ISR management: debulking plus DCB in complex femoropopliteal disease

In this PVI expert commentary, Prof. Grigorios Korosoglou discusses a prospective two-centre study evaluating a combined strategy of rotational thrombectomy and drug-coated balloon angioplasty for complex femoropopliteal in-stent restenosis and occlusions. 

Despite the central role of stents in peripheral interventions, stent failure remains a frequent long-term limitation, with high rates of restenosis reported over time. In this context, debulking before drug delivery aims to address key challenges such as high thrombotic burden and limited luminal gain in complex lesions, where DCB therapy alone may be insufficient. 

Including 215 patients with long, often occlusive lesions and advanced disease severity, the study demonstrates high procedural success, substantial lumen gain, and a favourable safety profile with very low complication rates and no major adverse events. 

At 12 months, primary patency reached 79.2%, with high freedom from clinically driven target lesion revascularisation, supporting the value of a stepwise approach in selected patients. 

Prof. Korosoglou also highlights predictors of restenosis and underscores the need for further comparative studies against alternative strategies such as covered stents, bypass surgery, and other debulking techniques.

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