State-of-the-art lesion preparation in femoropopliteal lesions - a case-based systematic approach

Vessel preparation has emerged as a key feature in endovascular treatment strategies as treated lesions are increasingly complex. While treatment algorithms have been presented, a practical systematic case-based approach, entailing contemporary vessel preparation tools, would provide assistance for vascular specialists in the daily routine. Based on patient characteristics, including clinical presentation, age and comorbidities and lesion specific parameters, team-based and patient-centered decisions are necessary for successful treatment. In addition, pre- and procedural imaging, lesion specific characteristics, such as the presence of chronic total occlusions, lesion length and calcification or the presence of thrombus are evaluated. Furthermore, run-off vessels serving as potential conduits for retrograde puncture in case of failed antegrade crossing need to be considered. Based on lesion-specific variables and the type of crossing (intraluminal versus subintimal), options for lesion preparation techniques, including plain-old-balloon angioplasty (POBA), specialty balloons, atherectomy, intravascular lithotripsy and/or thrombectomy are selected prior to the definitive treatment of the lesion. The selection of such vessel preparation strategies depends on the current scientific evidence, guidelines and expert opinion statements. Treatment of patients with intermittent claudication or chronic limb threatening ischemia (CLTI) are now discussed, where a recently published lesion preparation algorithm is applied. By the establishment of this algorithm in daily practice, harmonization of endovascular practice and further improvements in vessel and patient specific outcomes are anticipated.