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Jamil Y, Nanna MG, Chaar CIO, Mena-Hurtado C, Attaran RR. Comparative Analysis of Mortality and Amputation Rates in Patients Undergoing Atherectomy for Infra-Popliteal Peripheral Arterial Disease: Insight From the VQI. J Endovasc Ther 2023:15266028231208895. [PMID: 37919968 DOI: 10.1177/15266028231208895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Infra-popliteal peripheral arterial disease (IPPAD) poses challenges due to high restenosis and occlusion rates. The BASIL-2 trial demonstrated the superiority of endovascular treatment compared with surgical bypass in patients with IPPAD. However, the association between different endovascular modalities and clinical outcomes has not been conclusive. HYPOTHESIS Combining plain old balloon angioplasty (POBA) with atherectomy is associated with improved clinical outcomes compared with POBA alone. METHODS Patients who underwent POBA vs POBA+atherectomy for IPPAD from the Vascular Quality Initiative database were identified. To mitigate potential selection bias, we employed propensity score matching (PSM) to balance the distribution of confounding variables for mortality identified on multivariable logistic regression. Subsequently, we compared patient characteristics and long-term outcomes between the 2 treatment groups. RESULTS Among patients who underwent endovascular intervention for IPPAD, 19 979 individuals (80.8%) were treated with POBA alone, while 4747 (19.2%) were treated with both POBA+atherectomy after PSM. Propensity score matching ensured minimal differences in baseline characteristics, such as indication for lower extremity revascularization (LER) and history of LER. After PSM, patients receiving POBA+atherectomy experienced higher rates of technical success and lower perioperative complications, such as renal complications and hematoma, compared with POBA alone. During long-term follow-up, patients who underwent atherectomy had lower rates of major amputation and major adverse limb events (MALE) but slightly lower freedom from reintervention. Nonetheless, there were no differences in mortality. CONCLUSION Combining POBA with atherectomy appears to be a safe approach in patients with IPPAD, with lower rates of long-term amputation and MALE at the cost of a higher risk of reintervention. CLINICAL IMPACT The use of adjunctive atherectomy is associated with improved long-term outcomes in patients with infra-popliteal disease.
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Affiliation(s)
- Yasser Jamil
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Michael G Nanna
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert Ramak Attaran
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
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Daoud FC, Létinier L, Moore N, Coste P, Karjalainen PP. Efficacy and Safety of TiNO-Coated Stents versus Drug-Eluting Stents in Acute Coronary Syndrome: Systematic Literature Review and Meta-Analysis. Biomedicines 2022; 10:3159. [PMID: 36551915 PMCID: PMC9775300 DOI: 10.3390/biomedicines10123159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/16/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
(1) Background: Practice guidelines define drug-eluting stents (DES) as the standard of care in coronary percutaneous coronary intervention (PCI), including in acute coronary syndrome (ACS). This is based on comparisons with bare-metal stents (BMS). However, non-drug-eluting titanium-nitride-oxide-coated stents (TiNOS) have not been taken into account. The objective of this study is to determine whether TiNOS can be used as an alternative to DES in ACS. (2) Methods: A prospective systematic literature review (SLR), conducted according to the PRISMA guidelines, was performed, wherein multiple literature databases from 2018 and 2022 were searched. Prospective, randomised, controlled trials comparing outcomes after PCI with TiNOS vs. DES in any coronary artery disease (CAD) were searched. Clinical outcomes were meta-analytic pooled risk ratios (RR) of device-oriented Major Adverse Cardiac Events (MACE) and their components. The analysis stratified outcomes reported with ACS-only vs. ACS jointly with chronic coronary syndrome (CCS). (3) Results: Five RCTs were eligible, comprising 1855 patients with TiNOS vs. 1363 with DES at a 1-year follow-up. Three enrolled patients presented with ACS only and two with ACS or CCS. The latter accounted for most of the patients. The one-year pooled RRs in those three RCTs were as follows: MACE 0.93 [0.72, 1.20], recurrent myocardial infarction (MI) 0.48 [0.31, 0.73], cardiac death (CD) 0.66 [0.33, 1.31], clinically driven target lesion revascularization (TLR) 1.55 [1.10, 2.19], and stent thrombosis (ST) 0.35 [0.20, 0.64]. Those results were robust to a sensitivity analysis. The evidence certainty was high in MACE and moderate or low in the other endpoints. (4) Conclusions: TiNOS are a non-inferior and safe alternative to DES in patients with ACS.
