← Product Code PRL · P160024

# LIFESTREAM BALLOON EXPANDABLE VASCULAR COVERED STENT (P160024)

_Bard Peripheral Vascular, Inc. · PRL · Apr 24, 2017 · Cardiovascular · APPR_

**Canonical URL:** https://fda.innolitics.com/device/P160024

## Device Facts

- **Applicant:** Bard Peripheral Vascular, Inc.
- **Product Code:** PRL
- **Decision Date:** Apr 24, 2017
- **Decision:** APPR
- **Device Class:** Class 3
- **Review Panel:** Cardiovascular
- **Attributes:** Therapeutic

## Intended Use

The LifeStream™ Balloon Expandable Vascular Covered Stent is indicated for the treatment of atherosclerotic lesions in common and external iliac arteries with reference vessel diameters between 4.5 mm and 12.0 mm, and lesion lengths up to 100 mm.

## Device Story

LifeStream™ is a balloon-expandable vascular covered stent pre-mounted on an over-the-wire delivery system. The device is inserted percutaneously, typically via the common femoral artery, and advanced over a guidewire to the target iliac artery lesion. The balloon is inflated to expand the stent, which is composed of 316L stainless steel encapsulated in ePTFE. The stent maintains luminal patency in previously stenosed or occluded vessels. The procedure is performed by an interventionalist in a clinical setting. Radiopaque marker bands on the delivery system aid in accurate deployment. The device provides a mechanical scaffold to restore blood flow, potentially improving patient functional status and reducing symptoms of claudication. Clinical decision-making is supported by angiographic visualization during the procedure and follow-up monitoring via duplex ultrasound.

## Clinical Evidence

PMA approval based on the BOLSTER prospective, multi-center, single-arm study (N=155). Primary endpoint: composite of 30-day procedure/device-related death or MI, and 9-month TLR, major amputation, or restenosis (PSVR > 2.4). Pre-specified analysis (N=130) showed 16.2% event rate (p=0.1987), missing the 19.5% performance goal. Post-hoc analysis (N=138) incorporating 12-month data and clinical factors showed 11.6% event rate. Secondary endpoints included acute technical success (98.3%) and sustained clinical success (90.5%). No unanticipated adverse device effects reported.

## Technological Characteristics

Implant: 316L stainless steel balloon-expandable stent encapsulated in ePTFE. Delivery system: over-the-wire, noncompliant balloon catheter (dual or triple lumen, 5.4F/6.5F). Compatible with 0.035" guidewires. Sterilization: Ethylene Oxide (SAL 10^-6). MR Conditional at 1.5T and 3.0T. Materials meet ASTM F138-13a. Design includes radiopaque marker bands.

## Regulatory Identification

For the treatment of de novo or restenotic lesions found in iliac arteries

## Submission Summary (Full Text)

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SUMMARY OF SAFETY AND EFFECTIVENESS DATA (SSED)

I. GENERAL INFORMATION

Device Generic Name: Iliac Covered Stent, Arterial

Device Trade Name: LifeStream™ Balloon Expandable Vascular Covered Stent

Device Procode: PRL

Applicant’s Name and Address: Bard Peripheral Vascular, Inc.
1625 West 3rd Street
Tempe, AZ 85281, USA

Date(s) of Panel Recommendation: None

Premarket Approval Application (PMA) Number: P160024

Date of FDA Notice of Approval: April 24, 2017

II. INDICATIONS FOR USE

The LifeStream™ Balloon Expandable Vascular Covered Stent is indicated for the treatment of atherosclerotic lesions in common and external iliac arteries with reference vessel diameters between 4.5 mm and 12.0 mm, and lesion lengths up to 100 mm.

III. CONTRAINDICATIONS

The LifeStream™ Balloon Expandable Vascular Covered Stent is contraindicated for use in:

- Patients with uncorrected bleeding disorders.
- Patients who cannot receive recommended antiplatelet and/or anticoagulation therapy.
- Patients who are judged to have a lesion that prevents full expansion of the implant
- Lesions in which the lumen diameter post balloon angioplasty is insufficient for the passage of the endovascular system.
- Lesion locations subject to external compression.

IV. WARNINGS AND PRECAUTIONS

The warnings and precautions can be found in the LifeStream™ Balloon Expandable Vascular Covered Stent labeling.

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# V. DEVICE DESCRIPTION

The LifeStream™ Balloon Expandable Vascular Covered Stent (hereafter referred to as LifeStream Covered Stent) is a balloon-expandable stent pre-mounted on an over-the-wire delivery system. Please refer to Figure 1 for an image of the device. The implant is pre-mounted on an over-the-wire balloon catheter that acts as the delivery system. The endovascular system (delivery system and implant) is inserted percutaneously into the arterial system (primarily through the common femoral artery) and advanced over a guidewire to the target lesion site. The balloon is then inflated to expand the implant at the target site.

This is a permanently implanted device used to maintain patency of a previously stenosed or occluded common or external iliac artery.

![img-0.jpeg](img-0.jpeg)
Figure 1: LifeStream™ Balloon Expandable Vascular Covered Stent

# Covered Stent:

The LifeStream Covered Stent implant is a 316L stainless steel balloon-expandable stent, which is laser cut from stainless steel tubes of different diameters and wall thicknesses (small tube and large tube). There are two different base stent designs (small tube and large tube), which have the same geometry but are laser cut from stainless steel tubes of different diameters and wall thicknesses. The small tube has slightly thinner struts and the large tube has slightly thicker struts as a result. Product configurations with diameters between  $5\mathrm{mm}$  and  $8\mathrm{mm}$  (small tube) will have a maximum post dilation diameter of  $10\mathrm{mm}$ . Product configurations with diameters between  $9\mathrm{mm}$  and  $12\mathrm{mm}$  (large tube) will have a maximum post dilation diameter of  $12\mathrm{mm}$ . The stent is encapsulated between two layers (inner and outer) of expanded polytetrafluoroethylene (ePTFE) over its entire length. Figure 2 shows the implant structure. The material of the base stent has sufficient strength to maintain the luminal diameter post-procedure.

![img-1.jpeg](img-1.jpeg)
Figure 2: LifeStream™ Balloon Expandable Vascular Covered Stent (Implant)

The LifeStream Covered Stent implant is offered in lengths of 16, 26, 37/38 and  $58~\mathrm{mm}$  and in diameters of 5 to  $12~\mathrm{mm}$  in the configurations shown in Table 1. These sizes are sufficient to bridge most stenoses and occlusions in the iliac arteries. The implant may be overlapped with an additional implant in the event the target lesion exceeds the length of the longest available implant.

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Table 1: Product Configurations

|  Stent Tube Design | Diameter (mm) | Balloon & (Implant) Length in Millimeters (mm)  |   |   |   |
| --- | --- | --- | --- | --- | --- |
|   |   |  20 (16) | 30 (26) | 40 (37/38) | 60 (58)  |
|  Small Tube | 5 | X | X | X (37) | Not Offered  |
|   |  6 | X | X | X (37) | X  |
|   |  7 | X | X | X (37) | X  |
|   |  8 | X | X | X (37) | X  |
|  Large Tube | 9 | Not Offered | X (38) | X  |   |
|   |  10 |   |   | X (38) | X  |
|   |  12 |   |   | X (38) | X  |

* Diameters 5-8 mm are offered in 37 mm implant length, and diameters 9-12 mm are offered in 38 mm implant length
** Color blocks indicate delivery shaft used

![img-2.jpeg](img-2.jpeg)

# Delivery System:

The covered stent is supplied pre-mounted on an over-the-wire delivery system with a noncompliant balloon (Figure 3). There are two different shaft designs (dual lumen and triple lumen). The dual and triple lumen shafts have profiles of 5.4F and 6.5F respectively.

The balloon catheter platform is  $0.035''$  ( $0.89 \, \mathrm{mm}$ ) guidewire compatible and is available in catheter working lengths of 80 and  $135 \, \mathrm{cm}$ . Two radiopaque marker bands on the balloon shaft indicate the length of the balloon and ends of the covered stent; these markers aid in accurate deployment of the covered stent.

