Peripheral atherectomy practice patterns in the United States from the Vascular Quality Initiative

Mohan, Sathish; Flahive, Julie; Arous, Edward J.; Judelson, Dejah R.; Aiello, Francesco; Schanzer, Andres; Simons, Jessica P.

doi:10.1016/j.jvs.2018.03.417

Cited by 22 publications

(11 citation statements)

References 25 publications

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“…The initial wave of enthusiasm for debulking plaque and attaining similar long-term patency without the need for adjunctive stenting led to a surge in atherectomy procedures. 33,34 More recently, atherectomy has been used in combination with drug-coated balloon angioplasty. 33,[35][36][37] Nonetheless, evidence for the clinical effectiveness of atherectomy is lacking compared with existing balloon angioplasty and stenting.…”

Section: Discussionmentioning

confidence: 99%

“…33,34 More recently, atherectomy has been used in combination with drug-coated balloon angioplasty. 33,[35][36][37] Nonetheless, evidence for the clinical effectiveness of atherectomy is lacking compared with existing balloon angioplasty and stenting. Investigators have suggested that the greater reimbursement for atherectomy procedures might be associated with the increased use.…”

Section: Discussionmentioning

confidence: 99%

“…Investigators have suggested that the greater reimbursement for atherectomy procedures might be associated with the increased use. 33,34,38 The VQI lacks robust data, however, regarding specific known associated risk factors such as severe calcification, length and degree of stenosis or occlusion, and other vessel features. Therefore, confounding factors could have been present that led to the use of atherectomy, in particular, unfavorable lesions, and should be remembered when evaluating these data.…”

Section: Discussionmentioning

confidence: 99%

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

Bath

Lawrence

Neal

et al. 2021

Journal of Vascular Surgery

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

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

Bath

Lawrence

Neal

et al. 2021

Journal of Vascular Surgery

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“…This number is significantly higher than the 15% published in the Vascular Quality Initiative. 10 There have been studies showing a benefit of atherectomy in conjunction with angioplasty 11 being practiced by our group. As discussed in the results, we did not have any complications from atherectomy.…”

Section: Discussionmentioning

confidence: 99%

Peripheral Arterial Endovascular Procedures Performed in a Non-Hospital-Based Facility by First-Year Vascular Surgery Fellows

Pineda

Calligaro

Tyagi

et al. 2019

Vasc Endovascular Surg

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Objective: Traditionally, vascular surgery fellows (VSFs) have learned to perform peripheral arterial endovascular procedures in a hospital setting. Many vascular surgeons currently perform these procedures in an “outpatient” non-hospital-based setting. Loss of these cases from the hospital setting may impact vascular surgery fellowship endovascular volume. We assessed the safety of first-year VSFs performing peripheral endovascular procedures under the supervision of vascular surgery attending surgeons in a non-hospital-based facility. Methods: Between January 1, 2012, and December 31, 2016, 166 patients underwent 193 endovascular procedures in a non-hospital-based ambulatory facility: 136 interventions (65 femoral, 40 iliac, 13 popliteal, and 9 infrapopliteal arteries) and 31 diagnostic arteriograms for claudication (57.8%; 85), rest pain (11.6%; 17), tissue loss (12.9%; 19), and failing grafts (17.7%; 26). Interventions included balloon angioplasty alone in 8.8% (12/136) of cases, stents in 16.9% (23/136), covered stents in 14% (19/136), atherectomy in 60.3% (82/136), and mechanical thrombolysis in 0.7% (1/136). Results: First-year VSFs performed an increasing percentage of these procedures during this interval: academic year 2012 to 2013 = 0% (0/49), 2013 to 2014 = 31% (17/54), 2014 to 2015 = 93% (56/60), and 2015 to 2016 = 82% (57/70). All but 5 (3%) patients having 167 procedures were discharged home after 2 to 6 hours of bed rest without any 30-day adverse outcomes. Four patients were immediately transferred to our hospital after the intervention: 2 for respiratory issues (hypoxia), 1 for groin hematoma (observation only), and 1 for arterial occlusion (required tibial stent not available at outpatient center). One patient returned to our hospital with rest pain due to treatment site occlusion the following day. Conclusion: Our results demonstrate that complex peripheral arterial endovascular procedures can be performed safely by first-year VSFs under vascular attending supervision in an outpatient, non-hospital-based setting.

