3.1 Advances in Infrainguinal Interventions for Claudicants: Data Supporting Best Applications for DCBs, DES and Endografts

Problem Presenter: Eric Dippel

These proceedings summarize the educational activity of the 18th Biennial Meeting of the International Andreas Gruentzig Society held January 27 to 30, 2026, in Puerto Ayora, Santa Cruz, Ecuador.

Faculty Disclosures     Sponsors

2026 IAGS Summary Document

Statement of problem or issue

• Claudication is more than a symptom
  • Age dependent, lifestyle-limiting, associated with higher mortality (3-5x)
  • Impacts social, personal, and occupational activities
  • SF-36 Quality-of-Life questionnaire
    • Patients with claudication perceive themselves worse than patients with severe migraines and on par with NYHA class 3 CHF patients
  • Leads to continued functional decline
  • Exists on the continuum and scale of a progressive disease
• Public awareness is abysmal
• Current guidelines are based on dogma, not data
  • Data demonstrate that interventions on claudicants improves functional outcomes, quality of life, lowers amputation rates, and lowers mortality rates
• The field of vascular medicine is multi-disciplinary and extremely heterogenous
  • No consensus among different specialties on treatment strategies, particularly open surgical vs endovascular approaches
  • There are “Turf Wars” among specialities
  • Attitudes often resemble religion (religious dogma) and religious disagreements
• Variable Training/Operator Experience in different specialties
  • Device selection
  • CTO crossing abilities
  • Alternative access skills
• The heterogeneities and disagreements dramatically affect patient access to care and also physician reimbursement
  • Interventionalists are often ostracized for treating claudicants and excluded from the narrative
  • Insurance companies deny payment for treating claudicants
  • Early vs later stage treatment
    • Do we deny women therapy for stage 1 breast cancer because they are not “sick enough” and therefore should wait for the disease to progress?

Gaps in current knowledge

• Surgical data and Endovascular data are not comparable
  • Definition of surgical graft patency (open vs closed, 100% vs <100%)
  • Definition of endovascular patency (<50% vs >50%)
• Historical dogma, with very little randomized data, drives vascular disease guidelines
  • PTA fails against all modalities, but remains the preferred treatment strategy
  • Tibial intervention remains forbidden
    • Yet, large atherectomy trials and randomized DES studies demonstrate positive data for intervention[1,2]
    • The Trans-Atlantic Inter-Society Consensus (TASC) did not even have a tibial classification system until 2015
  • Ignoring Good Data is worse than using Bad Data which is worse than No Data
• We do not have “best-endovascular” versus “best-surgery” data
  • There is no CREST-2 for peripheral intervention versus medical management [3]

Possible solutions or future directions

• Endovascular societies need to take a stronger stance
• Inter-Disciplinary Cooperation
• More rigorous physician training and education
  • Cross-training surgical and endovascular Fellows
  • We need more physicians!
• CREST-2[3]
  • Do we need a mega-randomized trial of state-of-the-art surgical therapy vs endovascular therapy vs medical therapy?
• Is there any possibility for AI to solve this problem?

References

1. Giannopoulos S, et al. Three-year outcomes from the LIBERTY 360 study of endovascular interventions for peripheral artery disease stratified by rutherford category. J Endovasc Ther. 2021;28(2):262-274. doi: 10.1177/1526602820962972. Epub 2020 Oct 5. PMID: 33016805.
2. Cui HJ, Wu YF. The efficacy of drug-coated balloons and drug-eluting stents in infrapopliteal revascularization: A Meta-analysis. J Endovasc Ther. 2025;32(6):1799-1820. doi: 10.1177/15266028231222385. Epub 2024 Jan 6. PMID: 38183240.
3. Brott TG, et al; CREST-2 Investigators. Medical Management and Revascularization for Asymptomatic Carotid Stenosis. N Engl J Med. 2026;394(3):219-231. doi: 10.1056/NEJMoa2508800. Epub 2025 Nov 21. PMID: 41269206.