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Imaging practices following peripheral vascular intervention in chronic limb-threatening ischemia and association
Kim G Smolderen1,2, Mufti M Rahman1, Gaëlle Romain1
1Department of Internal Medicine, Cardiovascular Medicine Section, Vascular Medicine Outcomes Program, Yale School of Medicine, New Haven, CT, USA.
Insights
Peripheral vascular interventions (PVI) for chronic limb-threatening ischemia (CLTI) show variable post-procedure imaging practices. More imaging was linked to higher amputation rates, suggesting a need for standardized follow-up protocols.
Area of Science:
- Vascular Surgery
- Health Services Research
- Medical Imaging
Background:
- Peripheral vascular interventions (PVI) aim to prevent amputation in chronic limb-threatening ischemia (CLTI).
- Current imaging practices following PVI for CLTI and their association with amputation outcomes are not well-defined.
- Understanding these practices is crucial for optimizing patient care and outcomes.
Purpose of the Study:
- To analyze post-PVI imaging patterns in CLTI patients.
- To assess variability in imaging utilization across different healthcare sites.
- To investigate the relationship between post-PVI imaging and 1-year major amputation rates.
Main Methods:
- Utilized Medicare-linked Vascular Quality Initiative data from 2017-2019.
- Identified patients undergoing PVI for CLTI and tracked imaging tests (ABI, duplex ultrasound, MRA, CTA) within one year.
- Employed median odds ratio (MOR) and intraclass correlation coefficient (ICC) for site variability; used competing risk analysis in a propensity-matched cohort for outcome association.
Main Results:
- 25.5% of 10,006 CLTI patients received no post-PVI imaging; ankle-brachial index (ABI) was most common.
- Significant site variability in imaging use was observed (MOR 1.64, ICC 7.6%).
- No imaging was associated with lower amputation rates (5.7%) compared to ≥1 imaging (8.8%), while more imaging correlated with higher amputation rates (SHR 1.83).
Conclusions:
- Post-PVI imaging practices for CLTI exhibit substantial variability.
- Higher rates of imaging were observed in patients with higher amputation rates, but causality is uncertain.
- Development and study of standardized follow-up imaging protocols are recommended to improve clinical outcomes.
Abstract:
Background: Peripheral vascular interventions (PVI) in chronic limb-threatening ischemia (CLTI) are used to prevent amputation. However, imaging practices following PVI and their correlation with amputation outcomes remain unclear. Methods: Using Medicare-linked Vascular Quality Initiative data (2017-2019), we identified imaging tests (ankle-brachial index [ABI], duplex ultrasound, magnetic resonance angiography, computed tomography angiography) ordered within 1 year post-PVI for CLTI. Site variability was assessed using median odds ratio (MOR) and intraclass correlation coefficient (ICC). The association between post-PVI imaging and 1-year major amputation was examined using competing risk analyses in a propensity-matched cohort. Results: We included 10,006 patients (mean age: 72.1 ± 11.0 years); 25.5% received no imaging. Over 50% of imaging tests were ABI and 83.1% were ordered within 3 months. Significant site variability was noted (none vs ⩾ 1: MOR 1.64, 95% CI 1.50-1.78; ICC 7.6%, 95% CI 5.2-9.9%; per one-unit increase in monthly volume: MOR 1.06, 95% CI 1.05-1.07; ICC 9.4%, 95% CI 7.0-11.8%). Having none versus ⩾ 1 imaging tests post-PVI occurred more in patients with lower 1-year major amputation rates (5.7%, 95% CI 5.0-6.6% vs 8.8%, 95% CI 7.9-9.9%, p < 0.001; subdistribution hazard ratio [SHR] 0.63, 95% CI 0.53-0.76, p < 0.001). More imaging ordered was correlated with a higher rate of major amputation (SHR 1.83, 95% CI 1.52-2.20, p < 0.001). Conclusions: Imaging practices post-PVI for CLTI are highly variable. Imaging tests are more often ordered in patients with higher amputation rates, but causality cannot be inferred. Additional information about symptom status and access to care are necessary. Standardized follow-up imaging protocols need to be developed and studied for improved clinical outcomes.
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