Index atherectomy peripheral vascular interventions performed for claudication are associated with more
Qingwen Kawaji1, Chen Dun2, Christi Walsh3
1Department of Plastics and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
Insights
Atherectomy use in peripheral vascular intervention (PVI) for claudication is linked to increased reintervention rates. High atherectomy use by physicians also correlates with more reinterventions, questioning its appropriateness for initial treatment.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Health Services Research
Background:
- Peripheral vascular intervention (PVI) use is increasing, with a notable rise in atherectomy despite limited comparative evidence.
- Previous studies identified significant variability in atherectomy practice patterns among physicians.
Purpose of the Study:
- To investigate the association between index atherectomy and subsequent peripheral vascular intervention (PVI) reintervention rates.
- To analyze patient and physician factors influencing PVI reintervention after initial treatment for claudication.
Main Methods:
- Retrospective analysis of Medicare fee-for-service claims for patients undergoing elective first-time femoropopliteal PVI for claudication (2019-2021).
- Comparison of reintervention rates using Kaplan-Meier curves for atherectomy vs. nonatherectomy index procedures.
- Hierarchical Cox proportional hazard modeling to identify predictors of reintervention.
Main Results:
- Atherectomy was used in 59.7% of index PVIs. Patients receiving index atherectomy had higher reintervention rates (48.9%) compared to nonatherectomy (29.8%).
- High physician atherectomy users (quartile 4) had significantly more reinterventions (56.8%) than standard users (39.6%).
- Index atherectomy (aHR, 1.33), Black race, diabetes, urban residence, male physician sex, high-volume PVI practices, and high physician atherectomy use were associated with increased reintervention. Vascular surgeons had lower reintervention risk than cardiologists, radiologists, and other specialties.
Conclusions:
- Index atherectomy for claudication is associated with higher rates of subsequent PVI reintervention compared to nonatherectomy procedures.
- Physician preference for atherectomy correlates with increased reintervention rates, suggesting a need to re-evaluate its appropriateness for initial claudication treatment.
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:
We used 100% Medicare fee-for-service claims to identify all beneficiaries who underwent elective first-time femoropopliteal PVI for claudication between January 1, 2019, and December 31, 2019. Subsequent PVI reinterventions were examined through June 30, 2021. Kaplan-Meier curves were used to compare rates of PVI reinterventions for patients who received index atherectomy versus nonatherectomy 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 an index PVI for claudication in 2019, of which 59.7% were atherectomy. After a median of 603 days (interquartile range, 77-784 days) of follow-up, 41.2% of patients underwent a PVI reintervention, including 48.9% of patients who underwent index atherectomy versus 29.8% of patients who underwent index nonatherectomy (P < .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 < .001). After adjustment, patient factors association with PVI reintervention included receipt of index atherectomy (adjusted hazard ratio [aHR], 1.33; 95% confidence interval [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 a 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). The location of services delivered was not associated with reintervention (P > .05).
Conclusions:
The use of atherectomy as an index PVI for claudication is associated with higher PVI reintervention rates compared with nonatherectomy 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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