Use of Atherectomy During Index Peripheral Vascular Interventions

OBJECTIVES

The aim of this study was to describe physician practice patterns and examine physician-level factors associated with the use of atherectomy during index revascularization for patients with femoropopliteal peripheral artery disease.

BACKGROUND

There are minimal data to support the routine use of atherectomy over angioplasty and/or stenting for the endovascular treatment of peripheral artery disease.

METHODS

Medicare fee-for-service claims (January 1 to December 31, 2019) were used to identify all beneficiaries undergoing elective first-time femoropopliteal peripheral vascular intervention (PVI) for claudication or chronic limb-threatening ischemia. Hierarchical logistic regression was used to evaluate patient- and physician-level characteristics associated with atherectomy.

RESULTS

A total of 58,552 patients underwent index femoropopliteal PVI by 1,627 physicians. There was a wide distribution of physician practice patterns in the use of atherectomy, ranging from 0% to 100% (median 55.1%). Independent characteristics associated with atherectomy included treatment for claudication (vs. chronic limb-threatening ischemia; odds ratio [OR]: 1.51), patient diabetes (OR: 1.09), physician male sex (OR: 2.08), less time in practice (OR: 1.41 to 2.72), nonvascular surgery specialties (OR: 2.78 to 5.71), physicians with high volumes of femoropopliteal PVI (OR: 1.67 to 3.51), and physicians working primarily at ambulatory surgery centers or office-based laboratories (OR: 2.19 to 7.97) (p ≤ 0.03 for all). Overall, $266.8 million was reimbursed by Medicare for index femoropopliteal PVI in 2019. Of this, $240.6 million (90.2%) was reimbursed for atherectomy, which constituted 53.8% of cases.

CONCLUSIONS

There is a wide distribution of physician practice patterns for the use of atherectomy during index PVI. There is a critical need for professional guidelines outlining the appropriate use of atherectomy in order to prevent overutilization of this technology, particularly in high-reimbursement settings.

Telemedicine platforms and their use in the coronavirus disease-19 era to deliver comprehensive vascular care

Implementation of telemedicine for patient encounters optimizes personal safety and allows for continuity of patient care. Embracing telehealth reduces the use of personal protective equipment and other resources consumed during in-person visits. The use of telehealth has increased to historic levels in response to the coronavirus disease 2019 (COVID-19) pandemic. Telehealth may be a key modality to fight against COVID-19, allowing us to take care of patients, conserve personal protective equipment, and protect health care workers all while minimizing the risk of viral spread. We must not neglect vascular health issues while the coronavirus pandemic continues to flood many hospitals and keep people confined to their homes. Patients are not immune to diseases and illnesses such as stroke, critical limb ischemia, and deep vein thrombosis while being confined to their homes and afraid to visit hospitals. Emerging from the COVID-19 crisis, incorporating telemedicine into routine medical care is transformative. By leveraging digital technology, the authors discuss their experience with the implementation, workflow, coding, and reimbursement issues of telehealth during the COVID-19 era.

Predictors of Groin Access Pseudoaneurysm Complication: A 10-Year Institutional Experience

Objective:

In clinical practice, the incidence of femoral pseudoaneurysms requiring repair is small, but at a tertiary care center, the repair rate is higher due to referrals. We sought to specifically study patients who suffered postcatheterization pseudoaneurysms requiring thrombin injection or operative repair and compare them to our routine transfemoral endovascular patients to identify predictors of clinically significant pseudoaneurysms. The underlying goal would be to identify what makes these patients that develop pseudoaneurysms different.

Methods:

A search of our billing records for Current Procedural Technology (CPT) codes of these 2 procedures between January 2008 and April 2018 was combined with our institution’s Peripheral Vascular Intervention Vascular Quality Initiative database spanning from January 2013 to December 2017. A comparison was then performed between patients who had the outcome of operative intervention for a pseudoaneurysm complication and those who did not, with the goal of elucidating patient demographics and periprocedural factors that would predict pseudoaneurysm formation using univariate and multivariate analyses.

Results:

There were 77 patients who required thrombin injection or open repair for access-related pseudoaneurysms and 324 patients who did not. Complications occurred more often in patients who were older than 75 (40.2% vs 21.9%; P = .0009), female (57.1% vs 38.6%; P = .003), obese (59.7% vs 33.3%; P < .001), hypertensive (96.1% vs 79.3%; P = .0005), who received a sheath >6F (32.4% vs 13%; P < .0001), intraoperative and postoperative anticoagulation (77.3% vs 32.7% and 52.1% vs 24.2%, respectively; P < .0001), and periprocedural P2Y12 inhibitors (48.7% vs 28%; P = .0005). Less complications were observed in patients who had a closure device used (42.9% vs 8.45%; P < .0001) and protamine reversal (26.5% vs 13.3%; P = .0163).

