[Lesion Preparation in Peripheral Arteries - Fact or Fashion?]

Peripheral arterial disease (PAD) is mostly caused by stenotic atherosclerotic lesions of lower limb arteries. Intermittent claudication is the most common manifestation, while, in more advanced stages of the disease, chronic limb-threatening ischemia (CLTI) occurs. Optimal medical therapy is an essential cornerstone in all stages of PAD, while endovascular and open surgical revascularisation are of great importance - depending on the patient and lesion characteristics and can be used in a complementary manner. In patients with claudication, the improvement in the pain-free walking distance is the primary therapeutic goal, while, in patients with CLTI, amputation-free survival is most important. In both patient groups, there is a need for strict control of cardiovascular risk factors, including blood pressure and diabetes control, nicotine abstinence and reduction in cholesterol levels using intensive statin therapy, in accordance with national and international guidelines. Endovascular treatment of PAD is used widely and by various specialist disciplines. However, conventional endovascular therapy procedures have limitations in complex and heavily calcified lesions, so that, for example, classic balloon angioplasty in such lesions is associated with "recoil" and/or severe dissections, which usually require the placement of permanent metallic implants. Lesion preparation procedures, such as atherectomy and intravascular lithotripsy (IVL) can improve compliance of calcified arteries, by either creating microfractures at calcified sites or removing calcified material. In this way, balloon angioplasty can be performed with less barotrauma and the need for stent implantation can be reduced, while subsequent treatment with drug-coated balloons (DCB) is associated with potentially improved penetration of the drug into the vessel wall, and thus increases the effectiveness of the procedure by enhancing anti-restenotic effects. In this manuscript, the potential - but also the limitations - of different lesion preparation strategies are presented and discussed.