Peripheral artery disease (PAD) remains one of the most prevalent yet underrecognized manifestations of systemic atherosclerosis, affecting more than 200 million individuals worldwide and contributing significantly to cardiovascular morbidity, impaired functional capacity, limb loss, and mortality. Despite its global burden, PAD is frequently diagnosed late, often after the onset of functional decline or advanced ischemic complications. This paradox reflects the complex and multifactorial nature of PAD, which encompasses not only macrovascular obstruction but also microvascular dysfunction, skeletal muscle pathology, and systemic metabolic derangements. Accordingly, contemporary PAD management has evolved beyond a purely revascularization-focused paradigm toward a comprehensive, patient-centered model integrating prevention, early detection, imaging, medical therapy, rehabilitation, and advanced interventions.

This special issue of the International Journal of Angiology brings together a diverse and highly relevant collection of manuscripts that collectively illustrate the rapid evolution of vascular medicine. These contributions span epidemiology, diagnostics, imaging, pharmacotherapy, mechanistic insights, digital innovation, endovascular technologies, and systems-based care models, highlighting the multidimensional transformation currently underway in PAD management.

A central theme emerging from this issue is the ongoing refinement of endovascular therapy, which continues to redefine the treatment landscape for infrainguinal disease. In a comprehensive review, Shammas provides an in-depth synthesis of contemporary advances in endovascular technologies, including drug-coated balloons, drug-eluting stents, intravascular lithotripsy (IVL), atherectomy platforms, and intravascular imaging modalities. These innovations have significantly improved procedural safety and long-term patency while supporting a strategic shift toward a “leave-nothing-behind” philosophy. The emergence of sirolimus-based platforms and bioresorbable scaffolds further underscores the continued evolution toward durable yet less invasive solutions.

Within this technological landscape, plaque modification and vessel preparation strategies have assumed a pivotal role, particularly in the management of heavily calcified lesions. The comparative study of IVL versus 355-nm laser atherectomy provides important real-world insights into these approaches, demonstrating that both modalities are safe and effective in achieving procedural success in calcified femoropopliteal disease, with differing procedural characteristics and stenting requirements. These findings highlight the growing importance of tailoring vessel preparation strategies based on lesion morphology, calcium burden, and procedural goals.

Complementing these comparative data, long-term outcome evidence remains critical in validating emerging technologies. The 3-year follow-up analysis of the Auryon 355-nm laser system provides valuable real-world data demonstrating sustained clinical improvement, acceptable freedom from target lesion revascularization, and stable limb outcomes in a complex PAD population. Notably, the durability of symptom relief and functional improvement observed over extended follow-up reinforces the role of laser atherectomy as a viable option in contemporary multimodality treatment strategies.

Beyond individual technologies, this issue also highlights the importance of integrated and systems-based approaches to vascular care. Damay and colleagues present a compelling framework positioning multidisciplinary vascular care as a formal governance model rather than an informal collaboration. By emphasizing structured decision-making, shared competency, and separation of procedural execution from treatment planning, this model addresses key limitations of fragmented care and aligns clinical decisions with long-term, patient-centered outcomes. Importantly, this paradigm extends beyond advanced disease to include prevention-oriented strategies, underscoring the need for continuity across the entire vascular disease spectrum.

These contributions align with broader themes explored throughout the issue, including the role of advanced imaging in procedural planning, the prognostic value of vascular function metrics such as arterial stiffness, and the biological underpinnings of exercise therapy and skeletal muscle adaptation. Collectively, they reinforce the concept that PAD is not solely an anatomic disease but rather a systemic and dynamic condition requiring multidimensional assessment and intervention.

Equally transformative is the expanding role of pharmacological and digital innovation. Advances in antithrombotic therapy, particularly dual pathway inhibition strategies, have reshaped risk reduction in high-risk PAD populations. At the same time, artificial intelligence and machine learning are beginning to influence vascular diagnostics, procedural planning, and outcome prediction, offering the potential to enhance precision and efficiency in clinical care.

At the most advanced end of the disease spectrum, the management of chronic limb-threatening ischemia continues to evolve rapidly. Advances in endovascular techniques, hybrid revascularization strategies, and emerging therapies such as deep venous arterialization reflect a growing emphasis on limb preservation. These developments are further strengthened by multidisciplinary care models, which have consistently demonstrated improvements in limb salvage and patient outcomes.

Taken together, the manuscripts in this special issue reflect a fundamental transition in vascular medicine. PAD management is moving away from a procedure-centric approach toward an integrated model that combines technological innovation, biological understanding, and systems-based care delivery. The convergence of advanced device therapies, precision imaging, pharmacological optimization, multidisciplinary governance, and digital health tools represents a new era in which treatment strategies are increasingly individualized and outcome-driven.

As Guest Editor, I am deeply grateful to the authors and contributors who have shared their expertise and insights. Their work not only advances our understanding of PAD but also provides a forward-looking perspective on how vascular care will continue to evolve in the coming years.

This special issue serves not only as a reflection of current progress but also as a call to action to continue advancing innovation, strengthening multidisciplinary collaboration, and ultimately improving the lives of patients affected by PAD.

Article published online:
14 April 2026

© 2026. International College of Angiology. This article is published by Thieme.

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