Editorial
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Nov 26, 2018; 10(11): 196-200
Published online Nov 26, 2018. doi: 10.4330/wjc.v10.i11.196
Revisiting endovascular treatment in below-the-knee disease. Are drug-eluting stents the best option?
Stavros Spiliopoulos, Panagiotis M Kitrou, Elias N Brountzos
Stavros Spiliopoulos, Elias N Brountzos, 2nd Radiology Department, Interventional Radiology Unit, University of Athens, Attikon University General Hospital, Athens 12461, Greece
Panagiotis M Kitrou, Department of Interventional Radiology, Patras University Hospital, Patras 26500, Greece
Author contributions: Spiliopoulos S conceived the study and made critical revisions to its content; Kitrou PM drafted the manuscript and made critical revisions to its content; Brountzos EN drafted the manuscript and made critical revisions to its content; All authors approved the final version of the article.
Conflict-of-interest statement: The authors have no conflict of interest to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author to: Stavros Spiliopoulos, MD, PhD, Assistant Professor, 2nd Department of Radiology, Division of Interventional Radiology, National and Kapodistrian University of Athens, School of Medicine, Attikon University General Hospital, Athens 12461, Greece. stavspiliop@med.uoa.gr
Telephone: +30-693-7403468
Received: July 12, 2018
Peer-review started: July 12, 2018
First decision: August 2, 2018
Revised: August 14, 2018
Accepted: October 11, 2018
Article in press: October 12, 2018
Published online: November 26, 2018
Abstract

Patients with below-the-knee arterial disease are primarily individuals suffering from critical limb ischemia (CLI), while a large percentage of these patients are also suffering from diabetes or chronic renal failure or both. Available data from randomized controlled trials and their meta-analysis demonstrated that the use of infrapopliteal drug-eluting stents (DES), in short- to medium- length lesions, obtains significantly better results compared to plain balloon angioplasty and bare metal stenting with regards to vascular restenosis, target lesion revascularization, wound healing and amputations. Nonetheless, the use of this technology in every-day clinical practice remains limited mainly due to concerns regarding the deployment of a permanent metallic scaffold and the possibility of valid future therapeutic perspectives. However, in the majority of the cases, these concerns are not scientifically justified. Large-scale, multicenter randomized controlled trials, investigating a significantly larger number of patients than those already published, would provide more solid evidence and consolidate the use of infrapopliteal DES in CLI patients. Moreover, there is still little evidence on whether this technology can be as effective for longer below-the-knee lesions, where a considerable number of DES is required. The development and investigation of new, longer balloon-expanding or perhaps self-expanding DES could be the answer to this problem.

Keywords: Critical limb ischemia, Infrapopliteal arterial disease, Drug-eluting stents, Peripheral arterial disease, Balloon angioplasty

Core tip: The use of infrapopliteal drug-eluting stents (DES) remains limited in clinical practice mainly due to concerns regarding the deployment of a permanent metallic scaffold and the possibility of valid future therapeutic perspectives. However, these concerns are not scientifically justified. Large-scale, multicenter randomized controlled trials investigating a significantly larger number of patients would consolidate the use of infrapopliteal DES in critical limb ischemia patients. Moreover, there is still little evidence on whether this technology can be as effective for longer lesions, where a considerable number of DES is required. The development and investigation of longer balloon-expanding or self-expanding DES could solve this problem.