Effects of Remote Ischemic Preconditioning on Restenosis Post Lower Limb Revascularization Angioplasty

September 22, 2017 updated by: KHALID AHMED, National University of Ireland, Galway, Ireland

Effects of Remote Ischemic Preconditioning on Restenosis Post Lower Limb Revascularization Angioplasty: A Pilot Randomized Control Trial

The investigators will established relation between restenosis and inflammatory response to shearing stress caused by angioplasty suggest that any mechanism that affect inflammatory response can consequently affect the restenosis rate. There is accumulated evidence that remote ischemic precondition has modifying suppressive effect on inflammatory response and the investigators hypothesized that RIPC may lead to reduction in post angioplasty restenosis rate.

Study Overview

Status

Suspended

Conditions

Intervention / Treatment

Detailed Description

Rationale:

The father of interventional radiology Charles Dotter (1920-1985) performed the first percutaneous transluminal angioplasty in university of Oregon hospital on Laura Shaw in 16th of January 1964. She presented with typical rest pain and foot gangrene on left leg and her angiogram show distal superficial femoral artery focal stenosis. He saved her leg and she was walking for the next 3 years of her life using his experimental dilating catheter Later in 1977 Zurich witnessed the first coronary angioplasty by German cardiologist Andreas Gruentzig (1939-1985) using same technique .

The angioplasty utilized gradually in the next years after Dotter to provide less invasive option for the growing number of peripheral vascular disease patients estimated to be in the range of 3% to 10%, increasing to 15% to 20% in persons over 70 years. Early diagnosis remains difficult because patients tends to be asymptomatic up to 50% or more of vessel narrowing. the strong association between prevalence of peripheral vascular disease and age increase the demand with world population ageing specially in western Europe and USA. The lower extremity revascularization USA statistics in year 2000 was 40/100,000 and increasing.

Restenosis or the gradual narrowing of the re vascularized vessel remains one of the main problems usually it occurs within 6 months of angioplasty . Restenosis percentages varies between 12% up to 63 % in different studies largely depends on the lesion type and site with below knee interventions being more liable for restenosis.

The restenosis phenomena can be explained by the physiological response to the trauma caused by the balloon when inflated to compress the atheroma. Many factors can influence the process e.g. patient , procedure and vessel condition before intervention.it can be considered as hypertrophic wound healing from the interaction between monocyte-derived macrophages , T cells and arterial wall .the inflammatory response lead to Neointimal Hyperplasia the terminology uses to describe the proliferation and migration of vascular smooth muscle cells . Elevated inflammatory and coagulation factors markers levels after angioplasty has been suggested as predictors for the possibility of restenosis . The inflammatory theory was more supported when using immunosuppressive drugs like Sirolimus shows positive effects on reducing restenosis rate.

Ischemic precondition introduced first as mechanism to reduced subsequent myocardium injury after applying intermittent periods of sub-lethal ischemia . Subsequently the concept examined on other body organs . The mechanisms through which remote ischemic preconditioning (RIPC) work was the subject for many studies suggesting neural, humoral and anti-Inflammatory pathways . Animal studies suggest powerful anti-inflammatory effect for RIPC . other studies shows endothelial protections by decrease formation of reactive oxygen species (ROS) and upregulates endothelial nitric oxide (eNOS) synthase which responsible for most of vasculature Nitric Oxide a very important protective molecule in reperfusion and shearing stress injuries . In human studies Ischaemic, preconditioning show endothelial protective effect and altered Neutrophils function including reduced adhesion, exocytosis, phagocytosis, and modified cytokine secretion. . In one study, RIPC stimulates modified leukocyte inflammatory gene expression in correlations with the first and second windows of the RIPC, which is 1-2 hours and 12-24 respectively.

Sampling Frame the peripheral vascular disease patients with medical profiles, which match trial criteria who are waiting for or admitted from emergency department for lower limb revascularization angioplasty in Galway university hospital, will be identified. Recruitment will be stopped at 10 months of 16 months of the trial period.

Trial Design Patients who need revascularization angioplasty classically had history of symptomatic peripheral vascular disease usually assessed in OPD using ABI and send for duplex ultrasound scan after which some get CT angiogram or Magnetic Resonance Angiography (MRA). Furthermore, intra operative images are the common practice. the investigators will be recruiting from this group in accordance with trial protocol.

The target number will be 40 patients divided into 2 groups. All groups candidates will undergo base line assessment which include history, examination, duplex, ABI and blood sample for inflammatory and coagulation markers.

The candidates will randomly allocated to:

Randomisation Age and DM are associated with many comorbidities. Randomization will be stratified for these two confounders using Minimpy computer software.

All trial candidates will have unique numbers to identify them and conceal their identity. Patients files will be locked in trial office with one-person access and each candidate will get their numbers in sequential way according to their allocation.

