Comparative Efficacy of Endovascular Interventions for Peripheral Artery Disease: A Systematic Review and Network Meta-Analysis.

PURPOSE: To compare the long-term efficacy of percutaneous transluminal angioplasty (PTA), bare-metal stents (BMS), drug-coated balloons (DCB), and drug-eluting stents (DES) for femoropopliteal peripheral artery disease (PAD). MATERIALS AND METHODS: A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing BMS, DES, DCB, and PTA for femoropopliteal PAD was performed. MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and INAHTA were searched from inception to February 2024. Primary outcomes were target lesion revascularization (TLR) and primary patency. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS: Thirty-three RCTs involving 7132 participants were included. At 12 months, DCB (OR: 0.27 [95% CI 0.19-0.38]), BMS (OR: 0.28 [95% CI 0.14-0.56]), and DES (OR: 0.30 [95% CI 0.14-0.62]) reduced the odds of TLR compared with PTA. Similar reductions were observed at 24 months. At 36 months, DCB (OR: 0.50 [95% CI 0.25-0.97]) and DES (OR: 0.33 [95% CI 0.14-0.75]) reduced the odds of TLR compared with PTA. Primary patency followed a comparable trend, with DES producing the highest odds of patency at 12 months (OR: 3.81 [95% CI 2.21-6.57]), followed by DCB and BMS compared to PTA, and all three remained significant through 36 months. CONCLUSIONS: For femoropopliteal PAD, DES, DCB, and BMS reduced the odds of TLR and improved the odds of primary patency compared with PTA. Drug-based technologies showed the most durable efficacy signal; however, long-term DES estimates should be interpreted cautiously because direct DES-versus-PTA evidence was sparse and several comparisons relied on indirect evidence. LEVEL OF EVIDENCE: Level 1, Systematic Reviews.