Provider Trends in Atherectomy Volume between Office-Based Laboratories and Traditional Facilities

Device regulation and surveillance in vascular care: Challenges and opportunities

Cardiovascular devices are essential for the treatment of cardiovascular diseases including cerebrovascular, coronary, valvular, congenital, peripheral vascular and arrhythmic diseases. The regulation and surveillance of vascular devices in real-world practice, however, presents challenges during each individual product's life cycle. Four examples illustrate recent challenges and questions regarding safety, appropriate use and efficacy arising from FDA approved devices used in real-world practice. We outline potential pathways wherein providers, regulators and payors could potentially provide high-quality cardiovascular care, identify safety signals, ensure equitable device access, and study potential issues with devices in real-world practice.

Effects of atherectomy on major adverse limb events for femoropopliteal interventions: Vascular Quality Initiative registry

BACKGROUND

Atherectomy use in treatment of femoropopliteal disease has significantly increased despite scant evidence of benefit to long-term clinical outcomes.

AIMS

We investigated the clinical benefits of atherectomy over standard treatment for femoropopliteal interventions.

METHODS

Using data from the Society of Vascular Surgery's Vascular Quality Initiative (VQI) registry, we identified patients who underwent isolated femoropopliteal interventions for occlusive disease. We compared 13,423 patients treated with atherectomy with 47,371 receiving standard treatment; both groups were allowed definitive treatment with a drug-coated balloon or stenting. The primary endpoint was major adverse limb events (MALEs), which is a composite of target vessel re-occlusion, ipsilateral major amputation, and target vessel revascularization.

RESULTS

Mean age was 69 ± 11 years, and patients were followed for a median of 30 months. Overall rates of complications were slightly higher in the atherectomy group than the standard treatment group (6.2% vs. 5.9%, p < 0.0001). In multivariable analysis, after adjusting for demographic and clinical covariates, atherectomy use was associated with a 13% reduction in risk of MALEs (adjusted odds ratio [aOR]: 0.87; 95% confidence interval [CI]: 0.77-0.98). Rates of major and minor amputations were significantly lower in the atherectomy group (3.2% vs. 4.6% and 3.3% vs. 4.3%, respectively, both p < 0.001), primarily driven by a significantly decreased risk of major amputations (aOR 0.69; 95% CI: 0.52-0.91). There were no differences in 30-day mortality, primary patency, and target vessel revascularization between the atherectomy and standard treatment groups.

CONCLUSIONS

In adults undergoing femoropopliteal interventions, the use of atherectomy was associated with a reduction in MALEs compared with standard treatment.

Safety considerations with the current ambulatory trends: more complicated procedures and more complicated patients

In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.

Incidence of Procedure-Related Complications in Patients Treated With Atherectomy in the Femoropopliteal and Tibial Vessels in the Vascular Quality Initiative

PURPOSE

To compare procedural complications in patients undergoing atherectomy plus angioplasty (A+A) and plain balloon angioplasty (POBA).

MATERIALS AND METHODS

Patients in the Vascular Quality Initiative (VQI) registry undergoing first-time peripheral vascular intervention (PVI) were included. Those undergoing aortoiliac or pedal interventions, primary stenting, or hybrid procedures were excluded. Patients were stratified by lesion location (femoropopliteal [FP] or tibial [TIB]). The primary outcomes were target vessel dissection, distal embolization, and provisional stent placement. Secondary outcomes included postoperative complications and the need for subsequent interventions.

RESULTS

12 499 patients undergoing FP (49.6% A+A) and 6736 patients undergoing TIB (17.0% A+A) interventions were identified. In the FP group, A+A was associated with greater intraoperative target vessel dissection (4.5% vs 2.6%, p<0.001), distal embolization (1.5% vs 0.7%, p =0.001), and provisional stent placement (1.5% vs 0%, p<0.001); and greater postoperative target vessel dissection (4.2% vs 2.0%, p<0.001) and distal embolization (0.9% vs 0.4%, p=0.034). In the TIB group, A+A was associated with fewer intraoperative vessel dissection (0.8% vs 2.3%, p=0.011) but greater provisional stent placement (0.3% vs 0%, p<0.001). TIB A+A was also associated with higher rates of technical success (97.6% vs 95.1%, p<0.001).

