Impact of Stepwise Balloon Angioplasty for De Novo Femoropopliteal Artery: A Retrospective Observational Study

Background and Aims Drug‐coated balloon use in the revascularisation of femoropopliteal (FP) lesions improves patency rates. However, conventional balloon angioplasty sometimes leads to severe artery dissection, which may be prevented using stepwise balloon angioplasty. This study aimed to examine the effects of stepwise balloon angioplasty, which is defined as a step‐up approach with a sequentially larger balloon size, on de novo FP artery disease. Methods A retrospective analysis was performed using data collected from patients who underwent endovascular treatment for FP artery disease between August 2018 and December 2021 at eight institutions. During this period, 549 FP lesions were analyzed, and propensity score matching analysis was performed to compare stepwise and conventional balloon angioplasties. The prognostic value was assessed based on the angiographic dissection pattern, rate of bail‐out stenting, procedural complications, and rate of clinically driven target lesion revascularisation (CD‐TLR) within 1 year. Results Propensity score matching was used to analyze 129 matched pairs of patients. The incidence of severe vessel dissection, defined as Type D or higher, and the rate of bail‐out stenting were significantly higher in conventional balloon angioplasty compared to stepwise balloon angioplasty (24.0% vs. 14.0%, p = 0.04; and 9.4% vs. 3.1%, p = 0.03, respectively). There were no significant differences between the two groups in procedural complications or the rate of CD‐TLR. Conclusion Severe dissection and bail‐out stenting rates were lower after stepwise balloon angioplasty.