ACHILLES and the Achilles Heel of Peripheral Vascular Intervention.

SEE PAGE 259 I n contrast to coronary artery disease in which a robust collection of data has demonstrated the merits of percutaneous revascularization, research investigating peripheral vascular intervention (PVI) has not yet matured in terms of magnitude, quality, or clarity. For example, only 1 randomized trial has assessed the efficacy of PVI relative to surgical bypass in patients with critical limb ischemia (CLI). That study was published more than 1 decade ago, and it examined what is now considered to be a rudimentary endovascular technique (e.g., balloon angioplasty [PTA]) (1). Many technologies such as drug-coated balloons, drug-eluting stents (DES), and atherectomy devices have been developed in recent years to treat peripheral artery disease (PAD). However, randomized trials comparing the performance of these novel innovations against each other are largely lacking, and the PVI published data has become inundated with small observational data sets of suboptimal scientific value. Moreover, procedural success rates for PVI are exceptional, even in the most complex lesion subsets, but technical success and even long-term vessel patency do not always translate into meaningful clinical benefits for patients (2). As such, the lingering dilemma for clinicians performing PVI is no longer “can I open this artery?” but rather “how should I treat this artery and how will I define success?” Answers to the latter, the Achilles heel of PVI, remain unclear. Within this framework, in this issue of JACC: Cardiovascular Interventions Katsanos et al. (3) report the