{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T11:10:07Z","timestamp":1790248207232,"version":"4.1.0"},"reference-count":24,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T00:00:00Z","timestamp":1790208000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: Clinically driven target lesion revascularization (CD-TLR) following endovascular recanalization of femoropopliteal chronic total occlusions (CTOs) remains a primary determinant of long-term procedural durability. This study aimed to identify clinical, anatomical, and procedural predictors associated with 12-month CD-TLR following successful femoropopliteal CTO endovascular treatment. Methods: This retrospective single-center cohort study evaluated 246 successfully recanalized patients who underwent endovascular treatment for femoropopliteal CTO between June 2020 and June 2025. The primary endpoint was 12-month CD-TLR. To overcome severe multicollinearity and prevent overfitting among correlated predictors, five survival algorithms were benchmarked across the complete 27-variable candidate set. Model discrimination was evaluated using Harrell\u2019s concordance index (C-index) with bootstrap correction. Results: Over a 12-month time-to-event follow-up (median 365 days), CD-TLR occurred in 114 patients (46.3%). Multivariable-regularized Elastic Net Cox regression retained 22 informative predictors, achieving an apparent C-index of 0.715 (95% CI: 0.66\u20130.77) and an optimism-corrected C-index of 0.653. Higher occluded below-the-knee vessel count, baseline Rutherford classes 4\u20136, popliteal CTO extension, distal runoff impairment, active smoking, and overall concomitant interventions showed positive associations with 12-month CD-TLR risk. Conversely, shorter lesion length (&lt;5 cm) and female sex showed inverse associations, while findings related to stent dimensions were considered exploratory. Conclusion: Twelve-month CD-TLR after endovascular treatment of femoropopliteal CTO was associated with greater distal vascular disease burden, anatomical complexity, a worse baseline Rutherford class and impaired distal runoff. The Elastic Net model provided the highest optimism-corrected discrimination among the evaluated strategies, although prospective external validation remains necessary before broad clinical application.<\/jats:p>","DOI":"10.3390\/jcm15197438","type":"journal-article","created":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T10:16:28Z","timestamp":1790244988000},"page":"7438","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Predictors of Clinically Driven Target Lesion Revascularization After Endovascular Treatment of Femoropopliteal Chronic Total Occlusions"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7946-1229","authenticated-orcid":false,"given":"Busra","family":"Guvendi Sengor","sequence":"first","affiliation":[{"name":"Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul 34865, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1424-2209","authenticated-orcid":false,"given":"Bark\u0131n","family":"Kultursay","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Tunceli State Hospital, Tunceli 62100, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"software","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"}]},{"given":"Mehmet","family":"Sengor","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, Bezmialem Vak\u0131f University Hospital, Istanbul 34093, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2646-4981","authenticated-orcid":false,"given":"Mustafa Ferhat","family":"Keten","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul 34865, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"visualization","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"resources","vocabulary":"credit"}]},{"given":"Tuba","family":"Unkun","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul 34865, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"resources","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0954-6347","authenticated-orcid":false,"given":"Abdulrahman","family":"Naser","sequence":"additional","affiliation":[{"name":"Department of Cardiology, K\u0131rklareli Education and Research Hospital, K\u0131rklareli 39010, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"resources","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"}]},{"given":"Ender Ozgun","family":"Cakmak","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Istanbul Health and Technology University, Istanbul 34445, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"supervision","vocabulary":"credit"},{"role":"project-administration","vocabulary":"credit"},{"role":"funding-acquisition","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"}]},{"given":"Regayip","family":"Zehir","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul 34865, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"funding-acquisition","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"},{"role":"resources","vocabulary":"credit"},{"role":"conceptualization","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1038\/s41572-025-00651-0","article-title":"Peripheral artery disease","volume":"11","author":"Aboyans","year":"2025","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"999","DOI":"10.1016\/j.jacc.2018.06.041","article-title":"Major Adverse Limb Events and 1-Year Outcomes After Peripheral Artery Revascularization","volume":"72","author":"Hess","year":"2018","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1038\/s41569-021-00663-9","article-title":"Update on the pathophysiology and medical treatment of peripheral artery disease","volume":"19","author":"Golledge","year":"2022","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"685","DOI":"10.4070\/kcj.2018.0216","article-title":"SFA Intervention: Intraluminal or Subintimal?","volume":"48","author":"Ko","year":"2018","journal-title":"Korean Circ. J."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"433","DOI":"10.1177\/15266028221083456","article-title":"Risk Factor Analysis for Crossing Failure in Primary Antegrade Wire-Catheter Approach for Femoropopliteal Chronic Total Occlusions","volume":"30","author":"Bernardini","year":"2023","journal-title":"J. Endovasc. Ther."