Optimal endovascular strategy for femoropopliteal claudication and infrapopliteal CLTI: a network meta-analysis stratified by lesion length.

While numerous endovascular technologies exist for lower extremity arterial disease (LEAD), evidence guiding device selection based on lesion length is limited. We therefore conducted a network meta-analysis to compare the efficacy of contemporary endovascular therapy (EVT) strategies, stratified by clinical presentation and lesion length. Following PRISMA guidelines (PROSPERO: CRD420251031338), we searched major databases for randomized controlled trials (RCTs) comparing nine contemporary endovascular therapy (EVT) modalities for femoropopliteal intermittent claudication (IC) or infrapopliteal chronic limb-threatening ischemia (CLTI). Analyses were stratified by lesion length (short vs. long) for each clinical subgroup. Primary outcomes were primary patency, target lesion revascularization (TLR), major amputation and all-cause mortality at multiple follow-up intervals. Seventy seven RCTs involving 11,788 patients were included. For short femoropopliteal IC lesions (≤ 73.0 mm), drug-coated balloon (DCB) and covered stent were most effective for maintaining patency. For long femoropopliteal lesions (> 73.0 mm), atherectomy with DCB (AT-DCB) and drug-eluting stent (DES) demonstrated superior patency. In short infrapopliteal CLTI lesions (≤ 44.1 mm), DES provided the most consistent benefits in both patency and freedom from TLR. For long infrapopliteal lesions (> 44.1 mm), AT-DCB was the most effective strategy for improving primary patency. Importantly, no significant differences in major amputation or mortality were detected among strategies in most subgroups. The optimal endovascular strategy for LEAD appears to be highly dependent on lesion length, supporting a shift towards a more individualized treatment strategy.