Comparison of isolated popliteal interventions in chronic limb-threatening ischemia

Although the Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia trial demonstrated superiority of bypass with single-segment great saphenous vein for chronic limb-threatening ischemia (CLTI), an endovascular-first approach remains appropriate for patients lacking single-segment great saphenous vein, those who are high risk for open surgery, and most patients with Global Limb Anatomic Staging System stage I disease. Isolated popliteal artery disease is an anatomically challenging disease pattern for which evidence to drive operative decisions is lacking. The objective of this study was to compare endovascular therapies (EVTs) for isolated popliteal artery disease with CLTI.

All isolated popliteal EVT performed for CLTI were identified within the Vascular Quality Initiative database from 2017 to 2022 and those with available long-term follow-up data were included. The main exposure was type of EVT and the primary end point was limb salvage.

There were 3330 EVT isolated to the popliteal segment, of which 881 (26.5%) were plain balloon angioplasty, 927 (27.8%) were special balloon angioplasty (drug coated, cutting, lithotripsy), 835 (25.1%) included stents, and 687 (20.6%) included atherectomy. Atherectomy as part of the endovascular treatment strategy was associated with higher 1-year freedom from major amputation when compared against all other interventions combined (94.7% vs 89.2%; adjusted hazard ratio [HR] for amputation, 0.632; P = .022), as well as plain balloon angioplasty alone (94.7% vs 88.3%; adjusted HR for amputation, 0.502; P = .003) and special balloon angioplasty alone (94.7% vs 87.4%; adjusted HR for amputation, 0.456; P < .001). Although including atherectomy and stent as part of the endovascular treatment resulted in equivalent 1-year freedom from major amputation (94.7% vs 92.1%; P = .201), this result was driven by greater use of atherectomy in patients with diabetes. When selecting only for patients with diabetes, atherectomy with or without other EVTs demonstrated greater 1-year freedom from major amputation than stenting (univariate, 93.4% vs 86.1%; adjusted HR for amputation, 0.541; P = .019).

Atherectomy as a part of an endovascular treatment strategy may be associated with improved limb salvage compared with other EVTs among patients with CLTI requiring interventions limited to the popliteal artery.