![img-3.jpeg](img-3.jpeg)
Figure 3: LifeStream™ Balloon Expandable Vascular Covered Stent (Endovascular System)

# VI. ALTERNATIVE PRACTICES AND PROCEDURES

Conservative therapy, medication, walking exercises, smoking cessation and change of diet can be highly effective in compliant patients with symptoms of claudication. Patients with a confirmed flow limiting stenosis often benefit from invasive treatment, which can include surgical bypass, angioplasty, atherectomy, or stenting when conservative therapy fails.

The most recent treatment recommendations according to the TransAtlantic Inter-Society Consensus (TASC) Work Group suggest endovascular treatment in all TASC A and B lesions and in TASC C lesions in higher risk surgical candidates. In all patients with TASC B and C lesions, the recommendations state that the patient's co-morbidity, fully informed patient preference and the local operator long-term success rates must be considered.

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The guidelines from the European Society of Cardiology state that a primary endovascular approach may also be considered in TASC D lesions in patients with severe comorbidities and the availability of an experienced interventionist. A patient should fully discuss these alternatives with his/her physician to select a method that best meets expectations and lifestyle.

## VII. MARKETING HISTORY

The LifeStream Covered Stent has been commercially available outside the United States since October 2014. It was first marketed in the European Union, and additionally has also been commercialized in Australia, New Zealand, Brazil, India, Russia, Taiwan, Chile, Colombia, Israel, Saudi Arabia, Singapore, Turkey, Thailand, Panama, the Dominican Republic, Algeria, Jordan, Iran, Georgia, South Africa, Oman Argentina, the Cayman Islands, Mexico, Brunei, Costa Rica, Vietnam, and Egypt. In response to complaint trending, the labeling for the 6 mm x 58 mm and 7 mm x 37 mm sizes were updated to recommend use of a larger introducer sheath size, in order to improve device compatibility. The device has not been withdrawn from marketing for any reason related to its safety or effectiveness.

## VIII. POTENTIAL ADVERSE EFFECTS OF THE DEVICE ON HEALTH

Complications and Adverse Events associated with use of the LifeStream Covered Stent may include the usual complications associated with endovascular stent and stent graft placement.

Previously reported complications include:

Abscess; allergic/anaphylactoid reaction; amputation; aneurysm/pseudoaneurysm; angina/coronary ischemia; arterial occlusion/thrombus, near the puncture site; arterial occlusion/thrombus, remote from puncture site; arterial occlusion/restenosis of the treated vessel; arteriovenous fistula; arrhythmia; balloon rupture; blockage of major collateral artery or arterial branch; bypass surgery; covered stent dislodgement from balloon during tracking procedure; covered stent misplacement during placement procedure; covered stent migration post placement procedure; covered stent insufficient wall apposition; covered stent deformation / kink / fracture; death; distal embolization; drug reaction or allergic reaction to medication, substances or materials used for the procedure (e.g. anticoagulation or antiplatelet agent, contrast medium, stent or catheter materials); edema; fever; hemorrhage/bleeding; hematoma and/or bleeding at puncture (access) site; hypotension/hypertension; inability to introduce/withdraw endovascular system; inability to track endovascular system to the target lesion; inability to inflate the balloon/deploy covered stent; infection at access site; infection at or around implant; inflammation; ischemia/infarction of tissue/organ; malposition; malappositions; myocardial infarction; pain; radiation injuries; renal insufficiency/failure/toxicity; respiratory arrest; restenosis in the treatment area/covered stent edge; sepsis; shock; stroke/transient ischemic attack (TIA);

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thromboembolic event/thrombosis; vasospasm; vessel wall trauma, and perforation/dissection/rupture.

For a discussion of Adverse Events that occurred during the clinical study of this device, please see Section X below.

## IX. SUMMARY OF NONCLINICAL STUDIES

### A. Biocompatibility Studies

Biocompatibility testing on the materials used in the LifeStream Covered Stent was performed following the recommendations provided in International Organization for Standardization (ISO) 10993, Biological Evaluation of Medical Devices and FDA’s Non-Clinical Engineering Tests and Recommended Labeling for Intravascular Stents and Associated Delivery Systems. All biocompatibility testing was conducted on the LifeStream Covered Stent graft and delivery system as categorized per ISO 10993-1, Biological Evaluation of Medical Devices Part 1: Evaluation and Testing within a Risk Management Process based on the intended duration and contact with or within the body.

Specific biocompatibility tests were performed based on the categorization of the covered stent and delivery system in accordance with ISO 10993, Biological Evaluation of Medical Devices. Table 2 provides a listing of the tests performed for both the implant and delivery system biocompatibility testing, along with the corresponding results. All biocompatibility tests were conducted in accordance with the Good Laboratory Practices (GLP) per 21 CFR, Part 58.

Table 2: Implant & Delivery System Biocompatibility Testing

|  Biocompatibility Test | Results |  | Biocompatibility Test | Results  |
| --- | --- | --- | --- | --- |
|  Implant Testing |   |   | Delivery System Testing  |   |
|  Cytotoxicity (MEM Elution) | PASS |   | Cytotoxicity – MEM Elution | PASS  |
|  Sensitization (Kligman Maximization) | PASS |   | Sensitization – Kligman Maximization | PASS  |
|  Acute Systemic Toxicity (Systemic Injection) | PASS |   | Acute Systemic Toxicity (Systemic Injection) | PASS  |
|  Intracutaneous Reactivity | PASS |   | Intracutaneous Reactivity | PASS  |
|  Pyrogen Testing (Material Mediated) | PASS |   | Pyrogen Testing (Material Mediated) | PASS  |
|  Hemocompatibility (Hemolysis) | PASS |   | Hemocompatibility (Hemolysis) | PASS  |
|  Hemocompatibility (Complement Activation) | PASS |   | Hemocompatibility (Complement Activation) | PASS  |

### B. In Vitro Bench Testing

In vitro bench testing was conducted as part of the design verification and validation to support the safety and effectiveness of the LifeStream Covered Stent and delivery system. This testing was conducted based on recommendations from risk assessments

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with consideration to FDA and industry recognized voluntary standards. The bench test results are summarized in Table 3.

Table 3: Summary of In Vitro Bench Testing

|  Test | Purpose/Objective | Acceptance Criteria | Results  |
| --- | --- | --- | --- |
|  IMPLANT  |   |   |   |
|  Material Composition | To verify the chemical composition of the stainless steel of the implant. | ASTM F138-13a | Pass  |
|  Stent Corrosion Resistance (post 10-year pulsatile accelerated durability) | To verify the implant’s ability to resist corrosion (fretting and pitting) and determine the presence of toxic byproducts released due to corrosion. | The breakdown, rest, and protection potentials (if available), and Eb- Er values will be reported for all samples for characterization purposes. Corrosion resistance was evaluated on devices after pulsatile fatigue testing (see below). Inspection for fretting, pitting, or crevice corrosion was performed via microscopic examination. | Pass  |
|  Dimensional Verification of Implant | To verify that critical implant dimensions (implant diameter and length at nominal pressure and rated burst pressure) are met. | Implant profile and length must be reported in the labeling. Testing was for characterization only. | Pass  |
|  Foreshortening | To quantify the percent decrease in length of the implant from between its crimped and deployed states. | Foreshortenings and final expanded length must be reported in the labeling. Testing was for characterization only. | Pass  |
|  Recoil for Balloon Expandable Implants | To quantify the percent decrease in diameter of the implant from between its deployed and relaxed states. | Recoil and final expanded diameter must be reported in the labeling. Testing was for characterization only. | Pass  |
|  Integrity (post-deployment) | To evaluate the integrity of the implant post-deployment and verify the implant shows no defects that would render it unsuitable for the intended use. | Implant must maintain structural integrity following fatigue evaluation per ISO 25539-1 and ISO 25539-2. | Pass  |
|  Radial Stiffness and Strength | To characterize the ability of the stent to resist collapse under short-term or long-term external loads. | Implant must have sufficient radial strength to withstand clinically-relevant forces, and the radial stiffness must be characterized. | Pass  |
|  Mechanical Properties | Material must be characterized and meet product specifications. | The covered stent must exhibit a tensile stress at yield, elongation, and minimum load per ASTM F138-13a. | Pass  |
|  Stress/Strain Analysis | Determine maximum stresses and strains within the device. | Strains were calculated using the worst-case configurations in a validated FEA model. | Pass  |
|  Fatigue Analysis | To assess durability of the device. | Fatigue analysis was conducted using the worst case configurations in a validated FEA model. | Pass  |

