Shifting Paradigms in Below-the-Knee Interventions

Recent advancements in drug-eluting stent (DES) technology are reshaping the treatment landscape for below-the-knee (BTK) lesions, delegates heard this afternoon when Elena Herrero, MD, from Jaén University Hospital in Spain, highlighted how emerging evidence supports a shift from DES as a bailout strategy to a primary treatment option in select cases.
 
Studies like DESTINY-I have demonstrated significantly better primary patency rates with DES compared to bare-metal stents (BMS) in BTK lesions, underscoring their growing role in primary interventions. “I believe that the primary use of stents should be indicated in calcified lesions, especially in diabetic patients or bifurcations,” Dr Herrero told LINC Today. However, she emphasized that primary stenting should focus on DES, not BMS.

Clinical trials, such as ACHILLES, have shown that sirolimus-eluting stents outperform standard angioplasty in tibial artery disease. Dr Herrero pointed to these findings as pivotal for evolving treatment strategies: “In heavily calcified lesions at the origin of the tibial arteries, the use of DES has better outcomes than standard angioplasty. Perhaps in this type of lesion, we should consider the primary use of stents.” 

While long-term data from studies like Giaquinta et al report promising 3-year patency and limb salvage rates with everolimus-eluting stents, Dr Herrero highlighted a critical focus: “When we talk about critical limb ischemia, the most important thing is limb salvage, independent of the durability or patency of the procedure.” 

In SPORTS, the authors revealed superior performance of the Eluvia DES (Boston Scientific) compared to both BMS and drug-coated balloons in complex femoropopliteal lesions. For Dr Herrero, she anticipates similar advantages in BTK interventions, especially in heavily calcified lesions. “We are increasingly using vessel preparation devices, such as atherectomy or intravascular lithotripsy, which will contribute to better outcomes in DES treatment,” she noted. 

Indeed, she underscored the importance of procedural preparation in maximizing DES success in BTK revascularization. “The preparation of the vessel prior to stent implantation and the use of intravascular ultrasound for correct diameter and length measurement from healthy area to healthy area are very important for good results,” she explained. 

As drug-eluting technology evolves, Dr Herrero also highlighted the increasing use of limus-eluting stents, which have shown superior benefits over paclitaxel-coated devices in studies and meta-analyses. “We will see if more studies confirm these results,” she added. 

On the other hand, as DES platforms become more widely adopted for complex BTK disease, Dr Herrero remains cautious about overextending their use. “As long as the vessel preparation is correct and we cover the entire lesion, our results will improve. However, my view is that we should not extend the use of DES to very large lesions,” she advised.