Endovascular Treatment Modalities for Infrapopliteal Artery Disease: A Bayesian Network Meta-Analysis with Exploratory Evaluation of Retrievable Scaffold Therapy.

BACKGROUND

Endovascular options for infrapopliteal artery disease include plain balloon angioplasty (PTA), drug‑coated balloons (DCB), drug‑eluting and bare‑metal stents (DES), and atherectomy. Retrievable scaffold therapy (RST) has recently emerged as a temporary scaffolding strategy used with DCB, but its comparative effectiveness remains uncertain.

METHODS

A comprehensive literature search identified 21 randomized and 4 single‑arm trials (n = 3184). Eligible studies reported at least one prespecified outcome: 30‑day major adverse events (MAE), 12‑month all‑cause mortality, 6‑month clinically driven target lesion revascularization (CD‑TLR), or 6‑month major amputation. Random‑effects models generated odds ratios (ORs) with 95% credible intervals (CrIs). SUCRA values summarized treatment rankings.

RESULTS

Atherectomy ranked best for 30‑day MAE (SUCRA 77.2%), though no treatment yielded a statistically significant reduction in the Odds Ratio. It was also associated with a significantly reduced 12‑month mortality versus PTA (OR 0.39, 95% CrI 0.15-0.90; SUCRA 97.8%). For 6‑month CD‑TLR, atherectomy (OR 0.26, 95% CrI 0.00-0.62), DCB (OR 0.42, 95% CrI 0.30-0.58), and DES (OR 0.43, 95% CrI 0.19-0.88) showed significant benefit. No treatment significantly reduced major amputation. RST showed favorable but nonsignificant reductions, indicating a smaller number of available studies, consistently ranking mid‑tier across all outcomes. Meta‑regression identified CKD and longer lesion length as predictors of higher CD‑TLR risk.

CONCLUSIONS

Atherectomy showed the most consistent benefits across mortality and reintervention outcomes, while RST demonstrated promising but inconclusive performance. Larger randomized trials are needed to clarify RST's role in infrapopliteal revascularization.