Territory- and Lesion-Specific Endovascular Strategies in Lower Limb Peripheral Artery Disease: A Cohort Study

TL;DR

This study shows that endovascular treatments for leg artery disease work best when tailored to the specific artery and lesion type.

Contribution

The study identifies optimal endovascular devices for different arterial territories in lower limb PAD using real-world data.

Findings

Covered stents in the iliac artery had the lowest restenosis rate (12.8%).

Interwoven nitinol stents in the SFA showed the best performance (15.4% restenosis).

Drug-coated balloons in the popliteal artery had the lowest restenosis (16.7%).

Abstract

(1) Background: Endovascular therapy is widely used for lower limb peripheral artery disease (PAD), yet device performance varies across vascular territories due to anatomical and biomechanical differences. This study evaluated territory- and lesion-specific outcomes following contemporary endovascular strategies in a real-world cohort. (2) Methods: This retrospective single-center study included consecutive patients undergoing endovascular revascularization of the iliac, superficial femoral (SFA), or popliteal arteries between 2010 and 2023. The primary endpoint was 12-month binary restenosis (≥50% diameter loss) assessed by duplex ultrasonography, CT angiography, or invasive angiography. Secondary outcomes included target lesion revascularization and procedural complications. Kaplan–Meier analysis was used to evaluate restenosis-free survival. Multivariable Cox models were constructed separately for each vascular territory, adjusting for relevant clinical and anatomical covariates. (3) Results: A total of 283 lesions were included (iliac n = 135; SFA n = 145; popliteal n = 102). At 12 months, restenosis rates differed substantially by treatment modality and arterial territory. In the iliac segment, covered stents demonstrated the lowest restenosis (12.8%), whereas in the SFA, interwoven nitinol stents yielded the most favorable profile (15.4%). In the popliteal artery, drug-coated balloons were associated with the lowest restenosis rate (16.7%). In multivariable analysis, covered stents (iliac), interwoven nitinol stents (SFA), and drug-coated balloons (popliteal) were independently associated with lower restenosis risk. Procedural success was high and complication rates were low. (4) Conclusions: Endovascular device performance is strongly influenced by arterial territory and lesion characteristics. Tailoring the treatment strategy to vessel biomechanics and lesion morphology may optimize mid-term patency in lower limb PAD. Larger prospective studies are warranted to validate these findings.

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