasty; however, long term patency
rates have been troubled by elastic recoil or neointimal hyperplasia. Two year patency rates
have been documented to range from 40-50% following balloon angioplasty. Stenting in the
femoropopliteal region in attempts to improve restenosis fall short with a primary patency
rate of 70-80% as seen in the FAST trial. Atherectomy is promising, but has not been studied
extensively.
The inability to obtain long term patency has led us to look at our success in the coronary
field where drug-eluting stents (DES) are often used. Antiproliferative drugs such as
paclitaxel prevent neointimal growth and have proven patency and long term success. There
have been initial animal and human studies which have shown potential in preventing
restenosis by using drug coated balloons and DES. Currently, there is no FDA approved drug
eluting balloon for use in femoropopliteal disease, leading us to search for alternative
therapies following femoropopliteal interventions.
Paclitaxel inhibits microtubule disassembly and disrupts normal cellular processes such as
protein signaling, mitosis, and migration. It is highly lipogenic and poorly water soluble.
Paclitaxel has been stated to prevent restenosis through several mechanisms in vitro. These
mechanisms include inhibiting proliferation and migration of human smooth muscle cells. Use
of the antiproliferative agent in the peripheral arena has been conducted, but no definitive
results have been achieved to date. One internal animal study showed promise in the
deliverability of localized paclitaxel into targeted segments of the vessel using the TAPAS
device. Concentrations of 0.67 mg/mL, 1.2 mg/mL, and 2.0 mg/mL were infused locally at a
duration of 2-5 minutes within the iliofemoral segment in pigs, then aspirated from the
vessel using the device. No differences in drug absorption were found among the three
concentrations. Drug retention remained greater than 50% in all groups at 3 and 24 hours. The
average drug concentration in the vessel wall of all groups was 1.73 ± 0.85 µg/g at 3 hours,
and 1.29 ± 0.47 µg/g at 24 hours after treatment. Approximately 77% of the total drug
administered was aspirated, with the assumption that the remaining drug was either absorbed
in the tissue, remained in the catheter, or lost systemically. On average, plasma paclitaxel
levels after treatment measured 22.5 ± 21.07 ng/mL at 2 minutes, 2.7 ± 0.85 ng/mL at 3 hours,
and less than 1.2 ng/mL at 24 hours. Histology showed no inflammation, injury, or other
adverse effect when compared with the contrast group.
The newly available Targeted Adjustable Pharmaceutical Application System (TAPAS)—TAPAS
Catheter Therapeutic System (Spectranetics, Colorado Springs, CO, USA)—has a proximal and
distal occlusion balloon with an adjustable length that allows local drug delivery to a
targeted arterial segment preventing systemic effects by allowing aspiration following
delivery.
The ResTAP study is a prospective, open label, observational study to assess the safety and
efficacy of the delivery of paclitaxel to prevent recurrent restenosis after percutaneous
intervention including atherectomy with or without stenting in patients who have restenosis
after a prior endovascular revascularization.
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