Long Femoropopliteal Lesions Challenge the Limits of Endovascular Technique: Contemporary Systematic Review and Meta-analysis

Background: Traditionally, patients with symptomatic femoropopliteal artery occlusive disease have been treated surgically. However, a growing body of clinical evidence has emerged supporting endovascular treatment in patients with long lesions. The objective of this systematic search and meta-analysis was to assess contemporary outcomes in patients undergoing endovascular treatment for long femoral-popliteal lesions. Methods: An updated systematic search of Embase, including MEDLINE, identified relevant records published between January 2000 and March 2023 reporting a minimum of 1-year follow-up of endovascular revascularization in patients with mean lesion length ≥20 cm. A pooled meta-analysis was performed using a random-effects model for all longitudinal cumulative event rates. Subgroup analyses explored stratification by lesion length, intervention, study design, and outcome definition. Quality of evidence and risk of bias assessments were conducted. Results: A total of 28 records, 2338 limbs, and 2311 patients, were analyzed. The pooled cumulative event rates (95% CI) for primary patency were as follows: 0.85 (95% CI, 0.81-0.89), 0.67 (95% CI, 0.61-0.73), 0.48 (95% CI, 0.38-0.57), and 0.42 (95% CI, 0.33-0.52); secondary patency: 0.90 (95% CI, 0.85-0.93), 0.84 (95% CI, 0.77-0.89), 0.72 (95% CI, 0.64-0.78), 0.63 (95% CI, 0.52-0.73); and freedom from target lesion revascularization: 0.93 (95% CI, 0.89-0.96), 0.79 (95% CI, 0.74-0.83), 0.68 (95% CI, 0.62-0.73), and 0.63 (95% CI, 0.57-0.69) at 6, 12, 24, and 36 months, respectively. Select subgroup analyses showed clinically relevant variation in event rates. Conclusions: This systematic search and meta-analysis provides important insight into the performance of endovascular revascularization in patients with long lesions. These findings will need to be considered as treatment decisions are made.