Conclusions:

Our findings validate published reports that incriminate a larger sheath size, perioperative anticoagulation, and female gender as increasing the rate of access site complications, with the use of a closure device being protective.

Enhanced anxiety-like behavior emerges with weight gain in male and female obesity-susceptible rats

Epidemiological data suggest that body mass index and obesity are strong risk factors for depression and anxiety. However, it is difficult to separate cause from effect, as predisposition to obesity may enhance susceptibility to anxiety, or vice versa. Here, we examined the effect of diet and obesity on anxiety-like behaviors in male and female selectively bred obesity-prone and obesity-resistant rats, and outbred Sprague-Dawley rats. We found that when obesity-prone and obesity-resistant rats do not differ in weight or fat mass, measures of anxiety-like behavior in the elevated plus maze and open field are similar between the two groups. However, once weight and fat mass diverge, group differences emerge, with greater anxiety in obesity-prone relative to obesity-resistant rats. This same pattern was observed for males and females. Interestingly, even when obesity-resistant rats were "forced" to gain fat mass comparable to obesity-prone rats (via prolonged access to 60% high-fat diet), anxiety-like behaviors did not differ from lean chow fed controls. In addition, a positive correlation between anxiety-like behaviors and adiposity were observed in male but not in female obesity-prone rats. Finally, diet-induced weight gain in and of itself was not sufficient to increase measures of anxiety in outbred male rats. Together, these data suggest that interactions between susceptibility to obesity and physiological alterations accompanying weight gain may contribute to the development of enhanced anxiety.

Superior Vena Cava Perforation and Cardiac Tamponade After Filter Placement in the Superior Vena Cava

The purpose of this paper is to report the complication of perforation of the superior vena cava (SVC) leading to cardiac tamponade after the insertion of a Trapease IVC filter in the SVC position. A 29-year-old man was hit by a motor vehicle and sustained numerous injuries including a left skull fracture, intracerebral hemorrhage, and left open tibial shaft fracture. During his hospitalization, he developed an extensive symptomatic right upper extremity deep venous thrombosis involving the brachial, axillary, subclavian, internal jugular, and brachiocephalic veins. Owing to an intracerebral bleed, anticoagulation was contraindicated. Therefore, a Trapease filter (Cordis Inc.) was placed in the SVC via the left subclavian vein. Four hours later, the patient became hypotensive with associated tachycardia and tachypnea. Computed tomography of his chest revealed a hematoma around the SVC, a moderate amount of fluid within the pericardium, and a moderate-sized right pleural effusion. The patient was taken to the operating room and a pericardial window was performed. Approximately 500 cc of blood was evacuated from the pericardium and immediate improvement in vital signs was noted. The patient was discharged from the hospital 2 weeks later and at 6-month follow-up had made a full recovery. This is the first case of SVC perforation leading to cardiac tamponade after the insertion of a Trapease filter. Owing to the rigid structure of the filter and associated motion of the SVC and pericardium, the Trapease filter may be contraindicated in the SVC.

EVAR for ruptured aneurysms: are the data complete?

Endovascular abdominal aneurysm repair is now the preferred therapy for many patients with abdominal aortic aneurysms and has been associated with reduced immediate and short-term morbidity and mortality. Because perioperative complications so often compromise the open repair of ruptured aortic aneurysms, EVAR has been considered as an attractive option in these patients. A number of small, typically single-center studies have demonstrated excellent results. In the absence of compelling, objective clinical data, there are certainly many patients with ruptured aortic aneurysms who are well-suited for EVAR. The development of protocols and systems for the expeditious diagnosis and treatment of ruptured aneurysms should further improve therapy for this life-threatening condition.

Percutaneous mechanical thrombectomy and pharmacologic thrombolysis for renal artery embolism: case report and review of endovascular treatment

Renal artery embolism (RAE) is an uncommon event that is associated with a high rate of renal loss. We present a case of RAE to a solitary kidney that was treated with combined percutaneous rheolytic thrombectomy, intra-arterial thrombolysis, and supplemental renal artery stent placement.

The Role of Embolic Protection Devices in Renal Artery Stenting

Renal artery angioplasty and stenting is commonly performed for the treatment of hypertension and ischemic nephropathy. An increasing number of procedures are being undertaken for "renal preservation" despite an associated risk of renal function decline related to the embolization of atheromatous debris liberated during the procedure. Although smaller, more flexible guidewires and stents have been developed to decrease the amount of debris created, interest in the off-label use of embolic protection devices has increased. We review the available embolic protection devices and currently available data regarding their use in renal artery interventions. Although not designed for use in the renal artery, there are at least theoretical reasons to believe that embolic protection during renal artery angioplasty may improve outcomes.