Prolonged Versus Brief Balloon Inflation for Arterial Angioplasty

Abstract

Angioplasty is a fundamental treatment of atherosclerotic disease; however, the optimal duration of balloon inflation has not been identified. Our study investigated whether prolonged inflation of at least 1 minute, compared with brief inflation, affects residual stenosis after arterial angioplasty. This study is registered on PROSPERO (92702). In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, two independent reviewers conducted a systematic review of Embase, MEDLINE, Cochrane Central Register of Controlled Trials, trial registries, and gray literature. Data abstraction and quantitative analysis were performed independently, according to prespecified criteria. The primary outcome was residual stenosis after initial angioplasty in addition to other prespecific clinical and radiographic outcomes. Six relevant articles were identified, of which one investigated peripheral vascular angioplasty and five investigated coronary artery angioplasty, encompassing a total of 1496 procedures (Fig 1, A). The studies were at moderate risk of bias and displayed features of publication bias (Fig 1, B and C). Minimal heterogeneity allowed meta-analysis. Prolonged balloon inflation was significantly associated with lower risk of residual stenosis after inflation (risk ratio [RR], 1.78; 95% confidence interval [CI], 1.49-2.14; Fig 2, A and B) in addition to less than half the risk of arterial dissection and need for adjunctive procedures such as stenting (RR, 2.42 [95% CI, 1.73-3.38] and RR, 2.14 [95% CI, 1.54-2.96], respectively). Following adjunctive procedures, less residual stenosis was still observed in the prolonged angioplasty group (RR, 1.50; 95% CI, 1.08-2.07; Fig 2, C). Follow-up did not reveal a significant difference in the incidence of restenosis; however, there was a significant benefit of prolonged inflation in reducing severity of stenosis (mean difference, 3.18; 95% CI, 0.43-5.92; Fig 2, D and E). Sensitivity analysis accounting for the effect of vascular bed location or study design did not reveal significant differences. Prolonged angioplasty significantly improves immediate radiographic results; however, the long-term effect is less pronounced. Prolonged angioplasty is justified, particularly in situations in which adjunctive stent placement is avoided. This is the first review investigating the ideal duration of balloon inflation. Because peripheral interventions are not limited by symptomatic end-organ ischemia to the same degree as coronary interventions are, a clinical trial evaluating further prolongation of angioplasty inflation duration in small-caliber peripheral arteries is warranted.Fig 2Selected forest plots of meta-analyses. Articles are listed in increasing order of disparity in balloon inflation duration between treatment arms. A, Primary outcome: risk of residual stenosis immediately after initial angioplasty inflation. B, Severity of residual stenosis immediately after initial angioplasty inflation, measured as a continuous outcome of percentage stenosis. C, Risk of residual stenosis on index procedure completion angiography, following any adjunctive procedures. D, Risk of stenosis on follow-up angiography, at least 3 months after index procedure. E, Severity of stenosis on follow-up angiography performed at least 3 months after index procedure, measured as a continuous outcome of percentage stenosis. CI, Confidence interval; IV, inverse variance; SD, standard deviation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)