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“…Atherectomy devices are increasingly used in endovascular interventions for the treatment of peripheral arterial disease (PAD), despite inconclusive evidence of their efficacy compared with more conventional therapies such as percutaneous transluminal angioplasty (PTA) and stenting. [1][2][3] Rather than forcing atherosclerotic plaque away from the lumen as in PTA and stenting, atherectomy debulks and removes plaque from occluded arteries by vaporizing (laser), pulverizing (orbital), or cutting (excisional). 4 The theoretical advantages of atherectomy have not consistently translated into improved clinical outcomes and increased enthusiasm is inconsistent with an emerging body of evidence.…”

Section: Introductionmentioning

confidence: 99%

Trends in Utilization and Outcomes of Orbital, Laser, and Excisional Atherectomy for Lower Extremity Revascularization

et al. 2021

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Purpose: The aim of this study is to analyze the utilization pattern of atherectomy modalities and compare their outcomes. Materials and Methods: All patients undergoing atherectomy in the 2010–2016 Vascular Quality Initiative Database were identified. Utilization of orbital, laser, or excisional atherectomy was obtained. Characteristics and outcomes of patients treated for isolated femoropopliteal and isolated tibial disease by different modalities were compared. Results: Atherectomy use increased from 10.3% to 18.3% of all peripheral interventions (n = 122 938). Orbital atherectomy was most commonly used and increased from 59.4% in 2010 to 63.2% of all atherectomies in 2016, while laser atherectomy decreased from 19.2% to 13.1%. Atherectomy was mostly used for treatment of isolated femoropopliteal disease (51.1%), followed by combined femoropopliteal and tibial disease (25.8%) and isolated tibial disease (11.7%). In isolated femoropopliteal revascularization, excisional atherectomy was associated with higher rate of perforation (1.2%) compared with laser (0.4%) and orbital atherectomy (0.5%). The technical success of orbital atherectomy (96.7%) was lower compared with excisional atherectomy (98.7%). Concomitant stenting was significantly higher with laser atherectomy (43.0%) compared with orbital (27.2%) and excisional (26.1%) atherectomy. Nevertheless, there was no difference in 1-year primary patency, reintervention, major amputation, improvement in ambulatory status, or mortality. Multivariable analysis also demonstrated no difference in 1-year primary patency and major ipsilateral amputation among the modalities. In isolated tibial revascularization, there were no differences in perioperative outcomes among the modalities. Excisional atherectomy was associated with the highest 1-year primary patency (88.1%). After adjusting for confounders, excisional atherectomy remained associated with superior 1-year primary patency compared with orbital atherectomy (odds ratio [OR] = 2.59, 95% confidence interval [CI] = [1.18–5.68]), and excisional atherectomy remained associated with a lower rate of 1-year major ipsilateral amputation compared with laser atherectomy (OR = 0.29, 95% CI = [0.09–0.95]). Conclusion: Atherectomy use has increased, driven primarily by orbital atherectomy. Despite significant variation in perioperative outcomes, there were no differences in 1-year outcomes among the different modalities when used for treating isolated femoropopliteal disease. In isolated tibial disease treatment, excisional atherectomy was associated with higher 1-year primary patency compared with orbital atherectomy and decreased major ipsilateral amputation rates compared with laser atherectomy. These differences warrant further investigation into the comparative effectiveness of atherectomy modalities in various vascular beds.

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Peripheral atherectomy practice patterns in the United States from the Vascular Quality Initiative

Cited by 22 publications

References 25 publications

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

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

Peripheral Arterial Endovascular Procedures Performed in a Non-Hospital-Based Facility by First-Year Vascular Surgery Fellows

Trends in Utilization and Outcomes of Orbital, Laser, and Excisional Atherectomy for Lower Extremity Revascularization

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