Choosing Between Drug-Coated Balloons, Drug-Eluting Stents, and Bypass for Femoropopliteal Disease

An Interview With Mike Watts, MD, FSIR

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VASCULAR DISEASE MANAGEMENT. 2026;23(6):E81-E83

At the 2026 Society of Interventional Radiology Annual Scientific Meeting in Toronto, interventional radiologist Mike Watts, MD, FSIR, from Atlantic Medical Imaging in New Jersey, presented a session exploring one of the most common and consequential questions in peripheral arterial disease treatment: when to use plain old balloon angioplasty (POBA), drug-coated balloons (DCBs), drug-eluting stents (DES), or surgical bypass. Drawing on evolving evidence, advances in vessel preparation, and real-world challenges in access to care, Dr Watts discussed how lesion characteristics, intravascular imaging, and patient-specific factors can guide treatment selection. He also highlighted the impact of health care deserts on clinical decision-making, stating that guideline recommendations for bypass surgery must be viewed through the lens of geographic and socioeconomic realities, particularly in underserved regions where access to vascular surgeons is limited and delays in treatment can increase the risk of limb loss.

Your presentation takes on a common but complex decision point choosing between POBA, DCBs, DES, and bypass. What are the key clinical factors that influence your decision-making in real-world practice? 

Over the past 5 or 10 years as technology has improved and there's been more interest in real-world outcomes and amputation prevention, we have put together a strong body of data about how we should be treating these patients when they have femoropopliteal disease. If you really stick to guidelines, it can inform your decisions and make it easy. What we have decided and figured out over the years is that just balloon angioplasty is not sufficient to treat someone. That treatment was developed in the ‘60s and ‘70s and is not okay for 50 years later, with all the technology we have. So, what we do to decide the best treatment is first, we evaluate the lesion we're treating. Intravascular ultrasound (IVUS) should be used for everyone to really understand what's going on in that lesion, what it consists of, if there's thrombus or how bad the calcium is, whether it's eccentric or concentric, and that changes what we do, but then we can use angioplasty to see how that lesion responds.

If it looks beautiful, the point is we still want to deliver a drug because we want to stop some of the anti-restenotic effect of that angioplasty, so we use a DCB. We can use IVUS to make sure there isn’t any under-expansion, recoil, or dissection, but if it looks good, a DCB is the next step. If after angioplasty there isn’t enough of an effect, there is still significant restenosis, a flow of dissection, under-expansion because of calcium, that's when we are going to use a stent. The stents really should be DES. There is very little room in the guidelines for just self-expanding bare metal stents anymore. We have 2 very good DES that have been in the market for a long time and have excellent data. The only time we change that is if we're in a high-flexion zone toward the knee or in bad calcium where a self-expanding stent may underperform or fracture. We'll use an interwoven nitinol or a biomimetic stent in that area, which will just hold up a lot better in that high-flexion, high-impact zone. That simple algorithm is very data-driven and is applicable to pretty much all the femoropopliteal disease we treat. It comes down to understanding what the lesion is, prepping the lesion for angioplasty, performing the angioplasty and seeing what the results are, and then working your way from there. 

With evolving data, how has your approach in selecting these treatment options changed in recent years, and are there any misconceptions you hope to clarify during your talk?

There has been a lot of drive to understand vessel preparation in the past few years. That means atherectomy, and now increasingly it means intravascular lithotripsy, it means specialty balloon angioplasty. There are multiple different ways to deal with that lesion before we decide what our drug delivery therapy may or may not be.

I think that's really the important part, understanding how different atherectomy devices work, how they interact with different types of lesions and different types of plaque based on the IVUS evaluation, and then how we're going to choose which treatment strategy to deal with a lesion before we move on to a DCB or DES. It really has to be something that each individual operator has to become familiar with, get their hands on the device, see how it actually works in patients, see before and after what their success level and what their results are, and then understand how that helps that vessel prep before we deliver our ultimate therapy. 

When does bypass come into the picture?

Bypass becomes a lot more complicated in a lot of ways. The most recent trial that was done was the BEST-CLI trial. The top-line takeaway from the BEST-CLI trial, is if a patient has chronic limb-threatening ischemia (CLTI) and a good greater saphenous vein that's adequate for bypass, bypass should be the go-to therapy for that patient. That made a lot of news across the vascular world. But there's a lot more in that study that I think we need to look at.

One of the things is that these patients who had bypasses had a very high rate of failed endovascular therapy. If those patients had endovascular therapy that was successful and potentially appropriate, those patients wouldn't have needed to bypass and may have done very well. That failure rate in that study was much higher than most of us really have. So that skews the results a little bit.

Then there’s the BASIL-2 trial, which showed that endovascular therapy may be better long term in the hands of skilled operators than bypass surgery as far as amputation-free survival goes. There is conflicting data, but the biggest problem is when you look at vascular health care deserts: there is 1 vascular surgeon for every 100,000 people in the United States. There are 83% of counties in the United States that do not have a vascular surgeon. That’s 90-some million people, almost a third of the population, who do not have easy access to a vascular surgeon. So, when someone says that the data says get a bypass, well, this patient has CLTI, and they have gangrene, and you are their only provider, and you are not a vascular surgeon. You're an interventional radiologist or a cardiologist. If you just follow the guidelines and say to the patient, you need a bypass, go find a vascular surgeon, the chances are, in much of this country, that patient is not going to find a vascular surgeon. That patient could lose their leg looking for that bypass.

The amputation rates in California vs Mississippi couldn't be more different. If you live in the southeast United States and you're impoverished and in a rural area, you just do not have that access to care. So, these guidelines need to be considered and translated through the spectrum of where you are in the country and what your availability of care is. So yes, we have some guidelines that say bypass should be the first treatment for CLTI with a good saphenous vein, but that is not always available. It is not always the prudent thing to do. As you kind of look deeper into the data, there were many patients at BEST-CLI sites who did not get bypasses and were not included. 

If you also look at the data between bypasses that are done at BEST-CLI sites, at high-volume academic sites, those patients do much better than people who get bypasses at community hospitals. So not all bypasses are the same, not all patients are the same, and certainly not all regions and areas of the country are the same. Bypass is great, and even if it is the superior treatment modality for some of these patients, it does not mean that it's possible, it does not mean that based on the BASIL-2 data. We as endovascular operators can help a patient who otherwise can't get a bypass. n