Current algorithm about the endovascular treatment of femoropopliteal atheromatous lesions?

L’INTERVENTIONNEL Algorithm for treatment of femoropopliteal lesions? What is your favorite approach? Why? Please describe what types of devices that you use to do it. What do you think about radial approach? In my practice, I consistently prefer the contralateral femoral approach using the cross-over technique. This approach has several important advantages. First, the access site is easier to manage, even with 7Fr systems, which is particularly beneficial considering that all patients are anticoagulated and on antiplatelet therapy. This translates into a lower risk of complications such as pseudoaneurysm formation and bleeding. In addition, the contralateral approach reduces radiation exposure to the hands, which is an important ergonomic and safety consideration for the operators. Finally, when using a braided sheath, there are no stability or pushability issues, ensuring effective device delivery and procedural control. I do not believe the antegrade approach is easier or safer. Especially in obese patients, advancing the delivery system can be technically challenging and often requires the use of a stiff guidewire. While the use of shorter devices and guidewires is certainly an advantage, it must be balanced against the discomfort of working close to the patient’s head, which can hinder optimal handling. In addition, since two operators are always present the use of 135 cm devices and 260 cm guidewires does not pose a significant logistical problem. As mentioned earlier, with a 65 cm braided sheath, excellent pushability, torquability, and stability can be achieved even with contralateral access. Of course, a different consideration applies to belowthe-knee procedures. In most cases, I use a 6Fr/65cm braided sheath, which provides compatibility with a wide range of devices and excellent deliverability. When an atherectomy device is required, I opt for a 7Fr system. While the radial approach is certainly an interesting and evolving option, its routine use is currently limited by the lack of sufficiently long devices. Therefore, in our practice, we reserve it for procedures involving the abdominal vessels or, at most, the common iliac artery. That said, I am not a strong proponent of the radial approach for peripheral procedures. While it is promising and may become more relevant in the future, especially with the development of longer and more compatible devices, its current limitations in reach and device compatibility make it less suitable for most of the peripheral procedures.   L’INTERVENTIONNEL Are you a subintimal or intraluminal crossing believer? What are the reasons? Could you describe your guidewire escalade to cross chronic total occlusion? How do you proceed in case of crossing failure (re-entry device? Retrograde access?) The choice between endoluminal and subintimal recanalization remains a topic of ongoing debate in the treatment of chronic total occlusions (CTOs), particularly in the superficial femoral artery (SFA). While endoluminal techniques aim to maintain passage within the true lumen, subintimal approaches often offer higher technical success rates when this is not feasible. Importantly, current studies have not demonstrated a clear superiority in long-term patency between the two strategies. In clinical practice, a patient- and lesion-specific approach is essential. Whenever possible, I prefer to maintain an endoluminal course. However, if re-entry cannot be achieved with an antegrade approach after two to three attempts, I typically proceed with a retrograde strategy, using access via the anterior tibial or popliteal artery to facilitate re-entry and completion of the procedure. Recanalization is typically initiated using a standard 0.035 hydrophilic guidewire with a support catheter, which provides good trackability and torque response in moderately complex lesions. If this approach fails to cross the occlusion, escalation to a stiffer 0.035» wire is used to increase pushability and penetration. In more resistant or heavily calcified occlusions, a 0.014» CTO-specific wire with high tip load is then used, often in combination with a dedicated support catheter, to facilitate controlled progression and improve the chances of successful re-entry into the distal true lumen. In cases where re-entry into the distal true lumen proves challenging, adjunctive techniques such as re-entry devices, retrograde access, or controlled dissection and re-entry strategies may be used to facilitate successful recanalization. Selection of the optimal technique should be tailored to lesion characteristics, operator experience, and available tools, emphasizing the importance of a flexible, patient-specific approach.   