Clinical Efficacy of Different Endovascular Approaches in Femoropopliteal Artery Disease with Moderate-to-Severe Calcification: A Meta-Analysis.

OBJECTIVE: To systematically evaluate the overall clinical outcomes of endovascular treatment in patients with peripheral artery disease (PAD) presenting with moderate-to-severe calcification of the femoropopliteal artery, and to descriptively summarize reported outcomes across different endovascular treatment strategies. METHODS: A systematic search was conducted in PubMed, Scopus, Embase, the Cochrane Central Register, and Web of Science Core Collection from database inception to July 2026 to identify studies related to endovascular treatment in patients with moderate-to-severe calcified PAD of the femoropopliteal artery. The primary outcome measures included the 12-month primary patency rate and freedom from clinically driven target lesion revascularization (f-CD-TLR). RESULTS: A total of 13 studies were finally included. The overall analysis showed that the pooled effect size of the 12-month primary patency rate after endovascular treatment was 83.8%, and the pooled effect size of f-CD-TLR was 90.7%. Sensitivity analysis confirmed the high stability of the conclusions. Subgroup analyses, stratified by treatment strategy and presented in a neutral technology-based order, showed the following descriptive estimates: stent-based strategies (primary patency: 83.0%; f-CD-TLR: 87.12%), atherectomy-based strategies (86.66% and 96.58%), and IVL-based strategies (82.75% and 89.2%). These subgroup estimates should be interpreted descriptively and should not be considered comparative rankings or evidence of superiority of one treatment strategy over another. No significant publication bias was detected; however, the reliability of these assessments may be limited in subgroups with a small number of studies. CONCLUSION: Endovascular treatment can achieve acceptable short-term outcomes in patients with moderate-to-severe calcified femoropopliteal artery disease. Descriptive subgroup analyses demonstrated variation in reported outcomes across treatment strategies. Given the limited availability of head-to-head comparisons, further high-quality comparative studies between different devices are warranted to better define their relative efficacy.