CONCLUSIONS

Atherectomy was associated with increased procedural-related complications in femoropopliteal, but not in tibial vessels. Future studies addressing lesion morphology, device design, and technique may help define its role in peripheral vascular interventions.

In-office needle arthroscopy is a cost-effective alternative for operating room diversion in medial meniscectomy: a financial analysis

BACKGROUND

In-office needle arthroscopy (IONA) has been described as a diagnostic alternative to magnetic resonance imaging (MRI) for intra-articular pathology. However, few studies have analyzed its impact on cost and wait times when used as a therapeutic intervention. The purpose of this study was to investigate the impact on cost and wait times associated with offering IONA for partial medial meniscectomy as an alternative to traditional operating room (OR) arthroscopy for patients with irreparable medial meniscus tears on MRI.

METHODS

Two models were created comparing the existing care pathway (current state) to a proposed future state utilizing IONA. Data sources were accounting data from an academically affiliated hospital in Canada and supplemented with literature values. A Monte Carlo simulation combined with DuPont analysis running 10,000 simulations was conducted to calculate the revenue, expenses, profits, and effect on surgical waitlists (i.e., throughput) between the states. Sensitivity analyses examined the influence of patient preference and revision rates on profit and throughput. Two-sample Student's t test was performed (p < .05).

RESULTS

An average of 198 (standard deviation (SD) 31) patients underwent arthroscopic meniscectomy or repair each year from 2016 to 2020. The IONA revision rate was calculated as 20.3%. Compared to the current state, annual expenses in the IONA pathway were significantly reduced ($266,912.68 versus $281,415.23, p < .0001), while improving throughput by 21.2% (3.54%). Sensitivity analysis revealed 10% of patients need to select IONA over traditional OR arthroscopy with the revision rate remaining below 40% for the proposed state profit to be higher than the current state.

CONCLUSIONS

IONA is a cost-effective alternative to traditional OR arthroscopy in patients undergoing partial medial meniscectomy. The next steps are to assess patients' perceptions of IONA as an alternative to traditional OR arthroscopy, and to carry out clinical trials to determine the efficacy, patient-reported outcome metrics, and complications of IONA.

Reprint of: Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia

OBJECTIVE

Despite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions.

METHODS

We evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs.

RESULTS

A total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75).

CONCLUSIONS

Early PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.

Revascularizations and limb outcomes of hospitalized patients with diabetic peripheral arterial disease in the contemporary era

BACKGROUND

Concomitant diabetes mellitus and peripheral artery disease (PAD) is a complex disease process. This retrospective analysis of the National Inpatient Sample sought to understand trends in limb outcomes of this unique and prevalent cohort of patients.

METHODS

The National Inpatient Sample was queried between 2003 and 2017 for hospitalizations of patients with both type 2 diabetes mellitus and PAD. Trends in hospitalizations, limb outcomes, vascular interventions, and costs were analyzed.

RESULTS

There were 10,303,673 hospitalizations of patients with concomitant diabetes mellitus and PAD that were identified between 2003 and 2017. The prevalence of hospitalizations associated with this disease process increased from 1644 to 3228 per 100,000 hospitalizations, a 96.4% increase. This included an increase of 288 to 587 per 100,000 hospitalizations of patients aged 18 to 49 years old, which was accompanied by a 10.8% increase in minor amputations. Nontraumatic lower extremity amputations decreased overall. Black and Hispanic ethnicity were associated with an increased risk for amputation, along with Medicaid insurance and lower income quartile. Inpatient endovascular revascularization has increased over time with an associated decrease in open revascularization procedures. Amputation-related hospital costs significantly increased from $6.6 billion in 2003 to $14.8 billion in 2017.

