Endovascular Revascularization in Intermittent Claudication

Quick Takes

  • In femoropopliteal peripheral artery disease (PAD), drug-coated balloons were associated with improved efficacy as compared to conventional angioplasty.
  • Both drug-eluting and bare-metal stenting had similar efficacy for the management of femoropopliteal PAD.
  • Significant evidence gaps exist for management of aortoiliac disease and for quality-of-life measures in PAD revascularization.

Study Questions:

What are the efficacy and safety outcomes associated with balloon angioplasty, bare-metal stenting (BMS), drug-coated ballooning (DCB), drug-eluting stenting (DES), covered stenting, and atherectomy for patients with intermittent claudication?


The authors performed a systematic review and meta-analysis of randomized controlled trials through November 2021. Efficacy outcomes were primary patency, target-lesion revascularization (TLR), and quality-of-life (QOL). Safety endpoints were all-cause mortality and major amputation. Outcomes were assessed at <1 year (short-term), 1-2 years (mid-term), and ≥2 years (long-term) of follow-up.


The authors identified 51 randomized trials including 8,430 patients/lesions. Among patients with femoropopliteal disease of low-to-intermediate complexity, DCBs were associated with higher likelihood of primary patency (short-term odds ratio [OR] 3.21 [2.44-4.24], long-term OR 2.47 [1.93-3.16]), lower TLR (short-term OR 0.33 [0.22-0.49], long-term OR 0.42 [0.29-0.60]), and similar all-cause mortality risk as compared with balloon angioplasty. Primary stenting using BMS was associated with improved short- to mid-term patency and TLR, but similar long-term efficacy when compared with provisional stenting. Mid-term patency (OR 1.64 [0.89-3.03]) and TLR (OR 0.50 [0.22-1.11]) estimates were comparable for DES and BMS. Atherectomy was not associated with efficacy benefits when compared with angioplasty (both conventional and drug-coated) or stenting. A lack of data and heterogeneity prevented any pooled analysis of aortoiliac disease and QOL measures.


The authors conclude that certain devices may provide benefits during revascularization of femoropopliteal disease.


In contrast to coronary revascularization, there exist several different strategies for endovascular revascularization of symptomatic peripheral artery disease. This meta-analysis identifies some key revascularization techniques that offer patient benefit, including the use of DCB and use of stenting for patients with femoropopliteal disease. More research is needed to guide revascularization techniques for aortoiliac disease and for correlating different techniques with patient-reported QOL measures.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and Vascular Medicine

Keywords: Amputation, Angioplasty, Balloon, Atherectomy, Drug-Eluting Stents, Endovascular Procedures, Intermittent Claudication, Myocardial Revascularization, Peripheral Arterial Disease, Quality of Life, Stents, Vascular Diseases

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