A State-of-the-Art Review published March 10 in JACC: Cardiovascular Interventions highlights a proposed treatment algorithm for the endovascular revascularization of femoropopliteal lesions and chronic total occlusions.

The international group previously developed a global algorithm for crossing of chronic total occlusions, and the lack of consensus on an approach for femoropopliteal lesions led to this proposed global algorithm to standardize the treatment of patients with peripheral arterial disease. Grigorios Korosoglou, MD, et al., recommend a series of steps aiming toward a more standardized approach to treatment of femoropopliteal lesions and chronic total occlusions, which focus on lesion-specific strategies and patient-centered approaches:

1. Evaluation of lesion morphology based on preprocedural imaging using Duplex sonography and intravenous ultrasound for selection of lesion preparation tools. Characteristics of lesions are mainly defined by calcification, lesion length, and the presence of total occlusion and in-stent restenosis.
2. Selection of vessel preparation strategies: plain old balloon angioplasty, atherectomy, thrombectomy, intravascular lithotripsy and specialty balloons, or a combination of these, based on lesion- and patient-specific characteristics. A Delphi consensus was applied for the appropriateness of lesion preparation strategies, depending on lesion anatomy, length, plaque morphology and subintimal versus intraluminal guidewire crossing.
3. Definitive lesion treatment strategies using drug-coated balloons, bare-metal stents, drug-eluting stents and/or covered stents or a combination.

"Our algorithm encompasses state-of-the-art endovascular decision-making and treatment strategies," the authors write. "The optimal strategy is influenced by personal experience and availability of devices, and the current expert opinion may provide guidance to support the complex considerations in everyday clinical practice. Notably, the heterogeneity of patient and lesion characteristics emphasizes that a one-fits-all solution is not available."