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|  Test | Purpose/Objective | Acceptance Criteria | Results  |
| --- | --- | --- | --- |
|  Accelerated Durability Testing | To evaluate the durability of the implant under arterial pulsatile fatigue conditions simulating ten (10) years of use. | Implant must maintain structural integrity following 380 million cycles (10 years) at physiological loads. Absence of covering delamination that results in flaps(s) that protrude into the inner lumen. | Pass  |
|  Particulate Evaluation | Characterize particulate following implant expansion to evaluate integrity of the covered stent. | The implant must not exhibit missing components/fragments following implant expansion to maximum recommended diameter. | Pass  |
|  MRI Safety and Compatibility | To evaluate MRI safety and compatibility. | The impact must be labeled as MR Conditional (as defined in ASTM F2503-18) at a field strength of 1.5T and 3.0T. | Pass  |
|  Radiopacity | To evaluate the radiopacity of the implant under fluoroscopy. | The implant radiopacity must be rated clinically acceptable by a physician expert. | Pass  |
|  Kink Resistance | To evaluate the implant's flexibility in its deployed configuration. | The angle and radius of the implant at the point at which conformance is lost must be characterized. Conformance is defined as: ≤ 30% lumen loss relative to the size of the vessel. | Pass  |
|  Porosity | To characterize porosity of the stent covering. | Implant porosity must be characterized per ISO 7198. | Pass  |
|  Migration Resistance | To verify that the covered stent adequately resists displacement during use. | The implant migration resistance must be rated as clinically acceptable in a chronic animal study. | Pass  |
|  Strength Covering Attachment | To verify that the force required to separate the two bonded ePTFE layers (implant encapsulation) is acceptable for the indication. | Covering bond strength must be characterized and must be sufficient to prevent delamination that results in covering flaps that protrude into the inner lumen. | Pass  |
|  ENDOVASCULAR SYSTEM / DELIVERY SYSTEM  |   |   |   |
|  Dimensional Verification | To verify that the delivery system meets dimensional criteria pre- and post-deployment. | The profile must be characterized. Compatibility of devices with recommended introducer sheath sizes was evaluated. | Pass  |
|  Delivery, Deployment, and Retraction | To ensure that the delivery system meets its pre-determined acceptance criteria with respect to its delivery, deployment, and retraction in a simulated use environment. | Endovascular system must track and track to the target site through a clinically representative model on the bench. System must also withdraw from model and pass visual inspection post deployment (i.e. must not exhibit missing components/fragments following inflation to labeled rated burst pressure). | Pass  |
|  Balloon Rated Burst Pressure | Evaluate rated burst pressure of the delivery system balloon. | The balloon must meet its labeled rated burst pressure (RBP) and must not exhibit circumferential bursts at or below RBP+5atm. | Pass  |

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|  Test | Purpose/Objective | Acceptance Criteria | Results  |
| --- | --- | --- | --- |
|  Balloon Fatigue | To evaluate performance of the delivery system balloon and its ability to withstand multiple inflations. | Delivery system must withstand 10 cycles of fatigue to RBP with a 30 second hold time within the implant without burst or leak failures. | Pass  |
|  Balloon Compliance | Characterize covered stent diameter based on balloon inflation pressure to ensure appropriate sizing selection of the covered stent. | The compliance of the balloon must be characterized and reported in the device labeling. | Pass  |
|  Balloon Inflation & Deflation Time | Characterize balloon inflation and deflation times to ensure they are clinically appropriate. | The inflation/deflation times must be clinically acceptable based upon physician expert opinion. | Pass  |
|  Catheter Bond Strength including Tip Pull Test | Evaluate strength of delivery system joints. | The delivery system must have sufficient strength to maintain its function under normal use. The joint strength must meet the requirements per ISO 10555-1. | Pass  |
|  Flexibility and Kink Test | Characterize the ability of the delivery system to withstand flexural forces typical of clinical use. | The endovascular system must have sufficient ability to withstand flexural forces required to track through a clinically-representative anatomical model. | Pass  |
|  Torque Strength | Characterize delivery system strength under torsional forces typical of clinical use. | The delivery system must remain functional after three (3) clockwise and counter-clockwise rotations with fixed tip while in a clinically-relevant anatomical model. Deflation time in the torqued condition must be clinically acceptable. | Pass  |
|  Stent Securement for Unsheathed Stents | Evaluate implant retention on the balloon. | Implant must not dislodge from the balloon in a clinically-representative anatomical model while tracking through an introducer sheath with a 95/97.5% confidence/reliability level. | Pass  |
|  Radiopacity | To evaluate the radiopacity of the delivery system under fluoroscopy. | The delivery system radiopacity must be rated clinically acceptable by a physician expert. | Pass  |
|  Assessment of Haemostasis | Assess the ability of any seals of valves in the system to maintain an adequate haemostatic seal. | The haemostasis must be rated clinically acceptable by a physician expert. | Pass  |
|  Tubing Tensile Strength | Assessed for the delivery system during testing for Catheter Bond Strength and Tip Pull Test. | The delivery system must have sufficient strength to maintain its function under normal use. The tensile yield strength must meet the requirements per ISO 10555-1. | Pass  |
|  Dogboning | Characterize the potential for the balloon outer diameter to exceed the stent outer diameter during implant deployment. | Dogboning information was collected for characterization per ISO 25539-2. | Pass  |
|  Profile Effect/Flaring | Determine the distance between the outer diameters of the stent and balloon. | Profile effect/flaring information was collected for characterization per ISO 25539-2. | Pass  |

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|  Test | Purpose/Objective | Acceptance Criteria | Results  |
| --- | --- | --- | --- |
|  PACKAGING  |   |   |   |
|  Packaging Integrity | To evaluate the stress resistance of the packaging during transportation and conditioning. | Packaging must maintain structural integrity post environmental and transit conditioning. | Pass  |
|  Stability of Product for Labeled Shelf Life | To ensure that the product performance characteristics are maintained for the stated shelf life of the product. | Expiration dating must be provided on the labeling. The LifeStream™ Balloon Expandable Vascular Covered Stent has a shelf life of 3 years based on product and package functional shelf life testing. | Pass  |

# C. Sterilization

The LifeStream Covered Stent is a single-use device that is distributed sterile to the end user. Sterilization and validation (in accordance with AAMI/ANSI/ISO 11135-1:2007 "Sterilization of Health Care Products - Ethylene Oxide - Part 1: Requirements for the Development, Validation, and Routine Control of Ethylene Oxide Sterilization Process for Medical Devices) for the LifeStream Covered Stent demonstrates a Sterility Assurance Level (SAL) of  $10^{-6}$ . Stability testing of the device and sterile packaging was performed and validated to ensure a 3-year shelf life.

# D. Animal Studies

The LifeStream Covered Stent was evaluated in the iliac arteries of non-atherosclerotic domestic Yorkshire crossbred swine. This model is an appropriate model in which to study the subject device, because it is widely accepted in the literature for evaluating peripheral vascular implant performance and safety. Table 4 summarizes the results of these animal studies. An acute study was performed to evaluate performance characteristics of the endovascular system. All acceptance criteria were met, and the LifeStream Covered Stent was considered to be clinically acceptable.

