Endovascular interventions for claudication do not meet minimum standards for the Society for Vascular Surgery
Jonathan Bath1, Peter F Lawrence2, Dan Neal3
1Division of Vascular Surgery, University of Missouri, Columbia, Mo.
Insights
Endovascular treatment for intermittent claudication (IC) shows suboptimal long-term outcomes, with only 32% of patients remaining symptom-free at two years. Medical management optimization and careful consideration of atherectomy and multivessel interventions are crucial for improving results.
Area of Science:
- Vascular Surgery
- Endovascular Interventions
- Public Health
Background:
- Intermittent claudication (IC) treatment is elective, necessitating excellent short- and long-term outcomes.
- The Vascular Quality Initiative (VQI) provides real-world data on peripheral vascular interventions.
- Society for Vascular Surgery (SVS) guidelines offer benchmarks for IC treatment success.
Purpose of the Study:
- To evaluate endovascular management outcomes for IC using VQI data.
- To compare real-world IC treatment results against SVS guidelines.
- To identify factors influencing IC recurrence and repeat procedures.
Main Methods:
- Analysis of 16,152 patients undergoing peripheral vascular intervention for IC (2004-2017) with >9-month follow-up.
- Primary outcomes: IC recurrence and repeat procedures within 2 years.
- Adjusted analyses and life-table analysis at 2 years.
Main Results:
- Only 32% of patients were free from IC recurrence at 2 years, falling short of SVS guidelines (>50%).
- Treatment of >2 arteries and use of atherectomy were associated with higher recurrence and repeat procedure rates.
- Discharge with antiplatelet and statin medications correlated with better long-term outcomes.
Conclusions:
- Most endovascular IC treatments do not meet SVS long-term efficacy guidelines.
- Many patients lack pre-procedure medical management optimization.
- Atherectomy and multivessel interventions are linked to poorer outcomes; patient counseling is essential.
Objective:
Because the treatment of intermittent claudication (IC) is elective, good short- and long-term outcomes are imperative. The objective of the present study was to examine the outcomes of endovascular management of IC reported in the Vascular Quality Initiative and compare them with the Society for Vascular Surgery guidelines for IC treatment to determine whether real-world results are within the guidelines.
Methods:
Patients undergoing peripheral vascular intervention for IC from 2004 to 2017 with complete data and >9 month follow-up were included. The primary outcome measures were IC recurrence and repeat procedures performed ≤2 years after the initial treatment.
Results:
A total of 16,152 patients met the inclusion criteria, with a mean age of 66 years. Of the 16,152 patients, 61% were men, 45% were current smokers, and 28% had been discharged without antiplatelet or statin medication. Adjusted analyses revealed that treatment of more than two arteries was associated with a shorter time to IC recurrence (hazard ratio [HR], 1.19; 95% confidence interval [CI], 1.09-1.31) and a shorter time to repeat procedures (HR, 1.25; 95% CI, 1.09-1.45). The use of atherectomy was also associated with a shorter time to IC recurrence (HR, 1.29; 95% CI, 1.08-1.33) and a shorter time to repeat procedures (HR, 1.31; 95% CI, 1.13-1.52). Discharge with antiplatelet and statin medications was associated with a longer time to IC recurrence (HR, 0.84; 95% CI, 0.78-0.91) and a longer time to repeat procedures (HR, 0.77; 95% CI, 0.69-0.87). Life-table analysis at 2 years revealed that only 32% of patients were free from IC recurrence, although 76% had not undergone repeat procedures. Stratified by anatomic treatment level, 37% of isolated aortoiliac interventions, 22% of aortoiliac and femoropopliteal interventions, 30% of isolated femoropopliteal interventions, and 20% of femoropopliteal and tibial interventions had remained free from IC recurrence at 2 years.
Conclusions:
Most patients treated with an endovascular approach to IC did not meet the Society for Vascular Surgery guidelines for long-term freedom from recurrent symptoms of >50% at 2 years. Many lacked preprocedure optimization of medical management. The use of atherectomy and treatment of more than two arteries were associated with poor outcomes after peripheral vascular intervention for IC, because only 32% of these patients were free from recurrent symptoms at 2 years. Even when risk factor modification is optimized before the procedure, vascular specialists should be aware of the association between atherectomy and multivessel interventions with poorer long-term outcomes and counsel patients appropriately before intervention.
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