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Objectives
Endovascular adjuncts, like atherectomy, have been developed in order to improve outcomes for patients undergoing endovascular treatment for peripheral arterial disease (PAD). The true impact of atherectomy on endovascular outcomes remains to be determined, and no data exists on the influence of atherectomy on tibial interventions. Our study compares both the early and late outcomes of tibial intervention with angioplasty versus atherectomy.
Methods
We completed a retrospective review of all tibial interventions between 2008 and 2010. Pre-procedural, procedural, and post-procedural data were collected using paper and electronic systems. Factors affecting patient outcomes were analyzed using single and multivariate analysis, Cox regression analysis, and Kaplan-Meier life-table curves. Primary outcomes were primary, primary assisted, and secondary patency rates, as well as limb salvage and survival.
Results
After review, 480 tibial interventions were completed for 421 limbs, 87% (n=418) presented with critical limb ischemia (CLI) and 13% (n=62) with claudication. 192 isolated tibial interventions were completed and 288 multisegment interventions were completed. The CLI cohort of 418 limbs were selected for analysis. These patients had a mean age of 71 years with a mean follow-up time of 16±15 months (range 0-59 months). The majority of patients (60%) were male with predominant risk factors of hypertension (92%), tobacco use (64%), diabetes (72%), hyperlipidemia (65%), and chronic kidney disease (39%). Of the 418 limbs, 339 underwent percutaneous transluminal angioplasty (PTA): 333 PTA alone, 6 PTA+stent. The remaining 79 limbs received atherectomy: 33 laser, 13 directional, and 33 orbital either alone or in conjunction with PTA (11 atherectomy only, 68 atherectomy + PTA). The groups did not differ significantly in terms of age, gender, risk factors, occlusion versus stenosis , or technical success. The atherectomy group had significantly more TASC B lesions (54% versus 38%, p=.013) while the PTA group had significantly more TASC D lesions (25% versus 13%, p=.049). TASC A and C lesions did not differ significantly between the two groups.
No significant differences existed with respect to the early (30 days) outcomes of loss of patency (11% versus 13%, p=.70), complications (9% versus 13%, p=.41), or major amputation (17% versus 13%, p=.34). Furthermore, there was no difference between treatment groups in symptomatic relief at first follow-up (61% versus 65%, p=.53) or Rutherford score improvement (70% versus 69%, p=.81).
Kaplan Meier analysis revealed no difference in primary outcomes of PTA versus atherectomy at the 12 and 36 month time points : primary patency (69%, 55% versus 61%, 46%, p=.15), primary assisted patency (83%, 71% versus 85%, 67%, p=.80), secondary patency (94%, 89% versus 95%, 89%, p=.89), limb salvage (79%, 70% versus 81%, 77%, p=.49), or survival (77%, 56% versus 80%, 50%).
Conclusion
The adjunctive use of atherectomy offered no improvement over PTA in either early or late outcomes in patients with CLI who underwent endovascular tibial interventions. Considering the additional cost and increased procedural time, these findings put into question the routine use of adjunctive atherectomy.