Endovascular Treatment Modalities for Infrapopliteal Artery Disease: A Bayesian Network Meta-Analysis with Exploratory Evaluation of Retrievable Scaffold Therapy

BACKGROUND: Endovascular options for infrapopliteal artery disease include plain balloon angioplasty (PTA), drug‑coated balloons (DCB), drug‑eluting and bare‑metal stents (DES), and atherectomy. Retrievable scaffold therapy (RST) has recently emerged as a temporary scaffolding strategy used with DCB, but its comparative effectiveness remains uncertain. METHODS: A comprehensive literature search identified 21 randomized and 4 single‑arm trials (n = 3184). Eligible studies reported at least one prespecified outcome: 30‑day major adverse events (MAE), 12‑month all‑cause mortality, 6‑month clinically driven target lesion revascularization (CD‑TLR), or 6‑month major amputation. Random‑effects models generated odds ratios (ORs) with 95% credible intervals (CrIs). SUCRA values summarized treatment rankings. RESULTS: Atherectomy ranked best for 30‑day MAE (SUCRA 77.2%), though no treatment yielded a statistically significant reduction in the Odds Ratio. It was also associated with a significantly reduced 12‑month mortality versus PTA (OR 0.39, 95% CrI 0.15-0.90; SUCRA 97.8%). For 6‑month CD‑TLR, atherectomy (OR 0.26, 95% CrI 0.00-0.62), DCB (OR 0.42, 95% CrI 0.30-0.58), and DES (OR 0.43, 95% CrI 0.19-0.88) showed significant benefit. No treatment significantly reduced major amputation. RST showed favorable but nonsignificant reductions, indicating a smaller number of available studies, consistently ranking mid‑tier across all outcomes. Meta‑regression identified CKD and longer lesion length as predictors of higher CD‑TLR risk. CONCLUSIONS: Atherectomy showed the most consistent benefits across mortality and reintervention outcomes, while RST demonstrated promising but inconclusive performance. Larger randomized trials are needed to clarify RST's role in infrapopliteal revascularization.