Predictors of Clinically Driven Target Lesion Revascularization After Endovascular Treatment of Femoropopliteal Chronic Total Occlusions

Background: Clinically driven target lesion revascularization (CD-TLR) following endovascular recanalization of femoropopliteal chronic total occlusions (CTOs) remains a primary determinant of long-term procedural durability. This study aimed to identify clinical, anatomical, and procedural predictors associated with 12-month CD-TLR following successful femoropopliteal CTO endovascular treatment. Methods: This retrospective single-center cohort study evaluated 246 successfully recanalized patients who underwent endovascular treatment for femoropopliteal CTO between June 2020 and June 2025. The primary endpoint was 12-month CD-TLR. To overcome severe multicollinearity and prevent overfitting among correlated predictors, five survival algorithms were benchmarked across the complete 27-variable candidate set. Model discrimination was evaluated using Harrell’s concordance index (C-index) with bootstrap correction. Results: Over a 12-month time-to-event follow-up (median 365 days), CD-TLR occurred in 114 patients (46.3%). Multivariable-regularized Elastic Net Cox regression retained 22 informative predictors, achieving an apparent C-index of 0.715 (95% CI: 0.66–0.77) and an optimism-corrected C-index of 0.653. Higher occluded below-the-knee vessel count, baseline Rutherford classes 4–6, popliteal CTO extension, distal runoff impairment, active smoking, and overall concomitant interventions showed positive associations with 12-month CD-TLR risk. Conversely, shorter lesion length (<5 cm) and female sex showed inverse associations, while findings related to stent dimensions were considered exploratory. Conclusion: Twelve-month CD-TLR after endovascular treatment of femoropopliteal CTO was associated with greater distal vascular disease burden, anatomical complexity, a worse baseline Rutherford class and impaired distal runoff. The Elastic Net model provided the highest optimism-corrected discrimination among the evaluated strategies, although prospective external validation remains necessary before broad clinical application.