Endovascular interventions for claudication do not meet minimum standards for the Society for Vascular Surgery efficacy guidelines

Abstract

Objective: Because the treatment of intermittent claudication (IC) is elective, good short-and long-term outcomes are imperative. The objective of the present study was to examine the outcomes of endovascular management of IC reported in the Vascular Quality Initiative and compare them with the Society for Vascular Surgery guidelines for IC treatment to determine whether real-world results are within the guidelines.Methods: Patients undergoing peripheral vascular intervention for IC from 2004 to 2017 with complete data and >9 month follow-up were included. The primary outcome measures were IC recurrence and repeat procedures performed #2 years after the initial treatment.Results: A total of 16,152 patients met the inclusion criteria, with a mean age of 66 years. Of the 16,152 patients, 61% were men, 45% were current smokers, and 28% had been discharged without antiplatelet or statin medication. Adjusted analyses revealed that treatment of more than two arteries was associated with a shorter time to IC recurrence (hazard ratio [HR], 1.19; 95% confidence interval [CI], 1.09-1.31) and a shorter time to repeat procedures (HR, 1.25; 95% CI, 1.09-1.45). The use of atherectomy was also associated with a shorter time to IC recurrence (HR, 1.29; 95% CI, 1.08-1.33) and a shorter time to repeat procedures (HR, 1.31; 95% CI, 1.13-1.52). Discharge with antiplatelet and statin medications was associated with a longer time to IC recurrence (HR, 0.84; 95% CI, 0.78-0.91) and a longer time to repeat procedures (HR, 0.77; 95% CI, 0.69-0.87). Life-table analysis at 2 years revealed that only 32% of patients were free from IC recurrence, although 76% had not undergone repeat procedures. Stratified by anatomic treatment level, 37% of isolated aortoiliac interventions, 22% of aortoiliac and femoropopliteal interventions, 30% of isolated femoropopliteal interventions, and 20% of femoropopliteal and tibial interventions had remained free from IC recurrence at 2 years.Conclusions: Most patients treated with an endovascular approach to IC did not meet the Society for Vascular Surgery guidelines for long-term freedom from recurrent symptoms of >50% at 2 years. Many lacked preprocedure optimization of medical management. The use of atherectomy and treatment of more than two arteries were associated with poor outcomes after peripheral vascular intervention for IC, because only 32% of these patients were free from recurrent symptoms at 2 years. Even when risk factor modification is optimized before the procedure, vascular specialists should be aware of the association between atherectomy and multivessel interventions with poorer long-term outcomes and counsel patients appropriately before intervention.

Needle fenestration of popliteal artery covered stent graft to salvage inadvertent stent misdeployment

“… 7 Also, evidence is mounting that restenosis rates can be exacerbated by the misuse of atherectomy. 3 , 8 Because of concerns regarding restenosis and occlusion, which plague any endovascular intervention to the femoropopliteal segment, different strategies have been used, including covered stents, which theoretically only have a risk of restenosis and occlusion at the margins of the stent, because neointimal ingrowth cannot occur in the body of the stent graft itself. The use of covered stents has resulted in good success in limited series.…”

“… 2 The widespread use of endovascular techniques has been called into question regarding the efficacy and durability, with one study using patient-reported outcomes suggesting only a 32% sustained benefit at 2 years for endovascular intervention for PAD. 3 Multiple modalities are available of endovascular treatment of femoropopliteal atherosclerotic disease, none of which has demonstrated clear superiority over the others. Atherectomy, drug-coated balloon angioplasty, bare metal stents, and covered stents have all been proposed as effective methods to treat femoropopliteal lesions.…”

Clinical implications of inflammation in atheroma formation and novel therapies in cardiovascular diseases

“…Traditionally, the main strategy to prevent/manage atherosclerosis relies on controlling its risk factors, i.e., blood LDL levels, hypertension or life habits like smoking. Although, atherosclerotic occlusion can be removed by atherectomy, a common recurrence of the disease within 2 years after the surgical intervention in up to 50% of patients has been noted ( Bath et al, 2021 ). Interestingly, this fact may be similar to the well-known recurrence of malignant growth after the surgical removal of tumour mass.…”

Cutting the queue: the need for evidence‐driven surgery

“…Pivotal clinical trials have found that some operations may be no more beneficial than sham surgery or non‐surgical alternatives, including lumbar fusion surgery and meniscectomy for degenerative disease, 4,5 arthroscopy for knee osteoarthritis, 6 and spinal cord stimulation for low back pain 7 . This problem is not limited to open surgery; some interventions in cardiac and peripheral vascular systems may not be beneficial for people with stable cardiovascular disease 8,9 …”