Commentary: Identifying the Best Device for Infrapopliteal Revascularization Through Quantitative Evidence Synthesis

Our mind always struggles with making sense of apparent confusion in order to eventually bring us some intelligible order. However, a correct conceptual framework cannot always be achieved unless we opt for oversimplification. Endovascular specialists treating patients with infrapopliteal artery disease face the challenge of first safely approaching the below-the-knee district, then successfully and safely recanalizing often challenging lesions, and finally the additional hurdle of correctly choosing and employing the most appropriate device to maximize shortand longterm results. Indeed, a plethora of techniques and devices are already available for infrapopliteal revascularization, from atherectomy to balloon angioplasty (BA), drug-coated balloons (DCB), bare metal stents (BMS), drug-eluting stents (DES), and bioresorbable vascular scaffolds (BVS). All too often, device choice is largely based on the knowledge base of the operator together with his or her own experience and set of skills with the chosen device. While the latter aspects are beyond the scope of our present contribution, it is important to maintain an updated and comprehensive knowledge base on the clinical evidence regarding devices for infrapopliteal revascularization to avoid undermining an apparently successful procedure with a poorly chosen device. The December 2016 issue of the JEVT provides an important adjunct to the biomedical literature focusing on infrapopliteal revascularization, thanks to the original contribution by Katsanos et al. Specifically, they report a systematic review and meta-analysis comparing different devices for infrapopliteal endovascular therapy. They included 16 randomized controlled trials (RCTs) totaling almost 2000 patients and employed state-of-the-art analytical models that can pool head-to-head comparisons, as well as borrow information from indirect comparisons within a network meta-analytic framework. Without focusing on the subtleties of this relatively novel statistical method, we may acknowledge that, providing several important assumptions are met, network meta-analysis is currently considered among the most comprehensive, reliable, and precise approaches for quantitative evidence synthesis. In order to provide a contemporary synthesis to guide endovascular practice, Katsanos and colleagues focused on RCTs comparing BA, DCB (all paclitaxel-eluting), BMS, and DES to demonstrate a clinical effect on several clinically relevant and objective outcomes, such as restenosis, target lesion revascularization (TLR), wound healing, and limb salvage. They intriguingly found that DES proved most likely to be beneficial for all endpoints, followed by DCB, BA, and BMS, typically (but not invariably) in decreasing order of efficacy. In particular, DES appeared capable of reducing the odds (ie, the number of patients with an event divided by the number of patients without the event, which is considered a reasonable approximation of risk) of restenosis by 56% in comparison 672122 JETXXX10.1177/1526602816672122Journal of Endovascular TherapyGiordano et al research-article2016