Predictors of restenosis after drug-coated balloon angioplasty for femoropopliteal chronic total occlusion lesions

BACKGROUND: Drug-coated balloons (DCBs) are widely used in endovascular therapy. While dissection angle and minimum lumen area (MLA) assessed by intravascular ultrasound (IVUS) are known predictors of restenosis, their specific role after DCB angioplasty remains to be fully elucidated. We aimed to identify predictors of restenosis following DCB angioplasty using IVUS findings. METHODS: We retrospectively enrolled 36 peripheral artery disease patients undergoing DCB angioplasty (Jan 2021-Dec 2023). We evaluated IVUS images post-guidewire and post-DCB at 3-cm intervals, classifying cross-sections by MLA/external elastic membrane area (EEMA) ratio: > 50%, 40%-50%, and < 40%. Primary patency at 1 year post-DCB was the primary outcome. Restenosis was objectively determined by a peak systolic velocity ratio of 2.4 on duplex ultrasound, and assessing each cross-sectional images. RESULTS: A total of 262 cross-sectional images were acquired and subsequently classified into three distinct groups based on their MLA/EEMA ratio: > 50% (n = 125), 40%-50% (n = 85), and < 40% (n = 52). All guidewires passed through the intraplaque route. Primary patency was significantly higher in the MLA/EEMA > 50% group (94.0% vs. 84.2% vs. 73.3%, log-rank p = 0.005). Specifically, for dissection angles > 60°, patency was markedly better in the MLA/EEMA > 50% group (93.3% vs. 75.0% vs. 55.6%, log-rank p = 0.03). Dissection angles < 60° showed no significant patency differences (93.9% vs. 88.0% vs. 84.2%, log-rank p = 0.14). CONCLUSIONS: The MLA/EEMA ratio and the degree of dissection angle may be predictors of primary patency following DCB angioplasty. These findings suggest that optimized vessel preparation strategies can effectively mitigate the adverse clinical impact of dissection.