Index Atherectomy Peripheral Vascular Interventions Performed for Claudication are Associated with More Reinterventions than Non-Atherectomy Procedures
Qingwen Kawaji, Chen Dun, Christi Walsh, David P. Stonko, Christopher J Abularrage, James H Black, III, Bruce Alan Perler, Martin A Makary, Caitlin Hicks
Johns Hopkins Hospital, Baltimore, MD
Background:Despite limited evidence supporting atherectomy over stenting/angioplasty during index peripheral vascular interventions (PVI), the use of atherectomy has rapidly increased in recent years. We previously identified a wide distribution of atherectomy practice patterns among US physicians. The aim of this study was to investigate the association of index atherectomy with reintervention.
Methods:100% Medicare fee-for-service claims were used to identify all beneficiaries who underwent elective first-time femoropopliteal peripheral vascular intervention (PVI) for claudication in 2019. Subsequent PVI reinterventions were recorded through 12/2020. Kaplan-Meier curves were used to compare the rate of PVI reinterventions for patients who received index atherectomy vs. non-atherectomy, and according to physician practice patterns. A hierarchical Cox proportional hazard model was used to evaluate patient and physician-level characteristics associated with reinterventions.
Results:A total of 15,279 patients underwent index PVI for claudication in 2019, of which 59.6% were atherectomy. After a median of 435 days (IQR 78 - 573) of follow-up, 38.6% of patients underwent a PVI reintervention, including 46.4% of patients who underwent index atherectomy vs. 27.1% of patients who underwent index non-atherectomy (P<0.001; Figure 1). Patients treated by high physician users of atherectomy (quartile 4) received more reinterventions than patients treated by standard physician users (quartiles 1-3) (54.6% vs. 36.5%, P<0.001; Figure 2). After adjustment, patient factors association with PVI reintervention included receipt of index atherectomy (aHR 1.33, 95% CI 1.20-1.47), Black race (vs. White, aHR 1.19, 95% CI 1.09-1.30), diabetes (aHR 1.14, 95% CI 1.07-1.22), and urban residence (aHR 1,11, 95% CI 1.02-1.22). Physician factors associated with reintervention included male sex (aHR 1.75, 95% CI 1.28-2.44), high-volume PVI practices (aHR 1.23, 95% CI 1.12-1.35), physicians working primarily at ambulatory surgery centers or office-based laboratories (aHR 1.11, 95% CI 1.01-1.21), and physicians with high use of index atherectomy (aHR 1.56, 95% CI 1.35-1.80). Vascular surgeons had a lower risk of PVI reintervention than Cardiologists (aHR 0.82, 95% CI 0.76-0.88), Radiologists (aHR 0.64, 95% CI 0.57-0.72), and other specialties (aHR 0.69, 95% CI 0.57-0.80).
Conclusions:The use of atherectomy during index PVI for claudication is associated with higher PVI reintervention rates compared to other technologies. Similarly, high physician users of atherectomy and physicians in outpatient settings perform more PVI reinterventions than their peers. The appropriateness of using atherectomy for initial treatment of claudication needs critical reevaluation.
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