CONCLUSIONS

An alarming increase of disease prevalence, negative in-hospital limb outcomes, and costs are seen in the current era in this analysis of patients with concurrent diabetes and PAD.

Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia

OBJECTIVE

Despite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions.

METHODS

We evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs.

RESULTS

A total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75).

CONCLUSIONS

Early PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.

Outcomes of elective peripheral endovascular interventions for peripheral arterial disease performed in hospital outpatient departments, ambulatory surgical centers and office-based labs

BACKGROUND

A recent shift in the location where peripheral endovascular interventions (PVI) are performed has occurred, from traditional settings such as hospital outpatient departments (HOPD), to ambulatory surgical centers (ASC) and outpatient-based laboratories (OBL). Different settings may influence the safety and efficacy of the PVI, as well as how it is done. This study aims to compare the postprocedural outcomes and intraprocedural details between the three settings.

METHODS

The Vascular Quality Initiative database was queried for all elective infrainguinal PVIs for occlusive peripheral arterial disease between January 2016 and December 2021. The primary outcomes were rates of postprocedural hospital admissions, postprocedural medical complications, and access site complications. Secondary outcomes included technical success and intraprocedural details, such as types and number of devices used, amount of contrast, and fluoroscopy time. The χ² test, analysis of variance, and multivariate logistic regression were used to analyze the outcomes.

RESULTS

A total of 66,101 PVI cases (HOPD, 57,062 [83.33%]; ASC, 4591 [6.95%]; OBL, 4448 [6.73%]) were included in the study. There were 445 cases requiring hospital admission (HOPD, 398 [0.70%]; ASC, 26 [0.57%]; OBL, 21 [0.47%]; P = .126). There were no significant differences in cardiac, pulmonary, or renal complications. Access site complications occurred in less than 1.7% of all cases and were significantly higher in OBLs when compared with ASCs (adjusted odds ratio [aOR], 3.70; 95% confidence interval [CI], 1.70-8.03; P = .001) and significantly lower in ASCs in comparison to HOPDs (aOR, 0.27; 95% CI, 0.18-0.41; P < .001). Technical success occurred in at least 92% of all cases, regardless of setting. There was a 16-fold increase in the use of atherectomy devices in an OBL vs HOPD setting (aOR, 16.79; 95% CI, 11.77-23.95; P < .001) and a five-fold increase in the use of atherectomy devices in an ASC vs HOPD setting (aOR, 5.37; 95% CI, 2.47-11.65; P < .001). There was a five-fold decrease in the use of special balloons in an OBL vs HOPD setting (aOR, 0.20; 95% CI, 0.10-0.39; P < .001) and a four-fold decrease when comparing ASCs with HOPDs (aOR, 0.25; 95% CI, 0.12-0.51; P < .001).

CONCLUSIONS

Elective PVIs performed in any outpatient setting proved to be safe and technically successful. However, there are significant differences in the way PVIs are performed in each setting, such as the greater use of atherectomy devices in OBLs and greater use of special balloons in HOPDs. Long-term studies are needed to evaluate the durability and reintervention outcomes and understand factors associated with practice pattern variability across these different settings.

National trends and variability of atherectomy use for peripheral vascular interventions from 2010 to 2019

OBJECTIVES

Small, older studies suggest atherectomy devices have become common in peripheral vascular interventions (PVI) despite the paucity of strong clinical guidelines. We analyzed the 10-year trends in the use of atherectomy for PVI across the United States and identified main predictors of atherectomy use.

METHODS

Using the Vascular Quality Initiative Registry, we identified all patients who had endovascular PVI for occlusive lower-extremity arterial disease from 2010 to 2019. Procedures in which an atherectomy device was recorded as the primary or secondary device were classified as the atherectomy group. We calculated frequency of atherectomy use over time and across geographic regions. Using regression modeling, we identified factors that were independently associated with atherectomy use.

