The Influence of Lesion Length on the Efficacy of Angioplasty with Atherectomy in Treating Infrapopliteal Artery Disease: Systematic Review and Meta-Analysis

Abstract

Purpose:

For the treatment of infrapopliteal artery disease (IPAD), endovascular intervention is a main choice, including atherectomy (ATH) and balloon angioplasty. However, the comparative efficacy between both approaches was heterogeneous in prior studies. Lesion length is a critical factor in IPAD anatomy classification. There is no meta-analysis to study the influence of lesion length on the effects of atherectomy for IPAD treatment. This meta-analysis aimed to determine the efficacy of angioplasty with ATH in different ranges of lesion length compared to angioplasty without ATH.

Methods:

Studies comparing ATH and angioplasty without ATH, which published up to April 2024 were retrieved from Pubmed, Embase, and Web of Science. Endpoints included limb prognosis and vessel complications. Referring to Trans-Atlantic Inter-Society Consensus, 10 cm lesion length was defined as a cutoff value for subgroup analysis. Pooled data were calculated using the Revman 5.4 and Stata 15, presented as odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was calculated using I² value. Methodological quality was assessed by Cochrane tool and Newcastle-Ottawa Scale. The robustness of findings would be evaluated by sensitivity analysis. Egger’s test was performed to detect publication bias.

Results:

Eleven studies (8412 patients) were included in this meta-analysis. Significant higher technical success was detected in ATH group (OR=1.99, 95% CI 1.44–2.76, I²=0%). In a subgroup of mean lesion length <10cm, ATH was associated with lower incidence of dissection (OR=0.19, 95% CI 0.05–0.67, I²=15%, p=0.01) and bailout stenting (OR=0.18, 95% CI 0.05–0.71, I²=16%, p=0.01). No significant differences were found between ATH and no ATH cohorts in primary patency (OR=1.65, 95% CI 0.85–3.19), all-cause death (OR=0.75, 95% CI 0.5–1.13), limb salvage (OR=1.03, 95% CI 0.75–1.41), target-lesion revascularization (OR=0.77, 95% CI 0.47–1.27), and embolization (OR=1.19, 95% CI 0.5–2.83).

Conclusion:

For IPAD, lesion length is a notable factor affecting the efficacy of ATH. In comparisons with angioplasty without ATH, the use of ATH is contributable in achieving higher technical success. The superiority of ATH may appear in reducing dissection and bailout stenting in treating IPAD with length <10cm. Nevertheless, regardless of lesion length, there seems that ATH cannot effectively improve limb salvage compared to angioplasty alone.

Clinical Impact

Prior results of several meta-analyses comparing angioplasty with atherectomy to angioplasty alone were inconsistent in prognosis of infrapopliteal artery disease (IPAD), due to high heterogeneity. Considering the lesion length plays a critical role in IPAD anatomy classification, we performed an updated meta-analysis and subgroup analysis based on average lesion length to furtherly evaluate the efficacy of angioplasty following atherectomy. Our study revealed atherectomy showed advantages in obtaining technical success for IPAD ≥ 10cm and reducing the risks of bailout stenting and dissection for IPAD < 10cm. Atherectomy may prevent target-vessel complications rather than improving late patency and limb salvage effectively.