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Influence of specialty on endovascular practice patterns and outcomes in the BEST-CLI Trial
Richard J Powell1, Matthew T Menard2, Kenneth Rosenfield3
1Dartmouth Health Heart and Vascular Center, Geisel School of Medicine at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Insights
Interventional radiologists (IRs) demonstrated better outcomes in the BEST-CLI trial for chronic limb-threatening ischemia (CLTI) compared to interventional cardiologists (ICs) and vascular surgeons (VSs). IRs had fewer major adverse limb events and deaths, with no difference in amputation rates.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Interventional Radiology
- Endovascular Therapy
- Chronic Limb-Threatening Ischemia (CLTI)
Background:
- The BEST-CLI trial compared endovascular therapy (EVT) and open surgical therapy for patients with CLTI.
- This analysis focuses on practice patterns and outcomes within the EVT arm across different specialties: interventional cardiologists (ICs), interventional radiologists (IRs), and vascular surgeons (VSs).
Purpose of the Study:
- To evaluate differences in endovascular practice patterns among ICs, IRs, and VSs within the BEST-CLI trial.
- To compare clinical outcomes, including major adverse limb events (MALE) and death (MALE-death), between specialties performing EVT for CLTI.
Main Methods:
- Analysis included patients undergoing EVT by credentialed ICs, IRs, and VSs in the BEST-CLI trial.
- Demographics and practice patterns were compared using analysis of variance.
- Primary endpoint: MALE-death. Secondary endpoints included major revascularization, amputation, and death.
Main Results:
- Vascular surgeons treated the majority of EVT patients and more frequently those with severe ischemia (grade 3).
- Interventional cardiologists utilized more P2Y12 inhibitors, clopidogrel, dual antiplatelet therapy, and treated tibial arteries more often, employing atherectomy, drug-coated balloons, and drug-eluting stents.
- Interventional radiologists showed a significantly lower incidence of MALE-death (driven by lower death and major revascularization rates) compared to ICs and VSs. No significant difference in amputation rates was observed between specialties.
Conclusions:
- Significant variations in practice patterns and patient characteristics exist among ICs, IRs, and VSs performing EVT for CLTI.
- Interventional radiologists demonstrated superior outcomes regarding MALE-death and overall mortality compared to interventional cardiologists and vascular surgeons.
- Despite outcome differences, amputation rates were comparable across specialties, highlighting the need for further investigation into practice variations.
Objective:
The Best Endovascular vs best Surgical Therapy in Patients with Chronic Limb-threatening Ischemia (CLTI) (BEST-CLI) trial was a multi-specialty trial that compared endovascular therapy with open surgery in patients with CLTI. We evaluated differences in endovascular practice patterns and outcomes among participating specialties.
Methods:
All patients who underwent endovascular therapy performed by interventional cardiologists (ICs), interventional radiologists (IRs), and vascular surgeons (VSs) who met credentialing criteria in the trial were included in the analysis. Between-specialty group differences in demographics and practice patterns were evaluated using analysis of variance. The primary endpoint was major adverse limb events (MALE) and death (MALE-death); subcomponents of major revascularization, above-ankle amputation, and death were also examined.
Results:
VSs treated the majority of the patients in the endovascular arm of BEST-CLI and more frequently treated patients of African-American descent and those with grade 3 limb ischemia (P = .016). ICs more frequently treated patients of Hispanic ethnicity, and utilized P2Y12 inhibitors (P = .005), clopidogrel (P = .021), and dual antiplatelet therapy (P = .002) compared with IRs and VSs. ICs also more often treated tibial arteries (P = .007), and utilized atherectomy (P < .001), drug-coated balloon angioplasty (P < .001), and drug-eluting stents (P < .001). There was no difference in endovascular technical failure between the groups. Over the course of follow-up, IRs had a lower incidence of MALE-death compared with ICs (IC vs IR: rate ratio [RR], 2.34; 95% confidence interval [CI], 1.45-3.77; P = .0005) and VS (IR vs VS: RR, 0.54; 95% CI, 0.37-0.77; P = .0007). This was largely driven by a lower incidence of death (IC vs IR: RR, 3.16; 95% CI, 1.80-45.55; P < .0001; IR vs VS: RR, 0.44; 95% CI, 0.28-0.70; P = .0005) and major revascularization (IC vs IR: RR, 1.56; 95% CI, 0.67-3.63; P = .30; IR vs VS: RR, 0.55; 95% CI, 0.32-0.96; P = .034). There was no difference in above-ankle amputation between the groups (IC vs IR: RR, 1.55; 95% CI, 0.74-3.22; P = .24; IC vs VS: RR, 1.12; 95% CI, 0.60-2.07; P = .72, IR vs VS: RR, 0.72; 95% CI, 0.42-1.24; P = .24).
Conclusions:
Significant differences in practice patterns were seen between ICs, IRs, and VSs in BEST-CLI. The majority of patients were enrolled by VSs. There was significant differences in severity of patient CLTI at presentation. Although IRs had a lower incidence of MALE-death, death, and major revascularization compared with ICs and VSs, there was no difference in major amputation between the specialties.
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