{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,20]],"date-time":"2026-06-20T22:43:51Z","timestamp":1781995431713,"version":"3.54.5"},"reference-count":34,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,3,28]],"date-time":"2026-03-28T00:00:00Z","timestamp":1774656000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCDD"],"abstract":"<jats:p>After vessel preparation, using different strategies such as balloon angioplasty, specialty balloons, atherectomy or intravascular lithotripsy, definitive treatment has emerged as a key feature in endovascular treatment strategies. Based on current guidelines, endovascular treatment is the most common treatment option in patients with claudication. In patients with chronic limb-threatening ischemia (CLTI), on the other hand, the best treatment modality, including bypass surgery and endovascular revascularization, needs to be selected by an interdisciplinary team, focusing on individual anatomic and patient-specific characteristics, on the availability of a vein graft and on cardiovascular and other comorbidities of the patients. With endovascular therapy, currently, a plethora of options are available for the treatment of femoropopliteal lesions, which are increasingly gaining in complexity. Therefore, a practical systematic case-based approach, entailing contemporary treatment options, like drug-coated balloon (DCB) angioplasty tools, self-expanding bare-metal stents (BMSs), drug-eluting stents (DESs), interwoven stents and covered stents, is crucial. Generally, most endovascular operators adhere to the \u2018leave nothing behind\u2019 concept, meaning that, after proper lesion preparation, lesions can be treated with DCBs, avoiding the implantation of permanent metallic implants. However, in the case of severe dissections or significant recoil, stent implantation becomes necessary to achieve adequate limb perfusion. The selection between long versus spot stenting and the different stent options depends on the current scientific evidence, guidelines and expert opinion statements. An interdisciplinary expert consensus was recently compiled on how these modalities should be used in specific lesions and patients in the femoropopliteal segment. Herein we present a practical case-based approach, which is based on this algorithm and aims at harmonization of endovascular treatment strategies in daily practice and ultimately at further improvements in limb and patient outcomes.<\/jats:p>","DOI":"10.3390\/jcdd13040150","type":"journal-article","created":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T09:57:11Z","timestamp":1774864631000},"page":"150","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["State-of-the-Art Definitive Femoropopliteal Lesion Treatment: A Case-Based Systematic Approach"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6038-2253","authenticated-orcid":false,"given":"Grigorios","family":"Korosoglou","sequence":"first","affiliation":[{"name":"GRN Hospital Weinheim, Cardiology and Vascular Medicine, 69469 Weinheim, Germany"},{"name":"GRN Hospital Eberbach, Cardiology and Vascular Medicine, 69469 Weinheim, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9912-2814","authenticated-orcid":false,"given":"Nasser","family":"Malyar","sequence":"additional","affiliation":[{"name":"Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, 48149 Muenster, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrej","family":"Schmidt","sequence":"additional","affiliation":[{"name":"Division of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Lichtenberg","sequence":"additional","affiliation":[{"name":"Vascular Center, Klinikum Arnsberg, 59821 Arnsberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gerd","family":"Gr\u00f6zinger","sequence":"additional","affiliation":[{"name":"Department of Radiology, SLK-Kliniken Heilbronn GmbH, 74078 Heilbronn, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dittmar","family":"B\u00f6ckler","sequence":"additional","affiliation":[{"name":"Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0406-3319","authenticated-orcid":false,"given":"Christian A.","family":"Behrendt","sequence":"additional","affiliation":[{"name":"Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, 22043 Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0205-9084","authenticated-orcid":false,"given":"Erwin","family":"Blessing","sequence":"additional","affiliation":[{"name":"University Heart and Vascular Center, Department of Angiology, University Hospital Hamburg-Eppendorf, 20246 Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0455-5081","authenticated-orcid":false,"given":"Ralf","family":"Langhoff","sequence":"additional","affiliation":[{"name":"Department of Angiology, Center for Internal Medicine I, Campus Clinic Brandenburg, Brandenburg Medical School Theodor Fontane, 14770 Brandenburg an der Havel, Germany"},{"name":"Department of Angiology and Vascular Medicine, Sankt Gertrauden Hospital, Humboldt University Berlin, 10713 Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2704-3871","authenticated-orcid":false,"given":"Thomas","family":"Zeller","sequence":"additional","affiliation":[{"name":"Department of Interventional Angiology, University Hospital Freiburg\/Bad Krozingen, 79189 Bad Krozingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christos","family":"Rammos","sequence":"additional","affiliation":[{"name":"Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, 45141 Essen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,28]]},"reference":[{"key":"ref_1","first-page":"366","article-title":"Analysis