RESULTS

There were 205,377 procedures on 152,693 unique patients. Over 10 years, 16.6% of PVI procedures used atherectomy, increasing from 8.5% in 2010 to 19.7% in 2019, P_trend <0.0001. Across 17 geographic regions, there was a significant difference in the prevalence of atherectomy use, ranging from 8.2% to 29%. The strongest predictor of atherectomy use was the procedure being done in an office setting (OR 10.08, 95% CI 9.17-11.09) or ambulatory center (OR 4.0, 95% CI 3.65-4.39) vs hospital setting. The presence of severe (OR 2.6, 95% CI 2.4-2.85) or moderate (OR 1.5, 95% CI 1.4-1.69) lesion calcification was also predictive of atherectomy use. Other predictors included elective status, insurance provider, lesion length, prior PVI, claudication symptoms, and diabetes mellitus.

CONCLUSIONS

Atherectomy use in PVI significantly increased between 2010 and 2019. There is wide regional variability in the use of atherectomy that seems to be driven more strongly by non-clinical factors.

Index Atherectomy Peripheral Vascular Interventions Performed for Claudication are Associated with More Reinterventions than Non-Atherectomy Interventions

OBJECTIVE

Despite limited evidence supporting atherectomy alone over stenting/angioplasty as the index peripheral vascular intervention (PVI), the use of atherectomy has rapidly increased in recent years. We previously identified a wide distribution of atherectomy practice patterns among US physicians. The aim of this study was to investigate the association of index atherectomy with reintervention.

METHODS

100% Medicare fee-for-service claims were used to identify all beneficiaries who underwent elective first-time femoropopliteal peripheral vascular intervention (PVI) for claudication between 1/1/2019-12/31/2019. Subsequent PVI reinterventions were examined through 6/30/2021. Kaplan-Meier curves were used to compare the rate of PVI reinterventions for patients who received index atherectomy vs. non-atherectomy procedures. Reintervention rates were also described for physicians by their overall atherectomy use (by quartile). A hierarchical Cox proportional hazard model was used to evaluate patient and physician-level characteristics associated with reinterventions.

RESULTS

A total of 15,246 patients underwent index PVI for claudication in 2019, of which 59.7% were atherectomy. After a median of 603 days (IQR 77, 784) of follow-up, 41.2% of patients underwent a PVI reintervention, including 48.9% of patients who underwent index atherectomy vs. 29.8% of patients who underwent index non-atherectomy (P<0.001). Patients treated by high physician users of atherectomy (quartile 4) received more reinterventions than patients treated by standard physician users (quartiles 1-3) (56.8% vs. 39.6%, P<0.001). After adjustment, patient factors association with PVI reintervention included receipt of index atherectomy (aHR 1.33, 95% CI 1.21-1.46), Black race (vs. White, aHR 1.18, 95% CI 1.03-1.34), diabetes (aHR 1.13, 95% CI 1.07-1.21), and urban residence (aHR 1.11, 95% CI 1.01-1.22). Physician factors associated with reintervention included male sex (aHR 1.52, 95% CI 1.12-2.04), high-volume PVI practices (aHR 1.23, 95% CI 1.10-1.37), and physicians with high use of index atherectomy (aHR 1.49, 95% CI 1.27-1.74). Vascular surgeons had a lower risk of PVI reintervention than Cardiologists (vs. Vascular, aHR 1.22, 95% CI 1.09-1.38), Radiologists (aHR 1.55, 95% CI 1.31-1.83), and other specialties (aHR 1.59, 95% CI 1.20-2.11). Location of services delivered was not associated with reintervention (P>0.05).

CONCLUSIONS

The use of atherectomy as an index PVI for claudication is associated with higher PVI reintervention rates compared to non-atherectomy procedures. Similarly, high physician users of atherectomy perform more PVI reinterventions than their peers. The appropriateness of using atherectomy for initial treatment of claudication needs critical reevaluation.

