Endovascular therapy

* **Aortoiliac interventions:** angioplasty with selective stenting ishas thebeen standarda approach;historical standard, but primary stenting is now preferred for common and external iliac artery lesions due to superior patency (5-year patency >85%).[@tasc2007]>85%).[@tasc2007, @conte2025-society] Kissing-balloon technique is used for aortic bifurcation lesions.
* **Femoropopliteal interventions:**
  + **Plain old balloon angioplasty (POBA):** initial treatment for short, focal lesions; limited by high restenosis rates (30–60% at 1 year).[@rutherford2018-rutherford]
  + **Drug-coated balloons (DCB):** paclitaxel-eluting balloons reduce restenosis compared with POBA (IN.PACT SFA and LEVANT 2 trials: ~65–70% vs ~50% primary patency at 1 year).[@tepe2015, @rosenfield2015] Recent guidelines for intermittent claudication (IC) favor DCB or drug-eluting stents (DES) over POBA for improved long-term patency.[@saadi2025-systematic, @conte2025-society]
  + **Nitinol bare-metal stents (BMS):** self-expanding stents for long lesions or POBA failure; subject to in-stent restenosis and stent fracture.
  + **Drug-eluting stents (DES):** polymer-based paclitaxel stents (e.g., Zilver PTX) improve patency over BMS in intermediate-length SFA lesions.[@dake2011]
  + **Covered stents:** ePTFE-lined stents (e.g., Viabahn) for long occlusions or aneurysmal segments; higher profile limits use in small vessels.
  + **Atherectomy and intravascular lithoplasty:** adjunctive therapies for heavily calcified lesions to facilitate balloon angioplasty and reduce dissection. However, routine use of atherectomy for IC is not recommended due to a lack of high-quality evidence demonstrating superior clinical outcomes over angioplasty alone.[@saadi2025-systematic, @conte2025-society]
* **Infrapopliteal interventions:** balloon angioplasty remains the primary approach for tibial arteries in chronic limb-threatening ischemia (CLTI); drug-eluting stents or DCB may be considered for focal lesions. Retrograde (pedal) access is used when antegrade crossing fails. For patients with IC, infrapopliteal endovascular intervention is generally not recommended.[@conte2025-society]
* **Outcomes:** endovascular therapy achieves high initial technical success (>90%), but restenosis remains a significant limitation, particularly in long femoropopliteal and tibial lesions, necessitating surveillance and reintervention.[@rutherford2018-rutherford]