Abstract / Summary
Background: Endovascular treatment of femoropopliteal atherosclerotic disease has evolved from plain balloon angioplasty and routine stenting toward lesion-oriented strategies that combine plaque assessment, selective vessel preparation, antiproliferative drug delivery, and provisional scaffolding. The increasing availability of drug-coated balloons, drug-eluting stents, atherectomy, intravascular lithotripsy, intravascular imaging, and sirolimus-based technologies has improved therapeutic options but has also made device selection more complex. Objective: To synthesize comparative evidence and present a practical lesion-oriented framework for selecting vessel preparation, antiproliferative therapy, and selective scaffolding. Methods: A structured narrative review of contemporary evidence was performed, prioritizing randomized controlled trials, head-to-head comparisons, systematic reviews, meta-analyses, and consensus documents relevant to femoropopliteal intervention. Results: Lesion morphology—particularly length, chronic total occlusion, calcification pattern, popliteal involvement, and in-stent restenosis—strongly influences procedural strategy and durability. Atherectomy and specialty balloons can optimize acute vessel preparation in selected lesions, although consistent long-term superiority has not been demonstrated. Intravascular lithotripsy has the strongest randomized evidence for heavily calcified lesions, reducing flow-limiting dissection and bailout stenting. Paclitaxel-coated balloons remain a central leave-nothing-behind therapy, with contemporary evidence not confirming the previously proposed late mortality signal. Sirolimus-coated balloons have now entered the field with randomized noninferiority data versus paclitaxel through 2 years. Drug-eluting and other contemporary stents remain important when recoil, dissection, or complex anatomy make a purely scaffold-free strategy unreliable. Conclusions: Contemporary femoropopliteal intervention is best approached as a sequence of lesion characterization, selective preparation, antiproliferative therapy, and selective scaffolding. Treatment should be matched to lesion morphology and the final mechanical result, with focal repair or stenting when dissection or recoil compromises flow.