Projected recruitment. Galway University hospital provides vascular services for a population of approximately 750000 served by the West-North West Hospitals Group. The patients for the trial will be actively recruited from out patient's clinics, in patients and theatre booking database. Information about the trial will be given to all vascular team including criteria for selection and exclusion. Those who qualified will be counselled by the trial team and consented if the agree to join. The target of 40 patients should be achievable within the recruitment window.

Patient recruitment & consent Eligible candidates will get all the information about the trial in written and verbal explanation for all the steps. Patients who are willing to take part will asked to provide written informed consent. Three copies of the consent form will be signed: one for the patient, one for the patient's clinical notes file and a one copy for the patient's trial folder.

Data collection Demographic and clinical data of eligible candidates who agree to participate will be collected. The candidates will be assign a trial number identifier after informed consent is signed and no personal information will be available on the data entry sheets. The original data-entry preform will be retained together with a copy of the consent form in the trial office with other trial documents in the trial office in CSI building. The code key for the trial numbers will be limited to the Chief Investigator. Encrypted back up copy will be prepared at the end of each data entry and will be kept looked separately. All data will be retained in the care of the principal investigator for a period of five years from the closure of the trial.

Statistical analysis A trial team member blinded to trial allocation will perform the statistical analysis with respect to the primary and secondary outcomes. This is a pilot study the results will be used to identify if there is a need for larger trial.

Trial monitoring Day-to-day management of the trial will be the responsibility of the trial manager, supervised by the principal investigator. A meeting will be held every two weeks between the trial manager and the principal investigator to monitor recruitment, data collection etc.

Study Type

Interventional

Enrollment (Anticipated)

40

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Ireland
      • Limerick, Ireland
        • Limerick University Hospital
    • Co Galway
      • Galway, Co Galway, Ireland
        • University Collage Hospital Galway

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion criteria

1. Patients planned for lower limb Angioplasty

Exclusion criteria

  1. Known upper limb PVD
  2. Previous history of upper limb deep vein thrombosis
  3. Patients on glibenclamide or nicorandil- May affect RIPC
  4. Raynaud's Disease
  5. Intra operative decision to use graft - will be documented

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Double

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
No Intervention: Control Group:
This group will be getting all the routine work up including Duplex scan . we will add request for inflammatory and coagulation markers in their blood samples before and after intervention . The pre-op blood sample will be collected within the 24 hours before intervention and the post intervention in the 24 hrs after (second RIPC window). The repeated duplex scan will be schedule after 6 months.
Active Comparator: RIPC Group
Remote Ischemic Preconditioning Group (RIPC):This group will have all the tests as for the control group with the additional component will be preconditioning. One hour prior to procedure candidates in this group will have structured intermittent periods of induced remote ischaemic preconditioning using standard blood pressure cuffs. The cuff will be inflated to 200 mmHg applied for 5 minutes alternating with 5 minutes rest to the total of 4 cycles, which needs 40 minutes.
Other: Remote Ischemic Preconditioning
standard blood pressure cuffs applied to upper limb . The cuff will be inflated to 200 mmHg applied for 5 minutes alternating with 5 minutes rest to the total of 4 cycles

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Restenosis
Time Frame: 6 months post procedure
using Duplex scan 30% stenosis increase in time of flow up. Increase of less than or 50 % stenosis to 70% or more. Loss of 50% of gain in luminal diameter.
6 months post procedure
Changes in inflammatory and coagulation markers comparing the 2 groups
Time Frame: 24 hours post procedure
CRP FBC D-Dimer Fibrinogen
24 hours post procedure

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Limb Amputation
Time Frame: 6 months post procedure
recording any limb amputation
6 months post procedure
Minor amputations
Time Frame: 6 months post procedure
recording minor amputations - digits
6 months post procedure
Percentage changes in ABI
Time Frame: 6 months post procedure
calculate the change in ABI pre and post intervention
6 months post procedure
Ulcer formation/ healing
Time Frame: 6 months post procedure
Documents ulcers formation/ healing
6 months post procedure
Progression of Rutherford classification
Time Frame: 6 months post procedure
Documents changes pre and post intervention
6 months post procedure

Other Outcome Measures

Outcome Measure
Measure Description
Time Frame
Related Data
Time Frame: 6 months post procedure
Demographic data Smoking DM Lesion type/site Ischemic heart disease Anti- coagulation and Antibiotic usage
6 months post procedure

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

National University of Ireland, Galway, Ireland

Collaborators

University Hospital of Limerick
University College Hospital Galway

Investigators

  • Principal Investigator: Stewart Walsh, Professor, NUIGalway - UCHG

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Anticipated)

April 1, 2018

Primary Completion (Anticipated)

December 1, 2019

Study Completion (Anticipated)

December 1, 2019

Study Registration Dates

First Submitted

March 19, 2015

First Submitted That Met QC Criteria

April 1, 2015

First Posted (Estimate)

April 2, 2015

Study Record Updates

Last Update Posted (Actual)

September 26, 2017

Last Update Submitted That Met QC Criteria

September 22, 2017

Last Verified

September 1, 2017

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • C.A. 1238

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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