Endovascular revascularization strategies for aortoiliac and femoropopliteal artery disease: a meta-analysis

David Koeckerling; Peter Francis Raguindin; Lum Kastrati; Sarah Bernhard; Joseph Barker; Andrea Carolina Quiroga Centeno; Hamidreza Raeisi-Dehkordi; Farnaz Khatami; Christa Niehot; Anne Lejay; Zoltan Szeberin; Christian-Alexander Behrendt; Joakim Nordanstig; Taulant Muka; Iris Baumgartner

doi:10.1093/eurheartj/ehac722

Endovascular revascularization strategies for aortoiliac and femoropopliteal artery disease: a meta-analysis

Eur Heart J. 2023 Mar 14;44(11):935-950. doi: 10.1093/eurheartj/ehac722.

Authors

David Koeckerling¹, Peter Francis Raguindin^{2

3

4}, Lum Kastrati^{2

5

6}, Sarah Bernhard¹, Joseph Barker⁷, Andrea Carolina Quiroga Centeno⁸, Hamidreza Raeisi-Dehkordi^{2

5}, Farnaz Khatami^{2

9}, Christa Niehot¹⁰, Anne Lejay¹¹, Zoltan Szeberin¹², Christian-Alexander Behrendt¹³, Joakim Nordanstig¹⁴, Taulant Muka^{2

15}, Iris Baumgartner¹

Affiliations

¹ Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland.
² Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.
³ Swiss Paraplegic Research, Guido A. Zäch Str. 1, 6207 Nottwil, Switzerland.
⁴ Faculty of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse, 36002 Lucerne, Switzerland.
⁵ Graduate School for Health Sciences, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.
⁶ Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland.
⁷ Department of Cardiovascular Sciences, University of Leicester, University Rd, Leicestershire LE1 7RH, UK.
⁸ Department of Surgery, Universidad Industrial de Santander, Cl. 9 Cra 27, Bucaramanga, Santander, Colombia.
⁹ Community Medicine Department, Tehran University of Medical Sciences, PourSina St., Tehran 1417613151, Iran.
¹⁰ Literature Searches Support, 3314SC Dordrecht, the Netherlands.
¹¹ Department of Vascular Surgery and Kidney Transplantation, University of Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France.
¹² Department of Vascular Surgery, Semmelweis University, XII. Városmajor u. 68., 1122 Budapest, Hungary.
¹³ Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Alphonsstraße 14, 22043 Hamburg, Germany.
¹⁴ Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg University, Blå stråket 5, 413 45 Gothenburg, Sweden.
¹⁵ Epistudia, 3011 Bern, Switzerland.

Abstract

Aims: Optimal endovascular management of intermittent claudication (IC) remains disputed. This systematic review and meta-analysis compares efficacy and safety outcomes for balloon angioplasty (BA), bare-metal stents (BMS), drug-coated balloons (DCB), drug-eluting stents (DES), covered stents, and atherectomy.

Methods and results: Electronic databases were searched for randomized, controlled trials (RCT) from inception 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 evaluated at short-term (<1 year), mid-term (1-2 years), and long-term (≥2 years) follow-up. The study was registered on PROSPERO (CRD42021292639). Fifty-one RCTs enrolling 8430 patients/lesions were included. In femoropopliteal disease of low-to-intermediate complexity, DCBs were associated with higher likelihood of primary patency [short-term: odds ratio (OR) 3.21, 95% confidence interval (CI) 2.44-4.24; long-term: OR 2.47, 95% CI 1.93-3.16], lower TLR (short-term: OR 0.33, 95% CI 0.22-0.49; long-term: OR 0.42, 95% CI 0.29-0.60) and similar all-cause mortality risk, compared with BA. Primary stenting using BMS was associated with improved short-to-mid-term patency and TLR, but similar long-term efficacy compared with provisional stenting. Mid-term patency (OR 1.64, 95% CI 0.89-3.03) and TLR (OR 0.50, 95% CI 0.22-1.11) estimates were comparable for DES vs. BMS. Atherectomy, used independently or adjunctively, was not associated with efficacy benefits compared with drug-coated and uncoated angioplasty, or stenting approaches. Paucity and heterogeneity of data precluded pooled analysis for aortoiliac disease and QoL endpoints.

Conclusion: Certain devices may provide benefits in femoropopliteal disease, but comparative data in aortoiliac arteries is lacking. Gaps in evidence quantity and quality impede identification of the optimal endovascular approach to IC.

Keywords: Atherectomy; Drug-coated balloon; Drug-eluting stent; Endovascular revascularization; Intermittent claudication; angioplasty.

Publication types

Systematic Review
Meta-Analysis
Research Support, Non-U.S. Gov't

MeSH terms

Angioplasty, Balloon* / methods
Femoral Artery / surgery
Humans
Peripheral Arterial Disease* / surgery
Popliteal Artery / surgery
Risk Factors
Treatment Outcome
Vascular Patency

Abstract

Publication types

MeSH terms

Grants and funding