Advances in Endovascular Therapy for Infrainguinal Peripheral Arterial Disease: Devices and Outcomes

Abstract The management of infrainguinal peripheral arterial disease (PAD) has undergone a remarkable transformation over the past two decades, driven by rapid innovation in drug delivery systems, plaque-modifying technologies, intravascular imaging, and minimally invasive bypass alternatives. This review summarizes contemporary advances in endovascular therapy and highlights the clinical evidence supporting each major device category. Drug-coated balloons and drug-eluting stents remain foundational technologies in treating PAD. Paclitaxel-coated platforms have demonstrated durable reductions in target lesion revascularization in multiple randomized trials, while sirolimus-based devices have recently emerged as viable alternatives. The LIFE-BTK trial established the first everolimus-eluting scaffold with proven improvements in restenosis among patients with chronic limb-threatening ischemia. Equally transformative has been the evolution of lesion-preparation strategies. Atherectomy, scoring balloons, and intravascular lithotripsy (IVL) have improved vessel compliance, reduced recoil, and optimized drug uptake, particularly in heavily calcified lesions. Among these, IVL has gained rapid global adoption due to its safety profile and ability to modify deep calcium using low-pressure balloon inflation. The 355-nm laser and contemporary orbital atherectomy systems have expanded treatment options for complex, long, calcified, and below-the-knee lesions. Intravascular ultrasound (IVUS) consistently outperforms angiography in vessel sizing, dissection detection, and optimization of stent deployment. Multiple large registries and randomized trials have demonstrated significant improvements in patency, limb salvage, and clinical outcomes with IVUS-guided therapy. Finally, the fully percutaneous DETOUR bypass system offers a novel alternative for patients with long-segment femoropopliteal occlusions who are poor surgical candidates. This stent-based bypass technique has shown promising mid-term patency, high limb salvage rates, and low deep-vein thrombosis incidence. Collectively, these advances underscore the importance of individualized, multimodal endovascular therapy that aims to leave the least amount of metal behind while maintaining good long-term outcomes. Ongoing randomized trials and long-term data will continue to sharpen best practices and define the optimal role of each technology in treating complex PAD.