Variations in Revascularization Strategies for Chronic Limb-Threatening Ischemia: A Nationwide Analysis of Medicare

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Aishwarya Raja1, Yang Song2, Siling Li2

  • 1Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

JACC. Cardiovascular Interventions
|January 11, 2025
PubMed

Insights

This study reveals significant hospital variations in treating chronic limb-threatening ischemia (CLTI). Endovascular treatment at high-volume centers improved limb salvage rates, suggesting a need for standardized CLTI revascularization strategies.

Area of Science:

  • Vascular Surgery
  • Interventional Cardiology
  • Health Services Research

Background:

  • Contemporary data support both surgical and endovascular revascularization for chronic limb-threatening ischemia (CLTI).
  • However, hospital-based practice patterns and their outcomes remain incompletely understood.
  • This study addresses this gap by examining variations in CLTI treatment strategies across U.S. hospitals.

Purpose of the Study:

  • To characterize contemporary variations in surgical-first versus endovascular-first revascularization approaches for CLTI.
  • To evaluate the outcomes associated with these different strategies across U.S. hospitals.
  • To identify potential factors influencing treatment decisions and patient outcomes in CLTI management.

Main Methods:

  • Analysis of Medicare beneficiaries (≥66 years) with CLTI treated between October 2015 and December 2021.
  • Inclusion of patients from institutions offering both surgical and endovascular revascularization options.
  • Utilized marginal Cox regression, adjusting for patient-level covariates to compare outcomes.

Main Results:

  • 82.5% of 196,070 patients underwent endovascular treatment, with significant interhospital variability (median OR 2.32).
  • Endovascular treatment at high-quintile hospitals correlated with lower major amputation rates (aHR 0.82) but higher repeat procedures (aHR 1.37).
  • Surgical bypass at high-quintile hospitals showed higher amputation rates (aHR 1.21) and fewer repeat procedures (aHR 0.73).

Conclusions:

  • Significant interhospital variability exists in CLTI revascularization strategies.
  • Endovascular treatment at higher-volume centers is associated with improved limb salvage outcomes.
  • Standardization of CLTI treatment protocols is crucial for enhancing limb salvage rates.
Abstract

Keywords:
CLICLTIDCBDESPADquality

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