Pre-endovascular intervention C-reactive protein levels and its association with femoropopliteal artery restenosis – a systematic review and meta-analysis
H Rai, H Pasha, K Jain, D O'Callaghan, J J Coughlan, R Colleran, R A ByrneAbstract
Background
Endovascular interventions have traditionally been used to manage atherosclerotic disease affecting the femoral and popliteal arterial domains. High restenosis rates in these treated lesions represent a prominent clinical challenge. Elevated C-reactive protein (CRP) levels, a marker of systemic inflammation, has previously been linked to coronary restenosis, however, its association with femoropopliteal artery restenosis remains to be unclear.
Purpose
We conducted a systematic review and study-level meta-analysis to assess the association between pre-procedural CRP levels and subsequent femoropopliteal artery restenosis.
Methods
Online search using appropriate search strings was conducted on databases of PubMed, EMBASE, MEDLINE-OVID, Scopus and Web of Science for relevant articles published until 30th September 2025. Studies reporting summary-level pre-procedural CRP levels in patients with and without the incidence of femoropopliteal restenosis during follow-up were included. Study-level data were pooled to obtain pooled standardized mean difference (SMD) and its 95% confidence intervals (CI), employing a z-test and a random effects model. Publication bias assessment was conducted visually using Begg’s funnel plot, while its statistical estimates were calculated using Egger’s test. The resultant p<0.05 indicated statistical significance. Obtained pooled results were further tested for robustness using a leave-one-out sensitivity analysis.
Results
After screening a total of 331 unique articles, 14 studies comprising of 2,097 patients (562 ISR cases/1,535 controls) were included for quantitative synthesis. Pooled results suggested higher pre-procedural CRP levels in patients who later developed femoropopliteal artery restenosis as compared to those who did not. (SMD= 0.44, 95% Cl= 0.09-0.78, p= 0.01). (Figure 1.) We found no evidence of publication bias, both visually via Begg’s funnel plot and statistically via Egger’s test results (p= 0.52). Our leave-one-out sensitivity analysis further attested to the robustness of our pooled results. (Figure 2.)
Conclusions
The present systematic review and study-level meta-analysis suggests an association between elevated pre-procedural CRP levels and subsequent femoropopliteal artery restenosis. Our findings should however be interpreted with caution and further large-scale prospective investigations are warranted to substantiate our results.Figure 1.For image description, please refer to the figure legend and surrounding text.Figure 2.For image description, please refer to the figure legend and surrounding text.