of endovascular therapy for peripheral arterial disease in all German hospitals","volume":"52","author":"Betge","year":"2023","journal-title":"Vasa"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"873","DOI":"10.1016\/j.ejvs.2020.08.027","article-title":"Editor\u2019s Choice\u2014International Variations and Sex Disparities in the Treatment of Peripheral Arterial Occlusive Disease: A Report from VASCUNET and the International Consortium of Vascular Registries","volume":"60","author":"Behrendt","year":"2020","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"545","DOI":"10.1016\/j.jcin.2024.11.038","article-title":"Global Algorithm for the Endovascular Treatment of Chronic Femoropopliteal Lesions: An Interdisciplinary Expert Opinion Statement","volume":"18","author":"Korosoglou","year":"2025","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1024\/0301-1526\/a001066","article-title":"Best crossing of peripheral chronic total occlusions","volume":"52","author":"Korosoglou","year":"2023","journal-title":"Vasa"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"317","DOI":"10.1016\/j.jcin.2022.11.036","article-title":"Crossing Algorithm for Infrainguinal Chronic Total Occlusions: An Interdisciplinary Expert Opinion Statement","volume":"16","author":"Korosoglou","year":"2023","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e432","DOI":"10.4244\/EIJ-D-21-01070","article-title":"Phoenix atherectomy for patients with peripheral artery disease","volume":"18","author":"Giusca","year":"2022","journal-title":"EuroIntervention"},{"key":"ref_7","unstructured":"Deutsche Gesellschaft f\u00fcr Angiologie (2024). S3-Leitlinie zur Diagnostik, Therapie und Nachsorge der peripheren arteriellen Verschlusskrankheit, Deutsche Gesellschaft f\u00fcr Angiologie."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"981","DOI":"10.1016\/j.jvs.2019.01.080","article-title":"Systematic review and updated meta-analysis of the use of drug-coated balloon angioplasty versus plain old balloon angioplasty for femoropopliteal arterial disease","volume":"70","author":"Caradu","year":"2019","journal-title":"J. Vasc. Surg."},{"key":"ref_9","first-page":"139","article-title":"Drug-coated balloon versus plain old balloon angioplasty in femoropopliteal disease: An updated meta-analysis of randomized controlled trials","volume":"94","author":"Shah","year":"2019","journal-title":"Catheter. Cardiovasc. Interv."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Feng, H., Chen, X., Guo, X., Zhang, Z., Zhang, Z., Liu, B., and Lian, L. (2020). Comparison of efficacy and safety of drug-eluting versus uncoated balloon angioplasty for femoropopliteal arterial occlusive disease: A meta-analysis. BMC Cardiovasc. Disord., 20.","DOI":"10.1186\/s12872-020-01667-y"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e011245","DOI":"10.1161\/JAHA.118.011245","article-title":"Risk of Death Following Application of Paclitaxel-Coated Balloons and Stents in the Femoropopliteal Artery of the Leg: A Systematic Review and Meta-Analysis of Randomized Controlled Trials","volume":"7","author":"Katsanos","year":"2018","journal-title":"J. Am. Heart Assoc."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"3732","DOI":"10.1093\/eurheartj\/ehz698","article-title":"Mortality after use of paclitaxel-based devices in peripheral arteries: A real-world safety analysis","volume":"41","author":"Freisinger","year":"2020","journal-title":"Eur. Heart J."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e012074","DOI":"10.1161\/CIRCINTERVENTIONS.122.012074","article-title":"Update From the Longitudinal Assessment of Safety of Femoropopliteal Endovascular Treatment With Paclitaxel-Coated Devices Among Medicare Beneficiaries: The SAFE-PAD Study","volume":"15","author":"Secemsky","year":"2022","journal-title":"Circ. Cardiovasc. Interv."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1115","DOI":"10.1016\/S0140-6736(25)01584-3","article-title":"Paclitaxel-coated versus uncoated devices for infrainguinal endovascular revascularisation in patients with intermittent claudication (SWEDEPAD 2): A multicentre, participant-masked, registry-based, randomised controlled trial","volume":"406","author":"Nordanstig","year":"2025","journal-title":"Lancet"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1103","DOI":"10.1016\/S0140-6736(25)01585-5","article-title":"Paclitaxel-coated versus uncoated devices for infrainguinal endovascular revascularisation in chronic limb-threatening ischaemia (SWEDEPAD 1): A multicentre, participant-masked, registry-based, randomised controlled trial","volume":"406","author":"Falkenberg","year":"2025","journal-title":"Lancet"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1818","DOI":"10.1007\/s00380-021-01871-6","article-title":"Frequency, predictors, and effect of the slow-flow phenomenon after drug-coated balloon angioplasty for femoropopliteal lesions","volume":"36","author":"Shirai","year":"2021","journal-title":"Heart Vessel."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1177\/1526602819881156","article-title":"What Now for the Endovascular Community After the Paclitaxel Mortality Meta-Analysis: Can Sirolimus Replace Paclitaxel in the Peripheral Vasculature?","volume":"27","author":"Tang","year":"2020","journal-title":"J. Endovasc. Ther."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"683","DOI":"10.1177\/1526602820941811","article-title":"Six-Month Outcomes From the First-in-Human, Single-Arm SELUTION Sustained-Limus-Release Drug-Eluting Balloon Trial in Femoropopliteal Lesions","volume":"27","author":"Zeller","year":"2020","journal-title":"J. Endovasc. Ther."