Local Referral of Peripheral Arterial Disease Patients to Improve Surgical Outcomes

The BEST-CLI trial demonstrated that in select patients with chronic limb threatening ischemia , open surgical bypass yields superior outcomes compared to an endovascular-first approach. Challenges in access to vascular surgeons who perform lower extremity bypass may hinder the adoption of BEST-CLI informed treatment strategies into routine clinical practice. We evaluated the contemporary procedural landscape of providers performing lower extremity peripheral vascular interventions (PVIs) and assessed the potential travel burden associated with transitioning care from non-surgical interventionalists to vascular surgeons.

We analyzed the Centers for Medicare & Medicaid Services (CMS) Provider Utilization and Payment Data Public Use Files from 2021-2023. Providers performing PVIs, including diagnostic angiography, percutaneous transluminal angioplasty, stenting, and atherectomy, were identified and categorized as cardiology, radiology, or vascular surgery. Procedures were aggregated at the provider level. Spatial analysis was performed to assess trends in procedural volume and the distance between provider ZIP codes.

More than 1 million PVIs were performed in the United States between 2021 and 2023, with approximately 60% performed by cardiology and radiology. Among the 642,353 PVIs performed by cardiology and radiology, 51% occurred in the same ZIP code as a practicing vascular surgeon. Overall, 90% of PVIs performed by radiology and cardiology were conducted within 25 miles of a vascular surgeon. Although travel distance varied by state, in 39 states and the District of Columbia, more than 75% of PVIs by cardiology and radiology occurred within 10 miles of a vascular surgeon.

Although a majority of PVIs are performed by cardiology and radiology, most occur with close geographic proximity to a practicing vascular surgeon. For the subset of patients most likely to benefit from open surgical bypass, these findings suggest that transitioning care from non-surgical interventionalists to vascular surgeons would impose minimal additional travel burden in most regions of the United States.