Principles of Vessel Preparation - A Review

Background: Vessel preparation (VP) has emerged as a cornerstone of contemporary endovascular intervention, particularly in calcified and complex lesions where balloon angioplasty and stenting alone yield suboptimal results. Necessity & Site-wise Applicability: VP facilitates drug transfer to the vessel wall for drug-coated balloons (DCB) and drug-eluting bioresorbable scaffolds (BRS), improves luminal gain, and optimizes stent expansion/apposition. It is critical in “no-stent zones” such as the popliteal fossa, infra-popliteal vessels, and across the inguinal ligament, and reduces distal embolization, acute recoil, and stent malapposition in stented segments. Types of VP & Atherectomy: Techniques include priming angioplasty, specialty balloons, atherectomy, and intra-vascular lithotripsy (IVL). Atherectomy is broadly classified into focal (directional) and circumferential (rotational, orbital, laser). Jack of All Trades: Atherectomy devices extend beyond debulking to vessel crossing, thrombectomy, and in-situ fenestration during complex aortic work. Future Directions: With increasing adoption of woven/braided stents and distal embolic protection, the role of VP devices continues to evolve, balanced against availability and cost.