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"148","DOI":"10.4244\/EIJV9I1A21","article-title":"Emerging technologies: Polymer-free phospholipid encapsulated sirolimus nanocarriers for the controlled release of drug from a stent-plus-balloon or a stand-alone balloon catheter","volume":"9","author":"Lemos","year":"2013","journal-title":"EuroIntervention"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"665","DOI":"10.1186\/s13063-021-05631-9","article-title":"Head-to-head comparison of sirolimus- versus paclitaxel-coated balloon angioplasty in the femoropopliteal artery: Study protocol for the randomized controlled SIRONA trial","volume":"22","author":"Teichgraber","year":"2021","journal-title":"Trials"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1696","DOI":"10.1016\/j.jvs.2016.05.073","article-title":"Results of primary stent therapy for femoropopliteal peripheral arterial disease at 7 years","volume":"64","author":"Stavroulakis","year":"2016","journal-title":"J. Vasc. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"472","DOI":"10.1016\/j.jcin.2014.10.016","article-title":"Outcomes of spot stenting versus long stenting after intentional subintimal approach for long chronic total occlusions of the femoropopliteal artery","volume":"8","author":"Hong","year":"2015","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e000937","DOI":"10.1161\/CIRCINTERVENTIONS.113.000937","article-title":"Wire-Interwoven Nitinol Stent Outcome in the Superficial Femoral and Proximal Popliteal Arteries: Twelve-Month Results of the SUPERB Trial","volume":"8","author":"Garcia","year":"2015","journal-title":"Circ. Cardiovasc. Interv."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1564","DOI":"10.1161\/CIRCULATIONAHA.122.059606","article-title":"Efficacy of a Drug-Eluting Stent Versus Bare Metal Stents for Symptomatic Femoropopliteal Peripheral Artery Disease: Primary Results of the EMINENT Randomized Trial","volume":"146","author":"Goueffic","year":"2022","journal-title":"Circulation"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1007\/s00270-020-02693-1","article-title":"Two-Year Efficacy and Safety Results from the IMPERIAL Randomized Study of the Eluvia Polymer-Coated Drug-Eluting Stent and the Zilver PTX Polymer-free Drug-Coated Stent","volume":"44","author":"Benko","year":"2021","journal-title":"Cardiovasc. Interv. Radiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1016\/j.jacc.2018.11.039","article-title":"Drug-Eluting Stent Versus Drug-Coated Balloon Revascularization in Patients With Femoropopliteal Arterial Disease","volume":"73","author":"Bausback","year":"2019","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"792","DOI":"10.1016\/j.jvir.2021.02.014","article-title":"Vascular Response of a Polymer-Free Paclitaxel-Coated Stent (Zilver PTX) versus a Polymer-Coated Paclitaxel-Eluting Stent (Eluvia) in Healthy Swine Femoropopliteal Arteries","volume":"32","author":"Sakamoto","year":"2021","journal-title":"J. Vasc. Interv. Radiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"865","DOI":"10.1016\/j.ejvs.2025.03.010","article-title":"Editor\u2019s Choice\u2014Comparative Analysis of Three Year Results of Two Paclitaxel Related Stents for the Management of Femoropopliteal Disease in a Real World Setting","volume":"69","author":"Shibata","year":"2025","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1824","DOI":"10.1016\/j.jcin.2023.06.006","article-title":"Reply: Drug-Coated Balloons for Complex PAD: More Study Is Needed","volume":"16","author":"Tepe","year":"2023","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1007\/s00270-014-1024-9","article-title":"Sustained benefit at 2 years for covered stents versus bare-metal stents in long SFA lesions: The VIASTAR trial","volume":"38","author":"Lammer","year":"2015","journal-title":"Cardiovasc. Interv. Radiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1177\/1526602814564385","article-title":"Superiority of stent-grafts for in-stent restenosis in the superficial femoral artery: Twelve-month results from a multicenter randomized trial","volume":"22","author":"Bosiers","year":"2015","journal-title":"J. Endovasc. Ther."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1134","DOI":"10.1016\/j.jcin.2024.03.015","article-title":"Randomized Trial Comparing a Stent-Avoiding With a Stent-Preferred Strategy in Complex Femoropopliteal Lesions","volume":"17","author":"Wittig","year":"2024","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e1313","DOI":"10.1161\/CIR.0000000000001251","article-title":"2024 ACC\/AHA\/AACVPR\/APMA\/ABC\/SCAI\/SVM\/SVN\/SVS\/SIR\/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"149","author":"Gornik","year":"2024","journal-title":"Circulation"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1024\/0301-1526\/a001161","article-title":"A call for interdisciplinary and guideline-recommended PAD treatment","volume":"54","author":"Korosoglou","year":"2025","journal-title":"Vasa"}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/4\/150\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T10:09:01Z","timestamp":1774865341000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/4\/150"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,28]]},"references-count":34,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["jcdd13040150"],"URL":"https:\/\/doi.org\/10.3390\/jcdd13040150","relation":{},"ISSN":["2308-3425"],"issn-type":[{"value":"2308-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,28]]}}}