Athanasios Saratzis, Lorenzo Patrone, Eric A. Secemsky, Anahita Dua, Hany Zayed, Giovanni Torsello, Isabelle Van Herzeele, Konstantinos Stavroulakis, VPAD collaborators, Athanasios Saratzis, Αθανάσιος Διαμαντόπουλος, Nicola Troisi, Hany Zayed, Edoardo Pasqui, Martin Andrassy, Daniela Branzan, Christopher Twine, Caroline Caradu, Mario D’Oria, Marianne Brodmann, Grigorios Korosoglou, Craig Nesbitt, Christian-Alexander Behrendt, Tania Sáez Gúzman, Michel J. BOSIERS, Jan Stana, Giuseppe Asciutto, Kareem Ep Sherbiny, Raphael Coscas, Marc Sirvent, Daniel Van Den Heuvel, Ahmed Sakr, Jean-Paul de Vries, Eric A. Secemsky, Lorenzo Patrone, Mustapha JA, Bruno Migliara, Ahmed M. Sayed, Jörg Teßarek, Alessandro Ucci, Selim Aydin, Maria Antonella Ruffino, Bernard Peeters, Fadi Saab, James McCaslin, Narayanan Thulasidasan, Matthew Popplewell, Badri Vijaynagar, Peter Mezes, Raghu Lakshminarayan, Konstantinos Tigkiropoulos, Athanasios Giannoukas, Toby Richards, Rajiv Pathak, Patrick Chong, Zahid Khan, Irfan Ahmed, Hari Nair, Efthymios (Makis) Avgerinos, Ankur Thapar, Ruth Benson, Gabriel Lopez, Safa Salim, David Bosanquet, Huw Davies, Shiva Dindyal, Panos Gkoutzios, Lewis Meecham, Ahmad Afify, Stefano Fazzini, Konstantinos Stavroulakis, Michael Lichtenberg, Bahaa Nasr, Gilles Goyault, Rafiuddin Patel, Luca Garriboli, Ralf Dr.Langhoff, Sameh Sayfo, Shagran Binkhamis, Emiliano Chisci, Kumar Madassery, Trisha Roy, Michael Siah, Conrad von Stempel, Theodosios Bisdas, Gioele Simonte, Tomas Baltrūnas, August Ysa, Mark Portou, Giacomo Isernia, Sabine Steiner, Gianmarco de Donato, Gianbattista Parlani, Paul Moxey, Ashish Patel, George Adams, Lieven Maene, Sandip Nandhra, Marta Lobato, Kaji Sritharan
PURPOSE: Peripheral arterial disease (PAD) is a major global health burden often requiring endovascular intervention. Complex lesion morphologies such as calcification or long occlusions limit procedural success. Vessel preparation (VP) techniques, including atherectomy and intravascular lithotripsy, are increasingly adopted, but consensus on their definition, purpose, and clinical role is lacking. The main objective was to define VP in endovascular PAD interventions, determine its primary aims, and identify key barriers and enablers for its adoption in clinical practice. MATERIALS AND METHODS: A modified Delphi process was conducted involving 103 international experts across vascular surgery, interventional radiology, angiology, and cardiology. Two rounds of online surveys and 11 structured interviews were completed, with ≥70% agreement predefined as consensus. Qualitative thematic analysis was used for free-text and interview data. RESULTS: VP was defined as "the initial step in an endovascular procedure to facilitate subsequent interventions by modifying lesion characteristics" (93% agreement). Six core aims were established: luminal gain, improved vessel compliance, plaque/calcification reduction, enhanced drug delivery, reduced complications, and improved technical success. Barriers included high device costs and insufficient evidence. High-level agreement supported VP use in femoropopliteal and popliteal segments, with intravascular lithotripsy preferred for calcified lesions. Imaging recommendations and modality-specific VP guidance were also developed. CONCLUSION: This work provides the first international definition and structured aims of VP in PAD. It identifies practical guidance, barriers to adoption, and priorities for future research. Findings will support standardisation in clinical practice, research, and health policy regarding VP technologies in PAD treatment(s).Clinical ImpactThis international consensus provides the first standardised definition, core aims, and practical guidance for vessel preparation in endovascular treatment of peripheral arterial disease (PAD), enabling more consistent clinical practice, research design, and health policy development worldwide.