Clinical outcomes of directional atherectomy versus plain balloon angioplasty as vessel preparation prior to drug-coated balloon treatment for femoropopliteal occlusive disease.

This retrospective multicenter cohort study from the PROMISING registry compared directional atherectomy (DA) and plain old balloon angioplasty (POBA) as vessel preparation before drug-coated balloon (DCB) therapy for femoropopliteal occlusive disease. After propensity score matching, 147 DA-treated and 480 POBA-treated patients were analyzed with well-balanced baseline characteristics. DA markedly reduced the need for stent implantation (8.8% vs. 20.4%) and shortened total stent length, while allowing subsequent use of larger-diameter DCBs. Major peri-operative complications were rare in both groups, but minor complications were more frequent after DA. Postoperative ankle-brachial index and Rutherford classification improved significantly in both groups, without intergroup differences. During 24-month follow-up, Kaplan-Meier analysis showed no significant differences between DA and POBA in all-cause mortality, clinically driven target lesion revascularization, amputation-free survival, or major adverse limb events. Subgroup analyses revealed that patients with chronic total occlusion (CTO) derived greater benefit from DA, with a significant interaction (P for interaction = 0.002), whereas outcomes were consistent across other subgroups. Overall, DA before DCB therapy effectively reduces stent use and enhances vessel preparation without compromising long-term efficacy or safety, supporting its selective application in complex femoropopliteal lesions, particularly those with CTO.