Perspective:

The 2018 meta-analysis that initially demonstrated an association between DCDs and mortality led to a large-scale pullback on use of this technology for lower extremity PAD interventions at many institutions. For readers who have not been following the DCD saga closely since then, the introduction section of this paper gives a succinct overview of the differences in study designs, data sources, follow-up, and outcomes from subsequent attempts to address these questions. As the authors eloquently put it, these “mixed results” have perpetuated uncertainty about the role of DCDs in lower extremity revascularization for PAD.

Results of this study suggest that unplanned repeat revascularizations are less common after revascularizations performed with DCDs. Although no difference in mortality between DCD versus non-DCD procedures was identified, it is important to remember that the median follow-up of 31 months only includes the initial portion of the period when mortality risk has been observed to unfold in previous studies (usually 2-5 years). The results therefore provide short-term reassurance.

Mortality is difficult to top when prioritizing tradeoffs, but it is possible that some patients might accept slightly increased mortality risk to avoid restenosis and need for repeat procedures. For patients with chronic limb-threatening ischemia (CLTI), who already face significant short-term mortality and amputation risk, there are no good alternatives to revascularization and the consequences of restenosis may be particularly severe. These factors may combine to tilt the balance toward more aggressive DCD use in patients with CLTI, particularly those who have already experienced patency and/or tissue loss. The majority of patients treated in this study were claudicants, however; availability of exercise and pharmacotherapy as alternatives to revascularization might also justify more selective DCD use when treating claudication.