Comparison of endovascular therapies for chronic limb-threatening ischemia and claudication.
Academic Article
Overview
abstract
OBJECTIVE: Analysis of regional data from the Vascular Quality Initiative (VQI) suggested improved survival for patients undergoing stent placement compared to balloon angioplasty and atherectomy. Utilizing national data from VQI linked to Medicare-claims data through the Vascular Implant Surveillance and Interventional Outcomes Network (VISION) program, this study aimed to compare the rates of mortality, reintervention, and amputation after endovascular interventions (atherectomy, stenting, and balloon angioplasty) for two separate cohorts: chronic limb-threatening ischemia (CLTI) and claudication. METHODS: This was a secondary data analysis of SVS National VQI data linked to Medicare claims, between October 2016 to December 2019. Patients age 65 years and older with symptoms of claudication or CLTI and a diagnosis of occlusive disease were included. Urgent or emergent interventions or those with concurrent procedures (endarterectomy, bypass, or bilateral intervention) were excluded. Interventions were grouped into: 1) balloon angioplasty only; 2) stent (with or without balloon angioplasty); 3) atherectomy (alone, with or without stent, with or without balloon angioplasty). Propensity score-matched cohorts were constructed to conduct pairwise intervention comparisons of mortality, reintervention, and amputation rates. Multivariable logistic regression was used to derive propensity scores for each patient. Kaplan-Meier estimates and Cox Proportional Hazards Ratios (95% CI) analyses were performed. RESULTS: A total of 9785 (2665 claudication, 7120 CLTI) eligible patients were identified. After propensity score matching for the CLTI group, 2826, 3608, and 2796 pairs of cases were used to compare balloon angioplasty versus atherectomy, balloon angioplasty versus stent, and stent versus atherectomy, respectively. No statistically significant difference in mortality was observed among all interventions. However, atherectomy was associated with a significant increase in reintervention rate compared to balloon angioplasty (HR 1.22; 95% CI: 1.06-1.39; p=0.01) and compared to stenting (HR 1.27; 95% CI: 1.10-1.46; p<0.01) within the first year after the index procedure (Fig. 1). Of note, both atherectomy (HR 0.82; 95% CI: 0.68-0.98; p<0.05) and stenting (HR 0.76; 95% CI: 0.64-0.90; p<0.01) showed lower rates of major amputation when compared to balloon angioplasty within 1 year after the index procedure. In the claudication group, there were no significant differences observed among PAD interventions for mortality, reintervention, or amputation rates. CONCLUSION: Further studies are needed to identify appropriate indications for atherectomy, as there may be a subset of CLTI patients who benefit from this therapy with respect to amputation rates. Until then, caution should be exercised when employing atherectomy as it is also associated with higher reintervention rates.