Use of Intravascular Ultrasound During First-Time Femoropopliteal Peripheral Vascular Interventions Among Medicare Beneficiaries

BACKGROUND

Intravascular ultrasound (IVUS) may be a useful adjunct to lower extremity peripheral vascular interventions (PVI) in certain clinical scenarios. We aimed to identify patient- and physician-level characteristics associated with the use of IVUS during first-time femoropopliteal PVI.

METHODS

We included all Medicare beneficiaries undergoing elective femoropopliteal PVI for claudication or chronic limb-threatening ischemia between 01/01/2019 and 12/31/2019. We excluded patients with prior open or endovascular femoropopliteal intervention and all physicians performing ≤10 PVI during the study period. We calculated the proportion of patients who had IVUS performed as part of their index PVI for each physician. Hierarchical logistic regression was used to evaluate patient- and physician-level factors associated with use of IVUS.

RESULTS

We identified 58,552 patients who underwent index femoropopliteal PVI, of whom 11,394 (19%) received IVUS. A total of 1,628 physicians performed >10 procedures during the study period, with IVUS utilization ranging from 0-100%. After hierarchical regression, claudication (versus chronic limb-threatening ischemia: OR 1.23, 95% CI 1.11-1.36), stenting (versus angioplasty alone: OR 1.57, 1.33-1.86) and atherectomy (versus angioplasty alone: OR 2.09, 1.83-2.39) were associated with higher odds of IVUS utilization. Higher-volume providers (tertile 3 vs. tertile 1: OR 3.78, 2.43-5.90) and those with high rates of service provided in an office-based laboratory (tertile 3 vs. tertile 1: OR 10.72, 6.78-19.93) were more likely to utilize IVUS. Radiologists (OR 11.23, 5.96-21.17) and cardiologists (OR 1.97, 1.32-2.93) used IVUS more frequently than vascular surgeons.

CONCLUSIONS

Wide variability exists in the use of IVUS for first-time femoropopliteal PVI. The association of IVUS with claudication, atherectomy, and office-based laboratories raises concern about its potential overuse by some physicians.

Exploring the rapid expansion of office-based laboratories and peripheral vascular interventions across the United States

OBJECTIVE

To characterize the relationship between office-based laboratory (OBL) use and Medicare payments for peripheral vascular interventions (PVI).

METHODS

Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty, stent placement, and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level.

RESULTS

Between 2014 and 2017, 2641 providers performed 308,247 procedures. The mean payment for OBL stent placement in 2017 was $4383.39, and mean payment for OBL atherectomy was $13,079.63. The change in the mean payment amount varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. The change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R2 = 0.40; P < .001). The majority of HRRs experienced an increase in rate of PVI within OBLs, which strongly correlated with changes in payments (R2 = 0.85; P < .001). Furthermore, 85% of the variance in change in payment was explained by increases in OBL atherectomy (P < .001).

CONCLUSIONS

A rapid shift into the office setting for PVIs occurred within some HRRs, which was highly geographically variable and was strongly correlated with payments. Policymakers should revisit the current payment structure for OBL use and, in particular atherectomy, to better align the policy with its intended goals.

Use of Atherectomy During Index Peripheral Vascular Interventions

OBJECTIVES

The aim of this study was to describe physician practice patterns and examine physician-level factors associated with the use of atherectomy during index revascularization for patients with femoropopliteal peripheral artery disease.

BACKGROUND

There are minimal data to support the routine use of atherectomy over angioplasty and/or stenting for the endovascular treatment of peripheral artery disease.

METHODS

Medicare fee-for-service claims (January 1 to December 31, 2019) were used to identify all beneficiaries undergoing elective first-time femoropopliteal peripheral vascular intervention (PVI) for claudication or chronic limb-threatening ischemia. Hierarchical logistic regression was used to evaluate patient- and physician-level characteristics associated with atherectomy.

