Initial Application of Excimer Laser Atherectomy for Femoropopliteal Thromboangiitis Obliterans: Preliminary Results and Exploratory Comparison With Balloon Angioplasty

INTRODUCTION: Long-segment femoropopliteal thromboangiitis obliterans (TAO) causes severe limb ischemia and remains challenging to treat, particularly given the poor distal runoff. Evidence regarding excimer laser atherectomy (ELA) for these complex lesions remains limited. MATERIALS AND METHODS: This single-center retrospective study included 50 male patients with Rutherford category 5 TAO and femoropopliteal occlusions treated between January 2016 and October 2024. The primary analysis focused on the ELA-assisted angioplasty cohort (n = 34), while patients treated with balloon angioplasty alone (n = 16) served as an exploratory comparator. Outcomes included technical success, perioperative complications, 12-month freedom from major adverse limb events (f-MALEs), primary patency, ulcer healing, and symptom improvement. RESULTS: In the ELA cohort, technical success was achieved in 97.1% of patients, with no vessel perforation, clinically significant distal embolization, or acute limb ischemia. At 12 months, f-MALE, primary patency, and ulcer healing rates were 61.8%, 52.9%, and 79.4%, respectively. In the exploratory comparison, despite longer femoropopliteal lesions, ELA showed numerically higher f-MALE and primary patency rates than balloon angioplasty alone, although the overall between-group differences were not statistically significant. A post hoc 3-month landmark analysis suggested possible time-dependent separation of the f-MALE curves, but this finding was hypothesis-generating only. Exploratory secondary outcomes also suggested potentially more favorable pain-relief and ulcer-healing patterns with ELA. No clear incremental clinical benefit of drug-coated balloon use was observed in descriptive analyses. CONCLUSION: In this initial single-center experience, ELA-assisted angioplasty appeared feasible and procedurally safe for Rutherford category 5 femoropopliteal TAO. These encouraging findings support further prospective evaluation in larger cohorts.Clinical ImpactExcimer laser atherectomy (ELA) was associated with a high procedural success rate of 97.1% and no severe intraoperative or perioperative complications in this initial cohort. For clinicians, ELA may represent a feasible endovascular debulking option for selected patients with complex femoropopliteal thromboangiitis obliterans. Single-arm outcomes were encouraging regarding f-MALE, pain relief, and ulcer healing. Exploratory comparisons with percutaneous transluminal angioplasty alone suggested possible favorable clinical patterns, but these findings were not adjusted for multiple comparisons and require confirmation in larger prospective studies.