title: Safety and feasibility of adjunctive dexamethasone infusion into the adventitia of the femoropopliteal artery following endovascular revascularization.
abstract: OBJECTIVE
  Restenosis following endovascular treatment of the femoropopliteal segment is associated with the inflammatory response produced in the artery wall at the time of the procedure. Although local drug delivery to the superficial femoral and popliteal arteries promises improved patency, data are currently limited. We hypothesized that improved percutaneous delivery of an anti-inflammatory compound into the adventitia of the femoropopliteal at the time of endovascular treatment would be safe, feasible, and decrease the inflammatory response.
  
  
  METHODS
  This was a prospective, investigator-initiated, phase I, first-in-man study testing the safety and feasibility of percutaneous adventitial delivery of dexamethasone. Following successful intervention, an adventitial microinfusion catheter was advanced over a 0.014-inch wire to the treated segment. Its microneedle (0.9 mm long × 140-μm diameter) was deployed into the adventitia to deliver dexamethasone (4 mg/mL) mixed with contrast agent (80:20 ratio), providing fluoroscopic visualization. The primary safety outcome measure was freedom from vessel dissection, thrombosis, or extravasation while the primary efficacy outcome was duplex-determined binary restenosis defined as a peak systolic velocity ratio >2.5.
  
  
  RESULTS
  Twenty patients with Rutherford clinical category 2-5 enrolled in this study. The mean age was 66, and 55% had diabetes mellitus. Treated lesion length was 8.9 ± 5.3 cm, and 50% were chronic total occlusions. Eighty percent of treated lesions were in the distal superficial femoral or popliteal arteries. All lesions were treated by balloon angioplasty with provisional stenting (n = 6) for suboptimal result. Three patients were treated with atherectomy as well. A mean of 1.6 ± 1.1 mg (0.5 ± 0.3 mL) of dexamethasone sodium phosphate was injected per centimeter of lesion length. In total, a mean of 12.1 ± 6.1 mg of dexamethasone was injected per patient. The mean number of injections required per lesion was 3.0 ± 1.3 cm, minimum one and maximum six injections. There was 100% technical success of drug delivery and no procedural or drug-related adverse events. The mean Rutherford score decreased from 3.1 ± .7 (median, 3.0) preoperatively to .5 ± .7 at 6 months (median, 0.0; P < .00001). Over this same time interval, the index leg ankle-brachial index increased from .68 ± .15 to .89 ± .19 (P = .0003). The preoperative C-reactive protein in this study was 6.9 ± 8.5 indicating severe baseline inflammation, which increased to 14.0 ± 23.1 mg/L (103% increase) at 24 hours following the procedure. However, this increase did not reach statistical significance of P = .14. Two patients met the primary efficacy end point of loss of primary patency by reoccluding their treated segment of the index lesion during the follow-up period.
  
  
  CONCLUSIONS
  Adventitial drug delivery via a microinfusion catheter is a safe and feasible alternative to intimal-based methods for adjunctive treatment in the femoropopliteal segment. The 6-month preliminary results suggest perivascular dexamethasone treatment may improve outcomes following angioplasty to the femoral and popliteal arteries, and support further clinical investigation of this approach.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California San Francisco Medical Center, San Francisco, Calif. Electronic address: christopher.owens@ucsfmedctr.org.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Owens
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California San Francisco Medical Center, San Francisco, Calif.
authors.forename: Warren J
authors.initials: WJ
authors.lastname: Gasper
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California San Francisco Medical Center, San Francisco, Calif.
authors.forename: Joy P
authors.initials: JP
authors.lastname: Walker
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California San Francisco Medical Center, San Francisco, Calif.
authors.forename: Hugh F
authors.initials: HF
authors.lastname: Alley
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California San Francisco Medical Center, San Francisco, Calif.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Conte
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California San Francisco Medical Center, San Francisco, Calif.
authors.forename: S Marlene
authors.initials: SM
authors.lastname: Grenon
mesh_terms: D063194:Adventitia; D000368:Aged; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001783:Blood Flow Velocity; D002908:Chronic Disease; D003251:Constriction, Pathologic; D003907:Dexamethasone / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000187:drug effects* / Q000503:physiopathology; D006801:Humans; D036502:Infusions, Intralesional; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D010865:Pilot Projects; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000187:drug effects* / Q000503:physiopathology; D011446:Prospective Studies; D011859:Radiography; D012039:Regional Blood Flow; D012495:San Francisco; D055502:Secondary Prevention; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency / Q000187:drug effects
chemical_list: D000893:Anti-Inflammatory Agents; C004180:dexamethasone 21-phosphate; D003907:Dexamethasone