A chronic study was performed using the same animal model with separate follow-up time points at 32 and 94/95 days. Each animal received either two single covered stents or two overlapping pairs of covered stents. All animals in the chronic study were implanted with the LifeStream Covered Stent in one iliac artery and a control balloon expandable covered stent as the control device in the opposite iliac artery. The LifeStream Covered Stent met all acceptance criteria and was considered clinically acceptable by a physician expert.

Table 4: Summary Results of Animal Studies

|  Study Type | Number of Stents / Number of Animals / Implant Location | Testing Summary  |
| --- | --- | --- |
|  Acute (0 day) performance study in Domestic Yorkshire Crossbred Swine | 19 study devices / 3 swine / 5 left SFA / 8 left iliac / 6 right iliac | All devices met the pre-established acceptance criteria for system trackability, deployment accuracy, retraction, inflation/deflation, radiopacity, haemostasis. No fractures or migrations were observed. PASS  |

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|  Study Type | Number of Stents / Number of Animals / Implant Location | Testing Summary  |
| --- | --- | --- |
|  Chronic (32 day) performance study in Domestic Yorkshire Crossbred Swine | 12 study devices / 12 control devices / 9 swine / 3 control (single) Left iliac / 2 control (overlapped) left iliac / 3 study device (single) left iliac / 4 study device (overlapped) left iliac / 3 control (single) right iliac / 4 control (overlapped) right iliac / 3 study device (single) right iliac / 2 study device (overlapped) | All devices met the pre-established acceptance criteria for system trackability, deployment accuracy, retraction, inflation/deflation, radiopacity, haemostasis. No fractures were observed. PASS

All evaluated vessels were patent with an excellent blood flow clinician rating.

No evidence of vessel injury, thrombus or stent migration was observed via angiography.

No statistical difference observed between the study device and the control article in stenosis measurements.

Study device demonstrated a statistically smaller average neointimal area and neointimal thickness between the struts in the single stent treatment groups and Neointimal thickness above the struts compared to the control device.  |
|  Chronic (94/95 day) performance study in Domestic Yorkshire Crossbred Swine | 12 study devices / 12 control devices / 9 swine / 3 control (single) left iliac / 4 control (overlapped) left iliac / 3 study device(single) left iliac / 2 study device (overlapped) left iliac / 3 control (single) right iliac / 2 control (overlapped) right iliac / 3 study device (single) right iliac / 4 study device (overlapped) right iliac | All devices met the pre-established acceptance criteria for system trackability, deployment accuracy, retraction, inflation/deflation, radiopacity, haemostasis. No fractures were observed. PASS

'The LifeStream™ Balloon Expandable Vascular Covered Stent demonstrated a statistically smaller average neointimal area and neointimal thickness between the struts in the single stent treatment groups above the struts compared to the control device.

No evidence of vessel injury or stent migration was observed via angiography for the study devices or control device.

Histopathology and clinical evaluators rate the study device at least similar to or superior to the control device with respect to thrombus formation.  |

X. SUMMARY OF PRIMARY CLINICAL STUDY

A prospective, multi-center, single arm clinical study in the United States (US), European Union (EU) and New Zealand was conducted to establish a reasonable assurance of safety and effectiveness of the LifeStream Covered Stent for atherosclerotic lesions in common and external iliac arteries. The data produced from the BOLSTER study under IDE #G140138 were the basis for a PMA approval decision for the LifeStream Covered Stent. A summary of the clinical study is presented below.

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## A. Study Design

Patients were treated between March 2, 2015 and July 29, 2015. The database for this PMA reflected data collected through June 27, 2016 and included 155 patients. There were 17 investigational sites.

The BOLSTER study under IDE #G140138 was a prospective, multi-center, single-arm clinical study to evaluate the safety and effectiveness of the LifeStream Covered Stent for the treatment of atherosclerotic lesions in common and external iliac arteries.

The primary endpoint of the study is a composite safety and effectiveness measure defined as device and/or procedure-related death or myocardial infarction (MI) through 30 days, or any Target Lesion Revascularization (TLR), target limb(s) major amputation, or restenosis through 9-months post-index procedure. The objective of the BOLSTER clinical study was to demonstrate that the LifeStream Covered Stent is safe and effective for treatment of atherosclerotic lesions in common and external iliac arteries by comparing the composite primary endpoint result to a pre-specified performance goal (PG) of 19.5%. The PG was derived using a metaanalysis of published data on other FDA-approved iliac stents.

The statistical analysis plan prospectively specified that subjects meeting all of the eligibility criteria would be used for analysis of study endpoints. A sensitivity analysis was performed for testing the primary hypothesis in the as-treated population, which included all enrolled subjects, as well as the pre-specified population which included only those subjects who met the study inclusion criteria, excluding those using additional devices.

All adverse events were reviewed and adjudicated by the Clinical Events Committee (CEC). The CEC determined the final relationship of each adverse event and categorized each adverse event as device-related, index procedure-related, disease-related (PAD), unrelated to device, procedure, or not related. The severity of each adverse event was determined by the site investigator based on the ISO 14155 definition of serious and non-serious adverse events. The Data Safety and Monitoring Board (DSMB) provided oversight of safety trends and reviewed site reported protocol deviations and source data related to subject eligibility. Independent core laboratories evaluated ultrasound imaging obtained during the study procedure and at follow-up visits.

## 1. Clinical Inclusion and Exclusion Criteria

Enrollment in the BOLSTER study was limited to patients who met the following inclusion criteria:

### Subject Inclusion Criteria

1. The subject provides written informed consent.
2. Subject agrees to comply with the protocol-mandated follow-up procedures and visits.

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3. The subject is a male or non-pregnant female ≥ 21 years old with an expected lifespan sufficient to allow for completion of all study procedures. Female subjects of childbearing potential must have a negative pregnancy test within 14 days prior to the procedure.
4. The subject has intermittent claudication (Rutherford Category 2-3) or ischemic rest pain (Rutherford Category 4).
5. The subject is able and willing to comply with any required medication regimen.

## Angiographic Inclusion Criteria

6. The subject has evidence of single, bilateral, or multiple de novo and/or restenotic (non-stented) lesion(s) in the native common and/or external iliac artery that is (are) ≥ 50% stenosed (including total occlusions) as determined by the Investigator’s visual estimate.
7. The target lesion(s) can be successfully crossed with a guide wire and pre-dilated with an appropriately sized percutaneous transluminal angioplasty (PTA) balloon. Devices such as chronic total occlusion (CTO) catheters or re-entry devices may be used to facilitate target lesion(s) crossing.
8. The reference vessel diameter(s) is (are) between 4.5 mm and 12.0 mm in diameter as determined by the Investigator’s visual estimate.
9. The target lesion(s) is (are) ≤ 100 mm in combined length (per side) as determined by the Investigator’s visual estimate.
10. The subject has angiographic evidence of a patent (< 50% stenosis) profunda and/or superficial femoral artery (SFA) in the target limb(s) as determined by the Investigator’s visual estimate. Ipsilateral and contralateral SFA lesions may be treated before or after target lesion treatment, considering the following criteria are met:
- ≥ 50% stenosis
- Stenosis(es) ≤ 15cm in total length or a Total Occlusion ≤ 5cm in length
- ≥ 1 vessel run-off
- No thrombus or severe calcification
- Use of on-label devices

Contralateral iliac lesions (not meeting study eligibility criteria) may be treated at the discretion of the investigator with on-label (non-investigational) devices at the time of the index procedure. Other planned interventions must take place 30 days before the index procedure or after 30 days post-index procedure.

Patients were not permitted to enroll in the BOLSTER study if they met any of the following exclusion criteria:

## Subject Exclusion Criteria

1. The subject is unable or unwilling to provide written informed consent, or is unable or unwilling to conform to the study protocol follow-up procedures and visits.
2. The subject is or plans to become pregnant during the study.

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3. The subject is asymptomatic, has mild claudication or critical limb ischemia with tissue loss described as Rutherford Category 0 (asymptomatic), 1 (mild claudication), 5 (minor tissue loss), or 6 (major tissue loss).