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Affiliation(s)
| | - Louis Létinier
- INSERM, BPH, U1219, Bordeaux University, 33000 Bordeaux, France
| | - Nicholas Moore
- INSERM, BPH, U1219, Bordeaux University, 33000 Bordeaux, France
| | - Pierre Coste
- Coronary Care Unit, Cardiologic Hospital, Bordeaux University, 33604 Pessac, France
| | - Pasi P. Karjalainen
- Cardiac Unit, Heart and Lung Center, Helsinki University Hospital, Helsinki University, 00280 Helsinki, Finland
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3
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Brown CS, Eton RE, Yaser JM, Syrjamaki JD, Corriere M, Henke PK, Englesbe MJ, Osborne NH. Assessment of Patterns of Atherectomy Use. J Am Heart Assoc 2022; 11:e023356. [PMID: 36300666 PMCID: PMC9750064 DOI: 10.1161/jaha.121.023356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 06/17/2022] [Indexed: 11/16/2022]
Abstract
Background Atherectomy has become the fastest growing catheter-based peripheral vascular intervention performed in the United States, and overuse has been linked to increased reimbursement, but the patterns of use have not been well characterized. Methods and Results We used Blue Cross Blue Shield of Michigan Preferred Provider Organization and Medicare fee-for-service professional claims data from the Michigan Value Collaborative for patients undergoing office-based laboratory atherectomy in 2019 to calculate provider-specific rates of atherectomy use, reimbursement, number of vessels treated, and number of atherectomies per patient. We also calculated the rate that each provider converted a new patient visit to an endovascular procedure within 90 days. Correlations between parameters were assessed with simple linear regression. Providers completing ≥20 office-based laboratory atherectomies and ≥20 new patient evaluations during the study period were included. A total of 59 providers performing 4060 office-based laboratory atherectomies were included. Median professional reimbursement per procedure was $4671.56 (interquartile range [IQR], $2403.09-$7723.19) from Blue Cross Blue Shield of Michigan and $14 854.49 (IQR, $9414.80-$18 816.33) from Medicare, whereas total professional reimbursement from both payers ranged from $2452 to $6 880 402 per year. Median 90-day conversion rate was 5.0% (IQR, 2.5%-10.0%), whereas the median provider-level average number of vessels treated per patient was 1.20 (IQR, 1.13-1.31) and the median provider-level average number of treatments per patient was 1.38 (IQR, 1.26-1.63). Total annual reimbursement for each provider was directly correlated with new patient-procedure conversion rate (R2=0.47; P<0.001), mean number of vessels treated per patient (R2=0.31; P<0.001), and mean number of treatments per patient (R2=0.33; P<0.001). Conclusions A minority of providers perform most procedures and are reimbursed substantially more per procedure compared with most providers. Procedural conversion rate, number of vessels, and number of treatments per patient represent potential policy levers to curb overuse.
