Endovascular treatment of femoropopliteal arterial occlusive disease: Current techniques and limitations

In an aging population with a rising incidence of peripheral artery disease, endovascular therapy is a favorable alternative to open surgical bypass. As a minimally invasive approach, endovascular therapy incurs less physiologic stress and periprocedural complications. Balloon angioplasty and stenting have been the predominant tools in peripheral endovascular therapy. The mechanisms of endovascular therapy have evolved beyond pneumatic dilation and forcing plaque against vessel wall with angioplasty and stenting. Technology has broadened to adjunctive local treatments with pharmaceutical agents coating balloons or eluting from stents, atherectomy to remove intimal and medial plaque, and more recently, intravascular lithotripsy to fracture and modify plaque. These technologies have performed well in curated clinical trials and in the real world for short-segment disease. Despite the excellent outcomes of treatment for short-segment occlusive disease, post-procedural patency of endovascular treatment for long-segment, highly calcified lesions remains challenging in the femoropopliteal region. The development of drug-coated balloons and stents brings the hope of improved patency. However, the results are incrementally better at best and are not superior to surgical bypass. In addition, there is controversy regarding the long-term mortality risk. With numerous devices and techniques as well as differing magnitudes of peripheral artery disease, it will be difficult to practically have a study to answer all questions regarding endovascular treatment of the femoropopliteal artery. This review examines current endovascular techniques for de novo and recurrent femoropopliteal arterial occlusive disease, as well as the applicability of intravascular ultrasound and optimal stenting strategies for long-segment disease.