RESULTS

A total of 58,552 patients underwent index femoropopliteal PVI by 1,627 physicians. There was a wide distribution of physician practice patterns in the use of atherectomy, ranging from 0% to 100% (median 55.1%). Independent characteristics associated with atherectomy included treatment for claudication (vs. chronic limb-threatening ischemia; odds ratio [OR]: 1.51), patient diabetes (OR: 1.09), physician male sex (OR: 2.08), less time in practice (OR: 1.41 to 2.72), nonvascular surgery specialties (OR: 2.78 to 5.71), physicians with high volumes of femoropopliteal PVI (OR: 1.67 to 3.51), and physicians working primarily at ambulatory surgery centers or office-based laboratories (OR: 2.19 to 7.97) (p ≤ 0.03 for all). Overall, $266.8 million was reimbursed by Medicare for index femoropopliteal PVI in 2019. Of this, $240.6 million (90.2%) was reimbursed for atherectomy, which constituted 53.8% of cases.

CONCLUSIONS

There is a wide distribution of physician practice patterns for the use of atherectomy during index PVI. There is a critical need for professional guidelines outlining the appropriate use of atherectomy in order to prevent overutilization of this technology, particularly in high-reimbursement settings.

Critical Appraisal of the Contemporary Use of Atherectomy to Treat Femoral-Popliteal Atherosclerotic Disease

OBJECTIVE

Atherectomy has become increasingly used as an endovascular treatment of lower extremity atherosclerotic disease in the United States. Concerns and controversies about its indication and outcomes exist. The goal of this systematic review and meta-analysis was to investigate the outcomes and complications related to atherectomy to treat femoropopliteal atherosclerotic disease.

METHODS

A systematic review following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was performed. Four major scientific repositories, MEDLINE, EMBASE, The Cochrane Library, and Thompson Web of Sciences were queried from their inception to April 5, 2020. Data was reviewed and entered in a dedicated dataset by the investigators. Outcomes included patency rates, clinical and hemodynamic improvement, and morbidity and mortality associated with atherectomy interventions.

RESULTS

Twenty-four studies encompassing 1900 patients met inclusion criteria for this study. 74.3% of patients presented with Rutherford class (RC) 1-3 and 25.7% presented with RC class 4-6. 1445 patients underwent atherectomy, and 455 patients were treated without atherectomy. Atherectomy patients underwent directional atherectomy (DA, n = 851), rotational atherectomy (RA, n = 851), laser atherectomy (LA, n = 201), and orbital atherectomy (OA, n = 78). The majority of patients additionally received adjunct treatments which were variable across studies and included a combination of stenting, balloon angioplasty (BA), or drug coated balloon (DCB) angioplasty. Technical success was achieved in 92.3% of cases. Distal embolization, vessel perforation, and dissection occurred in 3.4%, 1.9%, and 4% of cases respectively. Initial patency was 95.4% and at 12-month median follow up primary patency was 72.6%. ABI improved from pre-operative mean of 0.6 to post-operative mean of 0.84. Incidence of major amputation and mortality over the follow up period was 2.2% and 3.4% respectively.

CONCLUSIONS

This review of the published data suggests that femoropopliteal atherectomy can be completed safely while modestly improving ABIs and maintaining one-year patency in nearly three out of four patients; however, this is based on heterogeneous studies that skew generalizable conclusions about atherectomy's efficacy. Atherectomy places a high cost burden on the healthcare system and is utilized in the United States at a higher rate than in other countries. Our review of the literature does not demonstrate clear atherectomy superiority to alternatives that would warrant pervasive and increasing use of this costly technology. Future work should focus on developing high quality randomized controlled trials to determine specific patient and lesion characteristics in which atherectomy can add value.

Iliac vein stenting is safe when performed in an office based laboratory setting

BACKGROUND

Venous stenting for iliac vein outflow obstruction is associated with excellent long-term stent patency and symptom resolution. However, the safety of iliac vein stenting performed in an office-based laboratory (OBL) setting is not well-defined. The purpose of our investigation was to determine the safety profile of iliac vein stenting in an OBL setting.