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Affiliation(s)
- Craig S. Brown
- Section of General Surgery, Department of SurgeryUniversity of MichiganAnn ArborMI
- Center for Healthcare Outcomes and PolicyInstitute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
| | - Ryan E. Eton
- Section of General Surgery, Department of SurgeryUniversity of MichiganAnn ArborMI
- Center for Healthcare Outcomes and PolicyInstitute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
| | - Jessica M. Yaser
- Center for Healthcare Outcomes and PolicyInstitute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
| | - John D. Syrjamaki
- Center for Healthcare Outcomes and PolicyInstitute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
| | - Matthew A. Corriere
- Center for Healthcare Outcomes and PolicyInstitute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
- Section of Vascular Surgery, Department of SurgeryUniversity of MichiganAnn ArborMI
| | - Peter K. Henke
- Section of Vascular Surgery, Department of SurgeryUniversity of MichiganAnn ArborMI
| | - Michael J. Englesbe
- Section of General Surgery, Department of SurgeryUniversity of MichiganAnn ArborMI
- Center for Healthcare Outcomes and PolicyInstitute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
| | - Nicholas H. Osborne
- Center for Healthcare Outcomes and PolicyInstitute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
- Section of Vascular Surgery, Department of SurgeryUniversity of MichiganAnn ArborMI
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George EL, Wagner TH, Arya S. Atherectomy Overuse: Do Policy Solutions Exist? J Am Heart Assoc 2022; 11:e027422. [DOI: 10.1161/jaha.122.027422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elizabeth L. George
- Department of Surgery, Division of Vascular Surgery Stanford University School of Medicine Stanford CA
- VA Palo Alto Health Care System, Surgical Service Line Palo Alto CA
| | - Todd H. Wagner
- Veterans Affairs Health Economic Resource Center Palo Alto CA
| | - Shipra Arya
- Department of Surgery, Division of Vascular Surgery Stanford University School of Medicine Stanford CA
- VA Palo Alto Health Care System, Surgical Service Line Palo Alto CA
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Hupalo YM, Denysov SY, Kutsyn AM, Lebedieva YO, Grusha MM. PERCUTANEOUS TRANSLUMINAL ROTARY ATHERECTOMY IN PATIENTS WITH ATHEROSCLEROTIC LESIONS OF BELOW THE KNEE ARTERIES. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:2589-2593. [PMID: 36591737 DOI: 10.36740/wlek202211106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The aim: To determine the effectiveness of the combination of the percutaneous transluminal rotational atherectomy (PTRA) techniques with plain old balloon angioplasty (POBA) and POBA monotherapy (POBA-mono) in endovascular treatment (ET) of patients with occlusive-stenotic lesions below the knee (BTK) arteries. PATIENTS AND METHODS Materials and methods: We studied two groups, the main included patients (n=9) aged who underwent PTRA and POBA of BTK arteries, and the comparative group (POBA-mono) of patients (n=24) who underwent POBA monotherapy of BTK arteries. RESULTS Results: Thrombosis of the reconstructed segments in the target arteries after 12 months was diagnosed in 95% of patients of the control and 1 - main groups (Ft, p=0.00001). Healing of trophic ulcers of the foot in the first month after ET was observed in 78% (n=7) of patients of the main group and in 13% (n=3) of the control group (χ2 (1, n=33) = 10.2961; p=0.0013), and after 3 months - in 100% (n=9) and 83% (n=20) of patients in the respective groups. CONCLUSION Conclusions: The combination of PTRA with POBA reduces the probability of repeated violations of the patency of the target artery. In addition, it increases the healing efficiency of trophic ulcers of the LE compared to POBA monotherapy.
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Affiliation(s)
- Yurii M Hupalo
- STATE INSTITUTION OF SCIENCE «RESEARCH AND PRACTICAL CENTER OF PREVENTIVE AND CLINICAL MEDICINE» STATE ADMINISTRATIVE DEPARTMENT, KYIV, UKRAINE
| | | | - Anton M Kutsyn
- STATE INSTITUTION OF SCIENCE «RESEARCH AND PRACTICAL CENTER OF PREVENTIVE AND CLINICAL MEDICINE» STATE ADMINISTRATIVE DEPARTMENT, KYIV, UKRAINE; CLINICAL HOSPITAL «FEOFANIYA» STATE ADMINISTRATIVE DEPARTMENT, KYIV, UKRAINE
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Giusca S, Hagstotz S, Lichtenberg M, Heinrich U, Eisenbach C, Andrassy M, Korosoglou G. Phoenix atherectomy for patients with peripheral artery disease. EUROINTERVENTION 2022; 18:e432-e442. [PMID: 35389346 PMCID: PMC10331978 DOI: 10.4244/eij-d-21-01070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Endovascular atherectomy enables minimally invasive plaque removal in peripheral artery disease (PAD). AIMS We aimed to evaluate the safety and the long-term effectiveness of the Phoenix atherectomy for the treatment of complex and calcified lesions in PAD patients. METHODS Consecutive all-comer patients with PAD underwent the Phoenix atherectomy. Device safety in terms of perforation and distal embolisation were evaluated. Lesion calcifications were