4. The subject has a vascular graft previously implanted in the native iliac vessel.

5. The subject suffered a hemorrhagic stroke or transient ischemic attack (TIA) within 3 months prior to the index procedure.

6. The subject has a known uncorrectable bleeding diathesis or active coagulopathy.

7. The subject has a serum creatinine ≥ 2.5 mg/dl or is currently on dialysis.

8. The subject has a known allergy or sensitivity to stainless steel (i.e., Nickel), ePTFE, or has intolerance to the antiplatelet, anticoagulant or thrombolytic medications required per the protocol.

9. The subject has a known allergy or sensitivity to contrast media, which cannot be adequately pre-medicated.

10. The subject had a prior vascular intervention(s) within 30 days before, or has an intervention planned for within 30 days after the index procedure. Refer to inclusion criterion #10 for exceptions on ipsilateral SFA lesions and contralateral iliac and SFA lesions.

11. The subject has another medical condition, which, in the opinion of the Investigator, may cause him/her to be non-compliant with the protocol, confound the data interpretation, or is associated with a life expectancy insufficient to allow for the completion of study procedures and follow-up.

12. The subject is currently participating in an investigational drug, biologic, or another device study. Studies requiring extended follow-up for products that are now commercially available are not considered investigational studies.

## Angiographic Exclusion Criteria

13. The subject has extensive peripheral vascular disease, which in the opinion of the Investigator, would preclude safe insertion of an introducer sheath. The ipsilateral common femoral artery should be patent (< 50% stenosis) by the Investigator’s visual estimate.

14. The target lesion(s) requires treatment other than angioplasty (e.g., atherectomy, cryoplasty, cutting/scoring balloons, etc.) to facilitate subject device delivery. Devices such as CTO catheters or re-entry devices may be used to facilitate target lesion(s) crossing.

15. The subject has severe calcification of the target lesion(s), which prevents inflation of a PTA balloon (pre-dilatation of the target lesion is required).

16. The target lesion(s) has been previously treated with a stent (bare or covered). A target vessel(s) with a previously placed stent is permitted as long as the subject device(s) will not come into contact with the previously placed stent during treatment of the target lesion(s).

17. The subject has angiographic evidence of acute thrombus at the target lesion(s).

18. The target lesion(s) involves the origin of the internal iliac artery such that successful treatment of the lesion(s) would require the subject device(s) to cross/occlude the side branch. Note, if the internal iliac artery is already occluded, the subject device(s) can be placed across the occluded vessel.

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19. The target lesion(s) is (are) located in the distal external iliac artery such that successful treatment of the lesion(s) would require the subject device(s) to cross/occlude side branches (inferior epigastric artery and/or deep circumflex iliac artery) or be exposed to compressive forces associated with the close proximity to the common femoral artery. Note, if the side branch(es) is (are) already occluded, the subject device(s) can be placed across the occluded vessel(s) as long as the device is above the inguinal ligament.

## 2. Follow-Up Schedule

All patients were scheduled to return for follow-up examinations at 30 days, and 9 months post-index procedure, and a telephone screen for all treated subjects was performed at 6 months post-procedure. The schedule of follow-up examinations is outlined in Table 5.

Table 5: Study Visit Assessment Table

|  Bard Peripheral Vascular, Inc.
LINKISIAAN™ Balloon Expandable Vascular Covered Stent
BOLSTER (BPV-12-001) Version 3.0
Page 51 of 51  |   |   |   |   |   |   |   |
| --- | --- | --- | --- | --- | --- | --- | --- |
|  APPENDIX 1: Time and Events Schedule  |   |   |   |   |   |   |   |
|  Observation | Baseline/Screening | Index Procedure | Hospital Discharge^{1} | 30 d^{2} (± 7d) | 6 mo^{2} (± 30d) | 9 mo (± 30d) | 12, 24, & 36 mo (± 30d)  |
|  Eligibility Criteria | ☑ | ☑ |  |  |  |  |   |
|  Informed Consent | ☑ |  |  |  |  |  |   |
|  Demographics | ☑ |  |  |  |  |  |   |
|  Medical History | ☑ |  |  |  |  |  |   |
|  Pregnancy test | ☑^{3} |  |  |  |  |  |   |
|  Labs (BUN or Creatinine, CBC including Platelets) | ☑ |  |  |  |  |  |   |
|  Concomitant Medications | ☑ | ☑ | ☑ | ☑ | ☑ | ☑ | ☑  |
|  Comprehensive Physical Exam | ☑ |  | ☑ | ☑ |  | ☑ | ☑  |
|  Angiogram | ☑^{4} | ☑^{4} |  |  |  |  |   |
|  Resting ABI | ☑ |  |  | ☑ |  | ☑ | ☑  |
|  Rutherford (Category & Grade) | ☑ |  |  | ☑ |  | ☑ | ☑  |
|  Adverse Event Assessment |  | ☑ | ☑ | ☑ | ☑ | ☑ | ☑  |
|  TLR/TVR Assessment |  |  |  | ☑^{4} | ☑^{4} | ☑^{4} | ☑^{4}  |
|  Color Flow Duplex Ultrasound |  |  |  | ☑^{5} |  | ☑^{5} | ☑^{5}  |
|  WIQ | ☑^{6} |  |  | ☑ |  | ☑ | ☑  |
|  ^{1}Subjects meeting the criteria for deployment failure will be evaluated at hospital discharge and the 30-day follow-up visit to assess and document any AEs or SAEs that may have occurred since the index procedure.
^{2}Telephone Screen
^{3}Uniform pregnancy test (pains or blood) for women who are of childbearing potential ≤ 14 days prior to the index procedure.
^{4}Send images to Angiographic Core Laboratory
^{5}Send images to Ultrasound Core Laboratory
^{6}Complete WIQ ≤ 30 days prior to the index procedure  |   |   |   |   |   |   |   |

## 3. Clinical Endpoints

### Primary Endpoints

With regards to safety and effectiveness, the primary endpoint of this study was a composite endpoint of Major Adverse Events (MAEs), defined as follows:

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- Procedure- or device-related events causing death, occurring within 30 days of the index procedure; and
- Myocardial Infarction (MI) occurring within 30 days of the index procedure; and
- Target Lesion Revascularization (TLR) occurring within 9 months of the index procedure; and
- Major amputation of the treated leg(s), resulting from a vascular event, occurring within 9 months of the index procedure; and
- Restenosis of the treated segment occurring within 9 months of the index procedure as assessed by duplex ultrasonography (DUS), where the target lesion is determined to have a peak systolic velocity ratio (PSVR) > 2.4 as determined by an independent DUS Core Lab.

## Secondary Endpoints

The secondary endpoints in this study include:
- The rate of MAE
- Acute Lesion Success
- Acute Procedure Success
- Acute Technical Success
- Freedom from TLR
- Freedom from Target Vessel Revascularization (TVR)
- Sustained Clinical Success
- Primary Patency
- Primary Assisted Patency
- Secondary Patency
- Quality of Life

All of these secondary outcomes were evaluated descriptively without any pre-specified performance criteria.

## B. Accountability of PMA Cohort

At the time of database lock, 138 (89%) of 155 patients enrolled in the BOLSTER study were available for analysis at the completion of the study, the 9 month post-operative visit, as describe in Figure 4.

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![img-4.jpeg](img-4.jpeg)
Figure 4: BOLSTER Study Subject Accountability

## C. Study Population Demographics and Baseline Parameters

Table 6 summarizes the patient demographics of the study subjects.

Table 6: Patient Demographics

|   | Bolster
(N=155)  |
| --- | --- |
|  Age(Years) |   |
|  N | 155  |
|  Mean (SD) | 64.3 (9.75)  |
|  Min - Max | 42.0 - 86.0  |
|  |   |
|  Gender |   |
|  Male | 107(69.0%)  |
|  Female | 48(31.0%)  |
|  |   |
|  Weight(kg) |   |
|  N | 151  |
|  Mean (SD) | 79.6 (16.60)  |
|  |   |
|  Height(cm) |   |
|  N | 154  |
|  Mean (SD) | 170.7 (8.80)  |
|  |   |
|  BMI(kg/m**2) |   |

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Table 7 summarizes the medical histories of the study subjects.

