Territory- and Lesion-Specific Endovascular Strategies in Lower Limb Peripheral Artery Disease: A Cohort Study

(1) Background: Endovascular therapy is widely used for lower limb peripheral artery disease (PAD), yet device performance varies across vascular territories due to anatomical and biomechanical differences. This study evaluated territory- and lesion-specific outcomes following contemporary endovascular strategies in a real-world cohort. (2) Methods: This retrospective single-center study included consecutive patients undergoing endovascular revascularization of the iliac, superficial femoral (SFA), or popliteal arteries between 2010 and 2023. The primary endpoint was 12-month binary restenosis (≥50% diameter loss) assessed by duplex ultrasonography, CT angiography, or invasive angiography. Secondary outcomes included target lesion revascularization and procedural complications. Kaplan-Meier analysis was used to evaluate restenosis-free survival. Multivariable Cox models were constructed separately for each vascular territory, adjusting for relevant clinical and anatomical covariates. (3) Results: A total of 283 lesions were included (iliac <i>n</i> = 135; SFA <i>n</i> = 145; popliteal <i>n</i> = 102). At 12 months, restenosis rates differed substantially by treatment modality and arterial territory. In the iliac segment, covered stents demonstrated the lowest restenosis (12.8%), whereas in the SFA, interwoven nitinol stents yielded the most favorable profile (15.4%). In the popliteal artery, drug-coated balloons were associated with the lowest restenosis rate (16.7%). In multivariable analysis, covered stents (iliac), interwoven nitinol stents (SFA), and drug-coated balloons (popliteal) were independently associated with lower restenosis risk. Procedural success was high and complication rates were low. (4) Conclusions: Endovascular device performance is strongly influenced by arterial territory and lesion characteristics. Tailoring the treatment strategy to vessel biomechanics and lesion morphology may optimize mid-term patency in lower limb PAD. Larger prospective studies are warranted to validate these findings.