Brave New World

Dr. Rastan and colleagues are to be congratulated for performing a well designed multicenter, prospective, randomized controlled trial comparing primary stenting with provisional stenting for moderate length (~42 mm) popliteal artery stenoses in primarily claudicators (79%) with one third having total occlusions (REF). 1 The Endovascular Treatment of Atherosclerotic Popliteal Artery Lesions - Balloon Angioplasty versus primary Stenting (ETAP) trial confirms, for what seems to be the "bazillionth" time, that provisional stenting, properly performed, achieves equal functional and patency outcomes as primary stenting. This has been shown for femoral lesions in multiple trials that often included lesions extending into the popliteal artery, and now it has been shown for the isolated popliteal disease. Although not reported in this paper, we would expect a cost analysis to demonstrate that provisional stenting, for appropriate indications, would be "resource sparing" compared to primary stenting. The popliteal segment was thought to be a hostile environment for stents due to repeated flexion, extension, and torsion at the knee joint, but this trial and others have dispelled that myth. As always there is the caveat that total occlusions, and longer more complex lesions, are more difficult to treat with endovascular techniques. This was confirmed by ETAP with a multivariate logistic regression analysis revealing that target lesion length [ 60mm lesion length; Odds ratio (OR): 0.26; Confidence interval (CI): 0.09-0.68; P=0.007], and total occlusions (stenosis versus occlusion; OR: 0.39; CI: 0.18-0.87; P=0.02) as independent predictors of restenosis.