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Peripheral vascular complications in the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-I)
N A Omoigui1, R M Califf, K Pieper
1Department of Medicine, University of South Carolina, Columbia, USA.
Insights
Peripheral vascular complications occurred in 6.6% of patients undergoing coronary intervention, with similar rates for angioplasty and atherectomy. Risk factors include older age, female gender, and post-procedure heparin, leading to increased costs and mortality.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Peripheral vascular complications (PVCs) after coronary interventions are not fully understood.
- Characterizing PVCs based on randomized therapy is crucial for risk assessment and cost analysis.
Purpose of the Study:
- To compare in-hospital PVCs between balloon angioplasty and directional atherectomy.
- To identify patient and procedural risk factors for PVCs.
- To evaluate the impact of PVCs on hospital costs and long-term outcomes.
Main Methods:
- 1,012 patients were randomized in the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-I).
- PVCs defined as pulse loss, pseudoaneurysm, large hematoma, or transfusion-requiring hemorrhage.
- Logistic models used to predict risk and assess impact on costs and outcomes.
Main Results:
- 6.6% of patients experienced PVCs; no significant difference between angioplasty and atherectomy.
- Predictors of PVCs included older age, female gender, postprocedural heparin, and intraaortic balloon counterpulsation.
- PVCs significantly increased hospital costs (nearly twofold) and 1-year mortality (sevenfold).
Conclusions:
- Balloon angioplasty and directional atherectomy have similar in-hospital PVC rates.
- Identifying and mitigating risk factors like advanced age and specific medications is essential.
- Preventing PVCs is critical due to their substantial impact on healthcare costs and patient survival.
Objectives:
In-hospital peripheral vascular complications of balloon angioplasty were compared with those of directional atherectomy in the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-I) to identify patients at risk and evaluate costs and outcomes.
Background:
The incidence, costs and outcomes of peripheral vascular complications after coronary intervention have not been fully characterized as a function of randomly assigned therapy.
Methods:
At 35 sites in the United States and Europe, 1,012 patients were randomized. Peripheral vascular complications were defined as the composite of pulse loss, pseudoaneurysm, hematoma > 4 cm in diameter or groin hemorrhage necessitating blood transfusion. Logistic models were derived to 1) predict these complications from baseline and procedural characteristics, 2) test the relevance of randomization assignment, and 3) assess their impact on hospital costs and long-term outcomes.
Results:
Sixty-seven patients (6.6%) developed peripheral vascular complications, of whom 15 (22.4%) required a blood transfusion, 14 (20.9%) underwent vascular surgery, and 2 (3.0%) died. Both in-hospital deaths occurred in patients with peripheral vascular complications. There was no difference in composite peripheral vascular complication rates among patients randomized to angioplasty or atherectomy. Greater age, female gender, postprocedural heparin and intraaortic balloon counterpulsation were predictive of increased risk. In a representative 60% subset, mean hospital costs increased from $9,583 in patients without to $18,350 in those with peripheral vascular complications (p = 0.0001). The unadjusted mortality rate at 1 year was 7.5% for patients with peripheral vascular complications compared with 1.1% for all others (p = 0.0001). These complications identified patients at greater risk of death, myocardial infarction or repeat revascularization at 30 days and 1 year. The atherectomy group had a trend toward more frequent deaths and myocardial infarction.
Conclusions:
Directional atherectomy and balloon angioplasty had similar in-hospital peripheral vascular complication rates. Female gender, greater age, postprocedural heparin and intraaortic balloon counterpulsation were predictive of higher risk. The twofold increase in cost and sevenfold increase in long-term deaths highlight the need to prevent these periprocedural events and monitor patients closely.