Table 7: Patient Medical History

|  Category | Term | Bolster (N=103)  |
| --- | --- | --- |
|  Cardiovascular Disease | Total | 142(91.6%)  |
|   | AAA | 7(4.5%)  |
|   | Angina | 11(7.1%)  |
|   | Aortic Disease | 7(4.5%)  |
|   | Atrial Fibrillation (A-FIB) | 12(7.7%)  |
|   | Congestive Heart Failure(CHF) | 9(5.8%)  |
|   | Coronary Artery Disease (CAD) | 49(31.6%)  |
|   | Dyslipidemia | 101(65.2%)  |
|   | Hypertension | 117(75.5%)  |
|   | Myocardial Infarction (MI) | 21(13.5%)  |
|   | Stroke | 8(5.2%)  |
|   | Other | 54 (34.8%)  |
|  |   |   |
|  Renal Disease | Total | 27(17.4%)  |
|   | Hemodialysis | 1(0.6%)  |
|   | Renal Failure | 3(1.9%)  |
|   | Other | 27(17.4%)  |
|  |   |   |
|  Other Disease | Total | 152(98.1%)  |
|   | Cancer | 13(8.4%)  |
|   | Cigarette Smoking | 132(85.2%)  |
|   | Diabetes | 50(32.3%)  |
|   | Gastrointestinal Disorder | 17(11.0%)  |
|   | Respiratory Disorder | 23(14.8%)  |
|   | Other | 78(50.3%)  |

Note: One subject may take multiple medications

Table 8 summarizes the baseline anatomical characteristics of the study subjects.

Table 8: Summary of Baseline Characteristics by Subject

|   | Bolster (N=155)  |
| --- | --- |
|  Treated Limb |   |
|  Bilateral | 34(21.9%)  |
|  Left Leg | 72(46.5%)  |
|  Right Leg | 49(31.6%)  |
|  |   |
|  Number of Target Lesions |   |
|  1 | 117(75.5%)  |
|  2 | 34(21.9%)  |
|  3 | 4(2.6%)  |
|  |   |
|  Target Lesion Location |   |
|  Common Iliac Artery | 103(66.5%)  |
|  External Iliac Artery | 36(23.2%)  |
|  Both Common and External Iliac Artery | 16(10.3%)  |
|  |   |
|  Number of Treated Lesion Location |   |
|  1 | 111(71.6%)  |

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Table 9 summarizes the lesion characteristics of the study subjects as reported by the Investigational Site.

Table 9: Summary of Target Lesions

|   | Bolster (N=155)  |
| --- | --- |
|  Degree of Calcification |   |
|  None | 19/197(9.6%)  |
|  Mild | 51/197(25.9%)  |
|  Moderate | 89/197(45.2%)  |
|  Severe | 38/197(19.3%)  |
|  |   |
|  Target Lesion Length (mm) |   |
|  N | 197  |
|  Mean (SD) | 30.7 (17.35)  |
|  Min – Max | 3.0 - 100.0  |
|  |   |
|  Reference Vessel Diameter (mm) |   |
|  N | 197  |
|  Mean (SD) | 8.0 (1.27)  |
|  Min – Max | 5.0 - 12.0  |
|  |   |
|  Target Lesion Stenosis (pre-intervention) % |   |
|  N | 197  |
|  Mean (SD) | 80.3 (13.60)  |
|  Min – Max | 30.0 - 100.0  |

# D. Safety and Effectiveness Results

# 1. Composite Primary Safety and Effectiveness Results

The primary endpoint of the study is a composite safety and effectiveness measure defined as device and/or procedure-related death or MI through 30 days, or any TLR, target limb(s) major amputation, or restenosis through 9-months post-index

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procedure. The primary composite endpoint was analyzed by subject. The proportion of subjects with these efficacy events was compared to the performance goal of  $19.5\%$ .

Restenosis was determined by the DUS Core Lab based on objective measures of DUS imaging and did not rely on other imaging modalities, the need for re-intervention, or other clinical factors in order to determine the patency of lesions treated with the LifeStream Covered Stent.

In a pre-specified analysis of the 155 subjects who were treated in the study, a total of 25 subjects were excluded from the 9-month analysis, as described previously in Figure 4. Seventeen (17) of these subjects were excluded for reasons such as unevaluable imaging, lost to follow-up before the 9-month assessment, or early termination. Eight (8) subjects missed or did not have evaluable imaging at their 9-month visit and completed their 12-month visit at the time of this analysis.

As analyzed on a pre-specified basis, the primary composite endpoint result was  $16.2\%$  (p-value  $= 0.1987$ ) and did not meet the pre-defined statistical performance goal (Table 10).

Table 10: Primary Composite Endpoint Results (Pre-Specified Analysis)

|   | Bolster (N=155) | 93.3% Confidence Interval  |
| --- | --- | --- |
|  Subjects with the Composite Events | 21/130 (16.2%) | (10.6%, 23.2%)  |
|  Subjects fail due to |  |   |
|  Device and/or procedure-related death (<=30 day) | 0 / 130 (0.0%) |   |
|  Device and/or procedure-related MI (<=30 day) | 0 / 130 (0.0%) |   |
|  Target limb(s) major amputation through 9 months* | 1 / 130 (0.8%) |   |
|  TLR through 9 months | 6 / 130 (4.6%) |   |
|  Restenosis through 9 months | 15 / 130 (11.5%) |   |

* Not device and / or procedure related

A post-hoc analysis was performed based on additional available imaging and other clinical factors. This analysis included the 8 subjects who missed or did not have evaluable imaging at their 9-month visit but were evaluable at the 12-month visit. All 8 subjects were subsequently judged patent by DUS Core Lab at 12-months. Additionally, 5 subjects were deemed patent at the 9-month analysis by the CEC chair based on a review of DUS imaging and evaluation of additional imaging where available, re-intervention status, improvements in Rutherford Category, and other clinical factors. Table 11 includes the results of this post-hoc analysis in which all of these 13 subjects were determined to be patent.

Table 11: Primary Composite Endpoint Results (Post-Hoc Analysis)

|   | Bolster (N=155) | 93.3% Confidence Interval  |
| --- | --- | --- |
|  Subjects with the Composite Events | 16/138 (11.6%) | (7.0%, 17.8%)**  |
|  Subjects fail due to |  |   |
|  Device and/or procedure-related death (<=30 day) | 0 / 138 (0.0%) |   |
|  Device and/or procedure-related MI (<=30 day) | 0 / 138 (0.0%) |   |

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The primary composite endpoint based on the post-hoc analysis utilizing 12-month assessments and additional clinical factors was 11.6%.

Based on the pre-specified analysis population, the per-limb primary composite endpoint was evaluated to be 21/157 = 13.4%. Note, no pre-specified hypothesis testing was performed on a per-limb basis. Based on the post-hoc analysis population described above, the primary composite endpoint was evaluated to be 16 / 168 = 9.5%.

## 2. Secondary Endpoints Results

Table 12 and Table 13 below provide a summary of secondary effectiveness endpoints at the time of data lock using the pre-specified analysis population and the post-hoc analysis population, respectively. Endpoint definitions below describe the number of evaluable subjects.

