Association of Lesion Complexity and Diabetes Mellitus with Target Lesion Failure after Femoropopliteal Atherectomy.

BACKGROUND

Diabetes mellitus (DM) is associated with adverse outcomes after femoropopliteal endovascular interventions, but diabetic patients often present with greater anatomical complexity and impaired distal outflow, potentially confounding its relationship with target lesion failure (TLF).

METHODS

We retrospectively reviewed 123 consecutive patients who underwent femoropopliteal atherectomy for symptomatic peripheral artery disease between January 2017 and August 2025. All patients received drug-coated balloon angioplasty after atherectomy, and no stents were implanted. The primary end point was TLF, defined as clinically driven target lesion revascularization, duplex ultrasound-proven restenosis, or target vessel occlusion. Multivariable Cox regression, logistic regression for early TLF (≤ 6 months), metabolic sensitivity analyses, stratified interaction testing, and 6-month landmark analysis were performed.

RESULTS

TLF occurred in 48.8% of patients. Diabetic patients had worse unadjusted TLF-free survival (log-rank P = 0.045), but DM was not independently associated with overall TLF after adjustment (hazard ratio [HR]: 1.15, 95% confidence interval, 0.72-1.84; P = 0.550). Lesion length ≥ 100 mm (HR: 2.05, P = 0.012), chronic limb-threatening ischemia (HR: 1.80, P = 0.040), and poor tibial runoff (HR: 1.68, P = 0.048) remained independently associated with adverse outcomes. A significant DM × poor runoff interaction was observed (P = 0.029), with TLF occurring in 82.5% of diabetic patients with poor runoff. HbA1c and glucose were not independently associated with TLF in sensitivity analyses.

CONCLUSION

DM was not independently associated with TLF after femoropopliteal atherectomy once lesion complexity and distal runoff were considered. Anatomical disease burden and distal hemodynamics may confound the observed association between DM and adverse outcomes.