Kawaji Q, Dun C, Walsh C, Sorber RA, Stonko DP, Abularrage CJ, Black JH, Perler BA, Makary MA, Hicks CW. Index Atherectomy Peripheral Vascular Interventions Performed for Claudication are Associated with More Reinterventions than Non-Atherectomy Interventions.
J Vasc Surg 2022;
76:489-498.e4. [PMID:
35276258 PMCID:
PMC9329163 DOI:
10.1016/j.jvs.2022.02.034]
[Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/16/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVE
Despite limited evidence supporting atherectomy alone over stenting/angioplasty as the index peripheral vascular intervention (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 between 1/1/2019-12/31/2019. Subsequent PVI reinterventions were examined through 6/30/2021. Kaplan-Meier curves were used to compare the rate of PVI reinterventions for patients who received index atherectomy vs. non-atherectomy procedures. Reintervention rates were also described for physicians by their overall atherectomy use (by quartile). A hierarchical Cox proportional hazard model was used to evaluate patient and physician-level characteristics associated with reinterventions.
RESULTS
A total of 15,246 patients underwent index PVI for claudication in 2019, of which 59.7% were atherectomy. After a median of 603 days (IQR 77, 784) of follow-up, 41.2% of patients underwent a PVI reintervention, including 48.9% of patients who underwent index atherectomy vs. 29.8% of patients who underwent index non-atherectomy (P<0.001). Patients treated by high physician users of atherectomy (quartile 4) received more reinterventions than patients treated by standard physician users (quartiles 1-3) (56.8% vs. 39.6%, P<0.001). After adjustment, patient factors association with PVI reintervention included receipt of index atherectomy (aHR 1.33, 95% CI 1.21-1.46), Black race (vs. White, aHR 1.18, 95% CI 1.03-1.34), diabetes (aHR 1.13, 95% CI 1.07-1.21), and urban residence (aHR 1.11, 95% CI 1.01-1.22). Physician factors associated with reintervention included male sex (aHR 1.52, 95% CI 1.12-2.04), high-volume PVI practices (aHR 1.23, 95% CI 1.10-1.37), and physicians with high use of index atherectomy (aHR 1.49, 95% CI 1.27-1.74). Vascular surgeons had a lower risk of PVI reintervention than Cardiologists (vs. Vascular, aHR 1.22, 95% CI 1.09-1.38), Radiologists (aHR 1.55, 95% CI 1.31-1.83), and other specialties (aHR 1.59, 95% CI 1.20-2.11). Location of services delivered was not associated with reintervention (P>0.05).
CONCLUSIONS
The use of atherectomy as an index PVI for claudication is associated with higher PVI reintervention rates compared to non-atherectomy procedures. Similarly, high physician users of atherectomy perform more PVI reinterventions than their peers. The appropriateness of using atherectomy for initial treatment of claudication needs critical reevaluation.
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