categorised by the Peripheral Arterial Calcium Scoring System (PACSS) and lesion complexity was assessed by the Transatlantic Inter-Society Consensus (TASC). Clinically driven target lesion revascularisation (TLR) was assessed. RESULTS A total of 558 lesions were treated in 402 consecutive patients. Clinical follow-up was available at 15.7±10.2 months for 365 (91%) patients. Of 402 patients, 135 (33.6%) had claudication, 37 (9.2%) had ischaemic rest pain and 230 (57%) exhibited ischaemic ulcerations. Lesions were mostly identified in the femoropopliteal segments (55%), followed by below-the-knee (BTK) segments (32%). Complex TASC C/D lesions and moderate to severe calcifications (PACSS score ≥2) were present in 331 (82%) and 323 (80%) patients, respectively. The mean lesion length was 20.6±14.3 cm. Five (1%) perforations and 10 (2%) asymptomatic embolisations occurred. Bail-out stenting was performed in 4%, 16% and 3% of patients with common femoral artery, femoropopliteal and BTK lesions, respectively. During follow-up, 5 (3.9%) patients with claudication and 52 (21.9%) patients with critical limb-threatening ischaemia (CLTI) died (hazard ratio [HR] 3.7; p<0.001). Freedom from TLR was 87.5% (112 of 128) in patients with claudication and 82.3% (195 of 237) in patients with CLTI, respectively (HR 1.8; p=0.03). CONCLUSIONS The Phoenix atherectomy can be safely performed in patients with complex lesions with a relatively low rate of bail-out stenting and clinically acceptable TLR rates. GERMAN CLINICAL TRIALS REGISTER DRKS00016708.
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Affiliation(s)
- Sorin Giusca
- GRN Hospital Weinheim, Cardiology and Vascular Medicine, Weinheim, Germany
| | - Saskia Hagstotz
- GRN Hospital Weinheim, Cardiology and Vascular Medicine, Weinheim, Germany
| | | | - Ulrike Heinrich
- Practice for Vascular Medicine and Gastroenterology, Weinheim, Germany
| | | | - Martin Andrassy
- Fuerst-Stirum Hospital, Cardiology and Vascular Medicine, Bruchsal, Germany
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Steiner S, Schmidt A. [Endovascular interventions for peripheral arterial disease]. Internist (Berl) 2022; 63:584-590. [PMID: 35532802 DOI: 10.1007/s00108-022-01351-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 12/24/2022]
Abstract
Successful revascularization of patients with peripheral arterial disease (PAD) requires a comprehensive understanding of the risk population and the available treatment options. Even the urgency of revascularization varies widely depending on the clinical presentation. Patients with intermittent claudication should undergo a structured exercise program before revascularization may become necessary, whereas acute limb ischemia is a medical emergency and must be revascularized within a few hours. Endovascular treatment techniques have evolved rapidly over the past 20 years. New technologies and procedural techniques allow even complex lesions to be successfully treated with endovascular techniques, and most patients can now be treated minimally invasively in line with an "endovascular first" strategy. Bypass surgery remains an important option for patients with advanced disease. The techniques used vary depending on the clinical presentation, location, and complexity of the lesion. Although the evidence for different techniques is limited, a variety of clinical and lesion factors are known to be critical for acute technical success and long-term patency rates. The use of paclitaxel-coated balloons and stents has been shown to significantly reduce restenosis and reintervention rates after femoropopliteal interventions. However, a late mortality signal associated with the use of these devices continues to be debated. After successful intervention, appropriate drug therapy and standardized follow-up should be established to prevent adverse limb events and reduce the high rate of cardiovascular events.
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Affiliation(s)
- Sabine Steiner
- Klinik und Poliklinik für Angiologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig (AöR), Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - Andrej Schmidt
- Klinik und Poliklinik für Angiologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig (AöR), Liebigstr. 20, 04103, Leipzig, Deutschland
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Brown CS, Eton RE, Corriere MA, Henke PK, Englesbe MJ, Osborne NH. Using Payment Incentives to Decrease Atherectomy Overutilization. Ann Vasc Surg 2021; 73:144-146. [PMID: 33485907 DOI: 10.1016/j.avsg.2021.01.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/10/2021] [Accepted: 01/14/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Craig S Brown
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.
| | - Ryan E Eton
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Matthew A Corriere
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Peter K Henke
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Michael J Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Nicholas H Osborne
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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