Vessel preparation concepts in modern vascular medicine Current evidence, fields of application and limitations

Despite rapid advancements in recent years, endovascular treatment of peripheral arteries still has limitations, with the risk of restenosis being a major one. To combat this, drug-coated balloons (DCB) were introduced which, however, also have their own limitations, especially in heavily calcified arteries. Vessel preparation is a group of procedures used before the definitive treatment with DCB or drug-eluting stents (DES) to remove or modify part of the atherosclerotic plaque (debulking) and thus minimize the risk of flow-limiting dissections after angioplasty as well as facilitating increased drug-uptake of the arterial wall. Various atherectomy devices, special balloon catheters (scoring, cutting and minimally traumatic balloons) and endovascular lithotripsy play an important role in vessel preparation with promising results; however, these treatment modalities are not without their limitations and risks, including high purchasing costs, a steeper technical learning curve and possible complications that often require bail-out measures. The aim of this article is to present an overview of the currently available data from the literature on vessel preparation, with the corresponding indications, goals, and limitations of these treatment modalities.