Table 12: Secondary Effectiveness Results (Pre-Specified Analysis)

|   | Result | N | 95% Confidence Interval 1  |
| --- | --- | --- | --- |
|  Rate of Major Adverse Events (MAEs) | 4.7% | 150 | (1.9%, 9.4%)  |
|  Acute Lesion Success | 98.4% | 191 | (95.5%, 99.7%)  |
|  Acute Procedure Success | 97.4% | 155 | (93.4%, 99.3%)  |
|  Acute Technical Success | 98.3% | 230 | (95.6%, 99.5%)  |
|  Target Lesion Revascularization (TLR) | 4.0% | 150 | (1.5%, 8.5%)  |
|  Target Vessel Revascularization (TVR) | 4.0% | 150 | (1.5%, 8.5%)  |
|  Sustained Clinical Success | 90.5% | 137 | (84.3%, 94.9%)  |
|  Primary Patency | 84.5% | 129 | (77.1%, 90.3%)  |
|  Primary Assisted Patency | 85.3% | 129 | (78.0%, 90.9%)  |
|  Secondary Patency | 87.5% | 128 | (80.5%, 92.7%)  |

1 Confidence intervals have not been adjusted for multiplicity and are provided to illustrate the variability of the corresponding summary statistic. They should not be used to draw statistical inference.

Table 13: Secondary Effectiveness Endpoints (Post-Hoc Analysis)

|   | Result | N | 95% Confidence Interval 1  |
| --- | --- | --- | --- |
|  Primary Patency | 89.1% | 137 | (82.6%, 93.7%)  |
|  Primary Assisted Patency | 89.8% | 137 | (83.4%, 94.3%)  |
|  Secondary Patency | 91.9% | 136 | (86.0%, 95.9%)  |

1 Confidence intervals have not been adjusted for multiplicity and are provided to illustrate the variability of the corresponding summary statistic. They should not be used to draw statistical inference.

- Rate of Major Adverse Events (MAEs) was defined as device and/or procedure related death or MI through 30 days, or any TLR or target limb(s) major amputation through 9 months post-index procedure. Analysis included all subjects followed through day 240, the minimum visit day for the 9 month visit (N=150).

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- Acute Lesion Success was defined as attainment of &lt; 30% residual stenosis of the target lesion after the index procedure using any percutaneous method and/or non-investigational device (i.e., post-dilatation). Analysis included all treated lesions with evaluable angiographic imaging at implant (N=191).
- Acute Procedural Success was defined as lesion success and no periprocedural complications (death, stroke, myocardial infarction (MI), emergent surgical revascularization, significant distal embolization in target limb, and thrombosis of target vessel) prior to hospital discharge. Analysis included all subjects with evaluable angiographic imaging at implant (N=152).
- Acute Technical Success was defined as successful deployment of the LifeStream Covered Stent at the intended location, as determined by the Investigator. Analysis included all LifeStream stents implanted (N=230).
- TLR was defined as the first revascularization procedure of the target lesion following index procedure. Analysis included all subjects followed through day 240, the minimum visit day for the 9 month visit (N=150).
- TVR was defined as the first revascularization procedure of the target vessel following index procedure. Analysis included all subjects followed through day 240, the minimum visit day for the 9 month visit (N=150).
- Sustained Clinical Success was defined as sustained cumulative improvement from baseline value of ≥ 1 Rutherford Category. Analysis included all subjects completing the 9 month visit where Rutherford Category was assessed by the Investigator (N=137).
- Primary Patency was defined as the target lesion(s) is determined to be no longer patent as assessed by DUS Core Lab. TLR was also considered a loss of patency. The pre-specified analysis included all subjects that completed the 9 month visit with evaluable DUS imaging (N=129). The post-hoc analysis also included any subject that missed the 9 month visit but subsequently completed the 12 month visit and was deemed patent by the DUS core lab (N=137).
- Primary Assisted Patency was defined as freedom from loss of patency whether or not patency was re-established via an endovascular procedure following restenosis. The pre-specified analysis included all subjects that completed the 9 month visit with evaluable DUS imaging (N=129). The post-hoc analysis also included any subject that missed the 9 month visit but subsequently completed the 12 month visit and was deemed patent by the DUS core lab (N=137).
- Secondary Patency was defined as freedom from loss of patency whether or not patency was re-established via an endovascular procedure following restenosis or occlusion. The pre-specified analysis included all subjects that completed the 9 month visit with evaluable DUS imaging (N=128). The post-hoc analysis also included any subject that missed the 9 month visit but subsequently completed the 12 month visit and was deemed patent by the DUS core lab (N=136).

To evaluate change in functional status from pre-procedure, Quality of Life was assessed by the Walking Impairment Questionnaire (WIQ). The mean baseline total

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score was 32.0. At 9 months, the mean total score was 64.7, which represents an increase over baseline in total score of 32.7. Overall, improvements were seen in each domain of the WIQ.

The Kaplan-Meier analysis of TLR per subject was performed and results are provided in Figure 5. The Kaplan-Meier estimate of the incidence of TLR at 9 months (day 300) was 3.9% (95% CI 1.8%, 8.6%).

![img-5.jpeg](img-5.jpeg)
Figure 5: Kaplan-Meier Analysis of TLR per Subject (As Treated Population)

# 3. Adverse Effects That Occurred in the PMA Clinical Study

Of the 155 subjects, 110 subjects (71.0%) reported 299 adverse events (AEs.) Sixty (60) subjects reported serious adverse events (60/110; 54.5%). The majority of the subjects had AEs that were not related to device (86/110; 78.2%) and/or related to the procedure (81/110; 73.6%). There were no unanticipated adverse device effects (UADEs) reported. This is summarized in Table 14 below.

Table 14: Summary of Safety

|   | Bolster (N=155)  |
| --- | --- |
|   | Site Reported  |
|  Total# of Events | 299  |
|  Total# of Subjects with at Least One AE | 110(71.0%)  |
|  Device Relatedness [1] [2] |   |
|  Definitely Related | 8(7.3%)  |
|  Possibly Related | 16(14.5%)  |
|  Not Related | 86(78.2%)  |
|  |   |
|  Procedure Relatedness [1] [2] |   |

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|  Definitely Related | 20(18.2%)  |
| --- | --- |
|  Possibly Related | 9(8.2%)  |
|  Not Related | 81(73.6%)  |
|  |   |
|  Serious AE (SAE) [1] | 60(54.5%)  |
|  Definitely or Possibly Device Related SAE | 9(15.0%)  |
|  Not Device Related SAE | 51(85.0%)  |

[1] Subjects are only counted once with the highest level of relatedness.
[2] Percentages are based on denominator of 110, the total number of subjects with at least 1 AE

The types of safety events experienced in the study are expected for this patient population. All of the device- and procedure-related adverse events reported were consistent with those identified in Section VIII, Potential Adverse Effects of the Device on Health. Overall, the adverse event profiles appear comparable to standard of care for PTA and stenting of the iliac arteries.

The most frequently reported AEs (≥ 5% overall) were peripheral artery stenosis (18 subjects; 11.6%), peripheral arterial occlusive disease (12 subjects; 7.7%) and peripheral artery dissection (9 subjects; 5.8%).

Nine subjects reported serious adverse events that were determined to be related to the LifeStream Covered Stent. Six of nine subjects reported restenosis or occlusion of the LifeStream device that resulted in TLR through 9 months. One subject reported restenosis of the LifeStream Covered Stent that resulted in TLR 441 days post-placement. One subject reported embolic occlusion of the tibial artery during the index procedure which was treated with heparin. One subject reported a type C dissection during the index procedure which was treated with post-dilatation.

Proper sizing (stent size relative to reference vessel diameter) and complete wall apposition are important factors when implanting stents, especially balloon expandable covered stents. The angiographic core lab analyzed all final implant images for subjects that had TLR or were deemed restenosed by the ultrasound core lab. Final implant images were analyzed to determine if stent sizes were appropriate for the reference vessel and that the stent or stents completely covered the target lesion. Seven of the twenty subjects that failed the primary composite endpoint had one or more LifeStream Covered Stents that were considered underexpanded (1), undersized and malapposed (3), undersized and placed in an ectatic area (1), or placed in an ectatic area (2) as determined by the CEC chair.

## 4. Patient Death Summary

Five subjects died as of the date of this report. None of the deaths were considered to be related to the study device or procedure, as adjudicated by the CEC.

## 5. Subgroup Analyses

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As shown in Table 15, the following preoperative characteristics were evaluated for potential association with outcomes: gender, target lesion location, baseline stenosis/occlusion, baseline TASC score, and limb disease. No differences were noted in these subgroups.

