Most contemporary studies describe no significant difference in primary and secondary patency between genders after femoropopliteal endovascular interventions [10, 14, 18, 19, 21–23].

The DURABILITY II trial evaluated the results of primary stenting for femoropopliteal disease; an analysis of the impact of sex on outcome was recently published [14]. Despite presenting at a later age, with more severe claudication, a shorter absolute claudication distance, and smaller vessels than men, women achieved equal patency rates using angioplasty and primary stenting (Fig. 17.2) with similar target lesion revascularization, major adverse event, and mortality rates. However, despite these findings, women subjectively had worse symptoms both before and 1 year after revascularization.

In the most challenging setting of long chronic total occlusions of femoropopliteal arteries, the results of stenting are less favorable, particularly in women. Sakamoto et al. recently described a multicenter series of 352 patients undergoing stent implantation of long femoropopliteal occlusion (mean occlusion length was 194 ± 89 mm); 5-year primary and secondary patency rates were 51.8 % and 79.5 %, respectively, and the rates of freedom from amputation and all-cause death were 96.2 % and 78.4 %, respectively [22]. Female gender (odds ratio, 1.95; P = 0.005) and mean stent diameter (odds ratio, 0.77; P = 0.03) were predictors of restenosis. Although primary patency was low, the secondary patency rate was acceptable.

The “Local Taxan With Short Time Contact for Reduction of Restenosis in Distal Arteries” (THUNDER) randomized trial investigated the efficacy of a drug-coated balloon (DCB) in the femoropopliteal arteries; no difference was observed between women and men in 6-month late lumen loss both in the control arm (1.61 mm vs. 1.76 mm) and DCB arm (0.37 mm vs. 0.42 mm) [23]. In contrast, 5 years after treatment, the cumulative target lesion revascularization rate was lower in men than in women treated in the DCB group (17 % vs. 38 %). Although absolute numbers of patients are small, this might reflect a gender-related difference in the response to DCB, which may partially be explained by the smaller diameter of femoropopliteal arteries in women. Currently there are no further published data describing an interaction between gender and the results of DCB or drug-eluting stents for PAD.

Endovascular interventions on BTK vessels in patients with CLI represent the most difficult challenge in the treatment of PAD and results are still far from being fully satisfactory. Recently Domenick et al. reported a gender and age analysis of their single-center experience of 201 patients (40 % female, 39 % aged more than 80 years) undergoing tibial artery angioplasty for CLI [24]. Consistent with previous reports, women were older than men at the time of presentation, but procedural success, comorbidities, and indications for intervention were comparable between sexes and age groups, as well as complications. Limb salvage rate was 88 % and was comparable by gender, while renal insufficiency was an independent predictor of limb loss. Age >80 years was a predictor of impaired wound healing, at variance with sex. Overall primary patency rate was 62 % at 1 year and was similar between genders and age groups, while reintervention rate was 65 % in women vs. 46 % in men (P = 0.03). Although the exact reasons for the higher reintervention rate are not known, anatomic and socioeconomic factors could account for these findings. Women have smaller arteries than men, and the same degree of intimal hyperplasia after interventions will be more likely to cause a hemodynamically significant restenosis. In addition, women often present at a later stage of disease than their male counterparts.

On the other hand, in a series of 81 patients (53 % women) undergoing percutaneous interventions on BTK vessels, Tye et al. reported statistically higher primary patency rates at 12 and 24 months in women (77.5 % ± 6.9 % and 72.9 % ± 7.8 %) than in men (58.7 % ± 9.3 % and 45.2 % ± 9.9 %; P = 0.03) [25]. Women also had statistically better secondary patency rates than men at 12 and 24 months (90.4 % ± 4.8 % and 85.1 % ± 6.8 % in women vs. 76.0 % ± 8.1 % and 58.5 % ± 10.8 % in men; P = 0.03). Female gender remained an independent predictor of superior patency even after controlling for gender-related differences in lesion anatomic complexity. There were no significant differences in limb salvage rates and overall survival rates at 12 and 24 months between genders. Importantly, in this series women were not older than men and had less advanced disease (chronic total occlusion rate 25.4 % in women vs. 25.4 % in men; P = 0.03). These results suggest that a timely diagnosis and the use of endovascular procedures may lessen the gap in gender-related treatment outcomes and postoperative complications seen after open arterial reconstructions for CLI.