Tools for Plaque Modification in Peripheral Arterial Disease

Peripheral arterial disease (PAD) continues to pose a major global health challenge, driven by population aging and the growing prevalence of diabetes. Effective management of complex, calcified lesions increasingly relies on targeted plaque-modification strategies that enhance vessel compliance and improve long-term patency. This review summarizes current vessel-preparation tools-including specialty balloons, atherectomy systems, and intravascular lithotripsy-highlighting their mechanisms, indications, limitations, and supporting evidence. While registries and observational studies demonstrate acute advantages such as greater luminal gain, improved drug uptake, and fewer severe dissections requiring bailout stenting, randomized data remain limited and heterogeneous. Key outcomes-including primary patency, distal embolization, and long-term clinical benefit-are inconsistently reported. These evidence gaps underscore the need for standardized endpoints and morphology-specific trials to better define optimal use. Collectively, plaque-modification technologies represent an expanding continuum of vessel-preparation options that complement angioplasty and drug-based therapies, aiming to deliver durable, anatomy-guided, and patient-centered revascularization in peripheral arterial disease.