Table 15: Subgroup Analyses Summary

|  Subgroup |  | Bolster (N=155) | 93.5% Confidence Interval | P-value  |
| --- | --- | --- | --- | --- |
|  Gender |  |  |  | 0.4759  |
|   | Male | 5/42 (11.9%) | (4.3%, 24.8%) |   |
|   | Female | 16/96 (16.7%) | (10.2%, 25.1%) |   |
|  Target Lesion Location |  |  |  | 0.0266  |
|   | Both Iliac Artery | 2/13 (15.4%) | (2.2%, 43.8%) |   |
|   | Common Iliac Artery | 9/92 (9.8%) | (4.8%, 17.3%) |   |
|   | External Iliac Artery | 10/33 (30.3%) | (16.3%, 47.7%) |   |
|  Baseline/Pre-procedure Stenosis |  |  |  | 0.3795  |
|   | Occlusion | 4/18 (22.2%) | (7.0%, 46.3%) |   |
|   | Stenosis | 17/120 (14.2%) | (8.7%, 21.3%) |   |
|  Baseline TASC Score |  |  |  | 0.3763  |
|   | A | 10/86 (11.6%) | (6.0%, 19.8%) |   |
|   | B | 9/39 (23.1%) | (11.7%, 38.4%) |   |
|   | C | 1/12 (8.3%) | (0.3%, 36.8%) |   |
|   | D | 1/1 (100.0%) | (3.3%, 100.0%) |   |
|  Target Disease Limb |  |  |  | 0.3122  |
|   | Bilateral | 2/24 (8.3%) | (1.2%, 25.9%) |   |
|   | Unilateral | 19/114 (16.7%) | (10.6%, 24.3%) |   |

# 6. Pediatric Extrapolation

In this premarket application, existing clinical data was not leveraged to support approval of a pediatric patient population.

# E. Financial Disclosure

The Financial Disclosure by Clinical Investigators regulation (21 CFR 54) requires applicants who submit a marketing application to include certain information concerning the compensation to, and financial interests and arrangement of, any clinical investigator conducting clinical studies covered by the regulation. The pivotal clinical study included 104 investigators of which none were full-time or part-time employees of the sponsor and 6 had disclosable financial interests/arrangements as defined in 21 CFR 54.2(a), (b), (c) and (f) and described below:

- Compensation to the investigator for conducting the study where the value could be influenced by the outcome of the study: 0
Significant payment of other sorts: 6
- Proprietary interest in the product tested held by the investigator: 0
Significant equity interest held by investigator in sponsor of covered study: 0

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The applicant has adequately disclosed the financial interest/arrangements with clinical investigators. The information provided does not raise any questions about the reliability of the data

## XI. PANEL MEETING RECOMMENDATION AND FDA'S POST-PANEL ACTION

In accordance with the provisions of section 515(c)(3) of the act as amended by the Safe Medical Devices Act of 1990, this PMA was not referred to the Circulatory System Devices Panel, an FDA advisory committee, for review and recommendation because the information in the PMA substantially duplicates information previously reviewed by this panel.

## XII. CONCLUSIONS DRAWN FROM PRECLINICAL AND CLINICAL STUDIES

### A. Safety and Effectiveness Conclusions

The safety and effectiveness of the LifeStream Covered Stent was evaluated with clinical and nonclinical evidence. Nonclinical testing included biocompatibility, in-vitro bench, sterility and animal studies (see section IX for a summary of this testing). All nonclinical testing met the acceptance criteria.

The prospective, multi-center, non-randomized, single-arm study of the LifeStream Covered Stent in the treatment of iliac artery occlusive disease (BOLSTER) compared a composite safety and effectiveness measure to a performance goal of 19.5% derived from iliac stent published literature. The clinical trial did not meet the performance goal (16.2%, p-value = 0.1987) based on the pre-specified analysis, partly due to the number of missing or uninterpretable DUS images. Restenosis and TLR accounted for most of the failures with one amputation. One salient factor in the data analysis is that the BOLSTER Trial included Doppler ultrasound evidence of stenosis at 9 months as a component of the composite primary endpoint, which is not always included as a primary endpoint in comparable trials. A post-hoc analysis, which incorporated additional imaging at 12-months and other clinical factors, resulted in a composite endpoint of 11.6%. Similar iliac stenting studies reported composite MAEs ranging from 0-15% at 9 months.

Overall, the nonclinical data and clinical study results support the reasonable assurance of safety and effectiveness of the LifeStream Covered Stent for the treatment of atherosclerotic lesions of the common or external iliac artery in the studied patient population.

### B. Benefit-Risk Conclusions

The probable benefits of the device are also based on data collected in a clinical study conducted to support PMA approval as described above. The primary potential benefit is the improvement or restoration of blood flow in the iliac arteries. In this study, patients

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demonstrated sustained clinical improvement in functional status and Rutherford category when compared to pre-procedure assessments.

The frequency and types of the adverse events reported throughout the pivotal clinical study are in alignment with what might be expected in the studied patient population and therapeutic area. No unanticipated device- or procedure-related adverse events were reported in the study.

In conclusion, given the available information above, the data support that the probable benefits outweigh the probable risks for the LifeStream Covered Stent when used for the treatment of atherosclerotic lesions in common and external iliac arteries with reference vessel diameters between 4.5 mm and 12.0 mm, and lesion lengths up to 100 mm.

1. Patient Perspectives

Patient perspectives considered during the review included Quality of Life assessments, specifically the WIQ. Scores for treated patients improved based on preprocedure assessments. It is expected that patients would place value on this treatment, are willing to take the risks of this treatment to achieve the benefit, and would be able to understand the benefits and risks of treatment with the LifeStream Covered Stent without difficulty.

C. Overall Conclusions

The data in this application support the reasonable assurance of safety and effectiveness of this device when used in accordance with the indications for use. The clinical study results are comparable to results from other iliac stent studies. Given all of the available data, it is reasonable to conclude that the benefits of the use of the device for the target population outweigh the risk of illness or injury when used as indicated in accordance with the labeling and Instructions for Use (IFU).

XIII. CDRH DECISION

CDRH issued an approval order on April 24, 2017. The final conditions of approval cited in the approval order are described below.

1. ODE Lead PMA Post-Approval Study – BOLSTER Continued Follow-Up Study. The Office of Device Evaluation (ODE) will have the lead for this clinical study, which was initiated prior to device approval. This study should be conducted per protocol BPV-12-001 version d.2 (dated June 15, 2015). This study is a prospective, multi-center follow-up of the BPV-12-001 pivotal study (G140138) that treated 155 subjects from 24 investigational sites. It will evaluate the long term safety and effectiveness of the LifeStream Balloon Expandable Vascular Covered Stent. All 148 remaining subjects (7 subjects have discontinued the study) will continue to be followed annually through 36 months. The primary endpoint to be assessed is freedom from target lesion revascularization at 36 months, as defined by the protocol. The secondary endpoints to be assessed include the following:

a. Freedom from target vessel revascularization (TVR) at 12, 24 and 36 months

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b. Freedom from target lesion revascularization (TLR) at 12 and 24 months
c. Primary patency at 12, 24 and 36 months
d. Primary assisted patency at 12, 24 and 36 months
e. Secondary patency at 12, 24 and 36 months
f. Sustained clinical success at 12, 24 and 36 months
g. Quality of life at 12, 24 and 36 months
h. Serious adverse events at 12, 24 and 36 months

The applicant’s manufacturing facilities have been inspected and found to be in compliance with the device Quality System (QS) regulation (21 CFR 820).

## XIV. APPROVAL SPECIFICATIONS

Directions for use: See device labeling.

Hazards to Health from Use of the Device: See Indications, Contraindications, Warnings, Precautions, and Adverse Events in the device labeling.

Post-approval Requirements and Restrictions: See approval order.

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**Source:** [https://fda.innolitics.com/device/P160024](https://fda.innolitics.com/device/P160024)

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