},{"key":"ref_6","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_7","doi-asserted-by":"crossref","first-page":"792","DOI":"10.1016\/j.jcin.2014.01.168","article-title":"Shared and differential factors influencing restenosis following endovascular therapy between TASC (Trans-Atlantic Inter-Society Consensus) II class A to C and D lesions in the femoropopliteal artery","volume":"7","author":"Iida","year":"2014","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1016\/j.carrev.2021.06.133","article-title":"Factors Contributing to Efficient Recanalization Procedures for Chronic Total Occlusion of the Superficial Femoral Artery","volume":"37","author":"Tadano","year":"2022","journal-title":"Cardiovasc. Revasc. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"385","DOI":"10.1002\/(SICI)1097-0258(19970228)16:4<385::AID-SIM380>3.0.CO;2-3","article-title":"The lasso method for variable selection in the Cox model","volume":"16","author":"Tibshirani","year":"1997","journal-title":"Stat. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1","DOI":"10.18637\/jss.v039.i05","article-title":"Regularization Paths for Cox\u2019s Proportional Hazards Model via Coordinate Descent","volume":"39","author":"Simon","year":"2011","journal-title":"J. Stat. Softw."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"284","DOI":"10.1177\/1526602818759333","article-title":"Chronic Total Occlusion Crossing Approach Based on Plaque Cap Morphology: The CTOP Classification","volume":"25","author":"Saab","year":"2018","journal-title":"J. Endovasc. Ther."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"S5","DOI":"10.1016\/j.jvs.2006.12.037","article-title":"Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)","volume":"45","author":"Norgren","year":"2007","journal-title":"J. Vasc. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"731","DOI":"10.1177\/1526602816656612","article-title":"Impact of Calcification on Clinical Outcomes After Endovascular Therapy for Superficial Femoral Artery Disease: Assessment Using the Peripheral Artery Calcification Scoring System","volume":"23","author":"Okuno","year":"2016","journal-title":"J. Endovasc. Ther."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"720","DOI":"10.1016\/j.jvs.2013.09.053","article-title":"Impact of runoff grade after endovascular therapy for femoropopliteal lesions","volume":"59","author":"Hiramori","year":"2014","journal-title":"J. Vasc. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Boc, V., Kozak, M., Er\u017een, B., Bo\u017ei\u010d Mijovski, M., Boc, A., and Blinc, A. (2023). Prognostic Factors for Restenosis of Superficial Femoral Artery after Endovascular Treatment. J. Clin. Med., 12.","DOI":"10.3390\/jcm12196343"},{"key":"ref_16","first-page":"2744","article-title":"Long-Term Clinical Association of Superficial and Nodular Calcification on Intravascular Ultrasound-Guided Successful Drug-Coated Balloon Endovascular Therapy for De Novo Femoropopliteal Artery Disease","volume":"106","author":"Roh","year":"2025","journal-title":"Catheter. Cardiovasc. Interv."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1406","DOI":"10.1016\/j.jvs.2010.01.062","article-title":"Endovascular interventions for TASC II D femoropopliteal lesions","volume":"51","author":"Baril","year":"2010","journal-title":"J. Vasc. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1186\/s42155-022-00329-8","article-title":"Clinical outcome of drug-coated balloons in patients with femoropopliteal chronic total occlusive lesions: Results from the multicenter EAGLE study","volume":"5","author":"Hayakawa","year":"2022","journal-title":"CVIR Endovasc."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e014024","DOI":"10.1161\/CIRCINTERVENTIONS.124.014024","article-title":"Femoropopliteal Endovascular Intervention: A Review of the Current Landscape","volume":"18","author":"Tannu","year":"2025","journal-title":"Circ. Cardiovasc. Interv."},{"key":"ref_20","first-page":"949","article-title":"Solid state, pulsed-wave 355\u2009nm UV laser atherectomy debulking in the treatment of infrainguinal peripheral arterial disease: The Pathfinder Registry","volume":"103","author":"Das","year":"2024","journal-title":"Catheter. Cardiovasc. Interv."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2600","DOI":"10.1177\/15266028251363466","article-title":"The Endovascular Therapy Using Excimer Laser Atherectomy for Complex Femoropopliteal In-Stent Restenosis Lesions","volume":"33","author":"Horie","year":"2026","journal-title":"J. Endovasc. Ther."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Marzano, A., Flora, F., Silvestri, O., De Chiara, M.S., Barbarisi, D., Gallicchio, V., Flora, L., Di Marzo, L., Peluso, A., and Mansour, W. (2026). Auryon 355 nm Laser Atherectomy for Femoropopliteal In-Stent Occlusions: A Retrospective Comparative Study of Technical Success and 12-Month Outcomes. Biomedicines, 14.","DOI":"10.3390\/biomedicines14071538"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1111\/j.1467-9868.2005.00503.x","article-title":"Regularization and Variable Selection Via the Elastic Net","volume":"67","author":"Zou","year":"2005","journal-title":"J. R. Stat. Soc. Ser. B Stat. Methodol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1080\/00401706.1970.10488634","article-title":"Ridge Regression: Biased Estimation for Nonorthogonal Problems","volume":"12","author":"Hoerl","year":"1970","journal-title":"Technometrics"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7438\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T10:37:16Z","timestamp":1790246236000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7438"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,24]]},"references-count":24,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2026,10]]}},"alternative-id":["jcm15197438"],"URL":"https:\/\/doi.org\/10.3390\/jcm15197438","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,24]]}}}