Index Below-Knee Endovascular Intervention for Intermittent Claudication Is Associated with Increased Amputation Risk

Guidelines advise against infrapopliteal peripheral vascular intervention (PVI) for intermittent claudication (IC) due to potential harm with unclear benefit. We hypothesized that below-knee intervention at index PVI for IC confers higher future amputation risk than above-knee-only treatment.

From the VQI PVI registry (2015-2025), we identified elective, initial PVIs for IC and compared those patients undergoing above-knee-only treatment (AK) to those having any below-knee intervention (BK). Using our previously described methodology, long-term amputation data were obtained by linking the PVI and amputation registries via unique patient identifiers. Demographic and procedural data were analyzed descriptively. Kaplan-Meier Analysis estimated risk of major and any (major+minor) amputation, with independent predictors of amputation identified by multivariable Firth logistic regression.

Among 92,899 treated limbs (81,338 AK; 11,561 BK), BK patients had increased rates of diabetes (54% vs. 41%), CHF (18% vs. 13%), and ESRD/dialysis (4.7% vs. 1.7%, p<0.001). BK patients were more likely to be Black (21% vs. 13%, p<0.001), Hispanic (8.8% vs. 4.3%, p<0.001), and Asian (1.5% vs. 1.0%, p<0.001). Smoking history predominated in AK (89% vs. 67%, p<0.001). 16,086 limbs required repeat PVI, 13,831 (17%) in the AK group vs. 2,255 (20%) in the BK group (p<0.001). At reintervention, BK patients were more likely to have progressed to CLTI (41% vs. 25%; p<0.001) and undergo ≥2 repeat interventions (32% vs. 27%; p<0.001). Initial below-knee intervention was associated with greater ipsilateral major (OR 2.39;1.70-3.35) and any (OR 2.36;1.75-3.18) amputation. Kaplan-Meier showed increased major [1-year (0.3% vs 0.1%);5-years (0.4% vs 0.1%)] and any amputation risk [1-year (0.5% vs 0.1%); 5-years (0.7% vs 0.2%).

Index below-knee intervention for IC portends greater risk of progression to CLTI, repeat PVI, and ipsilateral amputation, highlighting the potentially dangerous treatment trap of infrapopliteal intervention in patients with intermittent claudicants.