L’INTERVENTIONNEL Vessel preparation. What are your techniques of vessel preparation? How do you evaluate the quality of vessel preparation? What are your thoughts about atherectomy, IVL or scoring balloons? Do you see any interest in IVUS or OCT for the SFA? Vessel preparation is a critical step in the endovascular treatment of femoropopliteal disease to optimize luminal gain and improve the performance of subsequent therapies such as drug-eluting balloons or stents. The choice of technique - whether plain balloon angioplasty, scoring or cutting balloons, atherectomy or intravascular lithotripsy - depends not only on lesion characteristics and operator preference, but also on reimbursement policies, which can significantly influence device selection in daily practice. In Italy, for example, atherectomy is unfortunately not reimbursed, which limits its routine use even though it is the only technique that actually debulks the lesion. As a result, when vessel modification is required, scoring balloons are often preferred as a practical and accessible alternative. Intravascular imaging modalities such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) provide valuable insight into vessel morphology, plaque composition and lesion severity. IVUS provides deep tissue penetration and is particularly useful for assessing vessel diameter, plaque burden, and detecting dissections or calcifications. OCT, with its superior resolution, allows detailed visualization of intimal structures and stent apposition; however, its use in peripheral interventions is significantly limited by the need for contrast injection to clear blood and by the relatively short pullback length, which is often insufficient for long femoropopliteal lesions. Personally, I have been routinely using IVUS in all cases for several years because it provides critical information that improves lesion assessment, guides optimal device sizing, and improves overall procedural outcomes. This practice is increasingly supported by the current literature, which highlights the clinical and technical benefits of IVUS-guided peripheral interventions. I use both drug-coated balloons (DCBs) and drug-eluting stents (DES) to treat femoropopliteal lesions: However, DCBs are my first choice. However, the choice of treatment modality is not solely based on lesion length, which does influence outcomes, but more on lesion morphology, particularly the distribution of calcification. In lesions with circumferential calcium distribution (360°), drug-eluting stents (DES) are preferred to effectively stabilize the lesion and improve long-term patency. In cases where the calcium is less extensive or eccentric, DCB remains the preferred option, offering an effective alternative. Personally, I never use covered stents, except in cases of bailout due to rupture, and I do not use bare metal stents because studies have consistently shown better results with DCBs and DES.   L’INTERVENTIONNEL Treatment. For medium length lesion, what is your strategy between DES & DCB? For long lesions (>15cm), does it change? Do you have still any indication for bare metal stent? What is the place of self-expendable covered stents in your strategy? How do you treat re-stenosis? Any ongoing/future studies that would help clarify femoropopliteal treatment? The treatment of in-stent restenosis (ISR) is based on the type of lesion. For Tosaka 1 lesions, characterized by focal restenosis, plain balloon angioplasty (PTA) is usually s ufficient to restore vessel patency, followed by DCB. However, more complex lesions with more extensive restenosis or significant plaque burden require more advanced interventions. In these cases, I prefer atherectomy followed by DCB. Alternatively, relining with drug-eluting stents may be used to ensure durable results. The use of Limus drug-coated balloons (DCBs) in femoropopliteal lesions is a promising approach, with early data showing favorable results in terms of reducing restenosis and improving patency. However, despite these encouraging early results, there is a lack of long-term follow-up data and a need for further studies to evaluate the performance of the device in different lesion types. While Limus DCBs may offer an exciting alternative to traditional therapies, it is too early to draw definitive conclusions about their overall efficacy and long-term benefits, particularly in more complex or heavily calcified lesions.   L’INTERVENTIONNEL Future & perspective. What are your thoughts on Limus technologies? BASIL BEST CLI have modified your strategy in CLTI patients? Any reactions about SPORTS? The BASIL trial and the BEST-CLI trial have provided valuable insights into the management of critical limb ischemia, but they have not significantly changed my strategy for treating patients. My approach remains focused on individualized treatment plans based on lesion characteristics, and patient comorbidities. The SPORTS study is certainly interesting, but I personally find it somewhat redundant to compare drug-coated balloons and drug-eluting stents with bare-metal stents, as many studies have already clearly demonstrated the superior efficacy of drug-eluting devices. The comparison with DCBs, particularly in long lesions, is more compelling as it reinforces the well-established positive results of the Eluvia DES. However, the results of the Eluvia stent were already known to be favorable when compared to the Zilver PTX. What would be really valuable is to see long-term results such as 5-year follow-up and stratified results by lesion morphology to further assess the durability of results across different lesion types.