Predictors and Procedural Outcomes of Additional Balloon Dilatation Success Following Vessel Preparation Failure in Femoropopliteal Lesions

Abstract

Background:

Vessel preparation failure (VPF) is a predictor of restenosis after drug-coated balloon treatment. However, evidence regarding interventional strategies using additional balloon dilatation for VPF following vessel preparation (VP) is limited.

Methods:

This retrospective study included 128 of 209 patients who underwent endovascular therapy for femoropopliteal lesions between January 2018 and August 2025 in whom VPF occurred after VP and repair was attempted. Vascular repair was defined as the absence of dissection grade D or higher and residual stenosis ≥50% after additional balloon dilatation following VPF. The primary outcome was the successful repair rate. Changes in residual stenosis and dissection, the use of finalizing devices, and predictors of successful repair were also investigated.

Results:

Before repair, 78 patients (60.9%) had grade D dissections or higher, and 115 (89.8%) had ≥50% residual stenosis. Repair was successful in 85 patients (66.4%). After repair, dissections of grade D or higher decreased to 40 (31.2%), and residual stenosis ≥50% was observed in 29 (22.7%). Patients with dissections of grade D or higher had significantly lower repair success rates than those with dissections lower than grade D (50.0% vs 92.0%, p<0.001). In the overall cohort, lesion length <20 cm and balloon pressure ≥14 atm were independent predictors of successful repair. In patients with dissections of grade D or higher, the absence of popliteal involvement and inflation time ≥180 seconds were also identified as predictors of successful repair.

Conclusion:

The success rate of VPF repair was modest, and repair was more difficult in cases of severe dissection. Shorter lesions, high-pressure dilatation, and, among severe dissections, the absence of popliteal artery involvement and a longer inflation time were associated with successful repair.

Clinical Impact

Understanding the success rate and predictors of VPF repair may help operators optimize VP strategies in FP interventions. This study suggests that high-pressure and prolonged inflations could improve repair success, whereas long lesions and PopA involvement may limit the likelihood of successful repair. These findings may assist clinicians in determining when additional attempts at repair are reasonable and when an early transition to a stent strategy is appropriate, thereby enabling more efficient decision-making in daily practice.