Due to knee flexion, the popliteal artery is under continuous stress by various biomechanical forces. Numerous endovascular modalities have been developed to treat these challenging lesions but reporting of outcomes after endovascular treatment of isolated popliteal lesions is limited. The aim of this study is to report the early and mid-term outcomes of endovascular treatment of isolated atherosclerotic popliteal artery lesions using different modalities of treatment in the setting of a multicentre cohort study.
A multicentre retrospective cohort study was conducted under the auspices of the "Research Collaborative in Peripheral Arterial Disease" (RCPAD), a pan-European scientific collaboration between vascular specialists. A total of 15 Departments from five countries participated. Between June 2016 and June 2021, 651 consecutive patients treated for isolated de novo atherosclerotic popliteal lesions using solely endovascular tools were included (409, 62.8% with critical limb threatening ischemia). Six techniques were used: plain balloon angioplasty (PTA), (286, 43.9%), drug coated balloon (DCB) angioplasty (98, 15.1%), stenting with low-chronic outward force (COF) stents (84, 12.9%), stenting with high-COF stents (76, 11.7%), atherectomy alone (17, 2.6%), and directional atherectomy with anti-restenotic therapy (DAART) (90, 13.8%). Primary outcomes measures were primary and secondary patency, and freedom from clinically-driven target lesion revascularization (F-CDTLR). PTA was compared with the other five endovascular treatment modalities using a Cox regression, adjusted for: age, sex, presence of critical limb threatening ischemia, smoking, diabetes, chronic kidney disease, number of run-off vessels, and degree of lesion calcification.
Immediate technical success was achieved in 94.8% of cases. Median follow-up was 26 months (range: 6-42). Actuarial survival for all patients at 26 months (per outcome measure) was: primary patency, 73.9%; secondary patency, 88%; F-CDTLR, 76.5%. When comparing PTA vs. all other treatments, F-CDTLR (75.2% for PTA vs. 76.5%, HR: 1.06, 95% CI: 0.75-1.48, p=0.46) appeared marginally inferior for PTA (adjusted regression); however, secondary patency was not statistically different (85.7% for PTA vs. 88%, p=0.20). In an adjusted Kaplan Meier analysis, estimated primary patency was inferior for PTA in pairwise comparisons vs. other treatments (<0.001 vs. atherectomy; 0.002 vs. DAART; 0.06 vs. high-COF stenting; 0.002 vs. low-COF stenting) (Table I).
Endovascular treatment of isolated popliteal lesions using modern techniques is safe and is associated with acceptable mid-term outcomes in terms of primary and secondary patency as well as F-CDTLR. PTA seems to be associated with inferior primary patency and F-CDTLR, compared to newer alternative endovascular treatments in this context. Given the frequent introduction of more endovascular treatments for these lesions, carefully designed prospective multicentre registries with uniform long-term follow-up are not warranted.
1. Rastan A, Krankenberg H, Baumgartner I, Blessing E, Müller-Hülsbeck S, Pilger E, et al. Stent placement versus balloon angioplasty for the treatment of obstructive lesions of the popliteal artery: a prospective, multicenter, randomized trial. Circulation 2013; 127: 2535-2541.
2. Stavroulakis K, Schwindt A, Torsello G, Stachmann A, Hericks C, Bosiers MJ, et al. Directional atherectomy with antirestenotic therapy vs drug-coated balloon angioplasty alone for isolated popliteal artery lesions. J Endovasc Ther 2017; 24: 181-188.