Lower limb PAD intervention is moving from “open the artery” to “optimize the vessel.” The most visible trend is the shift toward drug-coated technologies and atherectomy-assisted lesion preparation to address calcified, long, and diffusely diseased segments. Drug-coated balloons and drug-eluting stents aim to reduce restenosis while minimizing permanent implants, and newer coating strategies are pushing teams to scrutinize drug dose, particle retention, and downstream embolic management. At the same time, intravascular imaging and physiologic assessment are gaining practical relevance, helping operators confirm true lumen passage, quantify calcification, and avoid underexpansion that silently drives failure.
Calcium is now the strategic battleground. In the femoropopliteal and below-the-knee territories, specialized plaque modification and intravascular lithotripsy are increasingly used to improve compliance before drug delivery or stenting. This “prepare, then treat” approach can improve acute gain and reduce the need for bailout, but it demands discipline in device selection and sizing. Embolic protection, once viewed as optional, is being reconsidered when treating heavy plaque burden or performing aggressive debulking-especially in limb-threatening ischemia where microvascular reserve is limited.
For decision-makers, the winning programs will be those that standardize pathways rather than chase single devices. Build algorithms that pair lesion morphology with a clear strategy for access, crossing, preparation, therapy, and surveillance, and align inventory to those pathways. Track outcomes that matter-patency, reintervention rates, wound healing time, and ambulatory status-so value is measured clinically and operationally. The next leap in lower limb intervention will come from integrating devices into reproducible, imaging-informed workflows that consistently protect the limb and the patient.
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