METHODS

Data were prospectively collected in the Center for Vascular Medicine electronic medical record system (NextGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. Standardized patient safety and sedation protocols were used in accordance with the accreditation standards of the Joint Commission for Accreditation of Hospital Organizations for office-based surgery centers. Patient consultations, interventions, and follow-up at 1 to 6 weeks were included in the present analysis. All the patients had received moderate sedation during their procedure. Complications requiring hospitalization were classified as major complications. Minor complications consisted of bleeding, hematoma, vasovagal response, in-stent thrombosis resulting in complete occlusion of the iliac vein stent, an allergic reaction, hematemesis, hypotension, pelvic discomfort, and pseudoaneurysm.

RESULTS

Between January 2015 and January 2019, 1223 iliac vein stents were placed in 1104 patients (23.7% male; 76.3% female). A total of 90 minor complications (7.36%) and 5 major complications (0.41%) were observed. The major complications included the following: one allergic reaction, one episode of atrial fibrillation, one episode of supraventricular tachycardia, one episode of chest pain, and one case of acute stent occlusion. The minor complications were primarily insertion site hematomas. No complications were related to sedation or acute renal failure. No patient died.

CONCLUSIONS

Major complications were rare after iliac vein stenting in an OBL setting. Minor complications were primarily insertion site hematomas, which did not require inpatient hospitalization. Our analysis has shown that iliac vein stenting in an OBL setting is a safe and well-tolerated procedure.

Excimer laser atherectomy in complex peripheral artery disease: a prospective European registry

BACKGROUND

This study aimed to investigate performance, effectiveness, and safety of excimer laser atherectomy for the treatment of complex lower limb artery disease in a real-world setting.

METHODS

In our prospective, multicenter registry, consecutive patients with complex lower limb lesions underwent excimer laser atherectomy with optional standard balloon angioplasty, paclitaxel-coated balloon angioplasty, and bailout stenting. Primary outcome was technical success. Secondary outcomes were device performance of the excimer laser system, freedom from target lesion revascularization (TLR), peri-procedural complications, and amputation-free survival in patients with critical limb ischemia (CLI).

RESULTS

A total of 294 patients were enrolled at 14 European centers (mean lesion length 109±103 mm, total occlusions 56.8% [167 of 294 lesions], CLI 47.3% [132 of 279 patients]. Adjuvant balloon angioplasty was conducted in 283 (96.3%), and complementary stent implantation in 98 patients (33.3%). Technical success was achieved in 95.3% of patients. Increasing lesion length was associated with decreased laser atherectomy performance (odds ratio [OR] per 10 mm: 0.94 [95% confidence interval [CI] 0.90 to 0.99], P=0.01). A total of 66 patients (22.4%) completed the 12-month follow-up. Freedom from TLR was 83.5% (95% CI: 74.9 to 92.1) at 12 months. Chronic total occlusions were associated with more TLR (OR 5.03 [95% CI: 1.01 to 25.1], P=0.049). Amputation -free survival in patients with CLI was 93.1% (95% CI: 83.9 to 100).

CONCLUSIONS

Excimer laser atherectomy substantially contributed to technical success of endovascular treatment of complex infra-inguinal lesions. Freedom from 12-month TLR was reasonable.

The impact of chronic kidney disease on outcomes following peripheral vascular intervention

Background

Patients with chronic kidney disease (CKD) have worsened clinical outcomes following percutaneous coronary intervention; however, limited evidence exists in patients undergoing peripheral vascular intervention (PVI).

Purpose

We aimed to assess the effect of CKD on outcomes following PVI for symptomatic peripheral artery disease.

Methods

Using patients from the LIBERTY 360 study, we compared the rates of 30 day and 1 year major adverse vascular events (MAVE), a composite of all‐cause mortality, major amputation, and target vessel/lesion revascularization, between patients with and without CKD (estimated glomular filtration rate less than 60) following PVI. Multivariable adjustment was performed to assess for independent association between CKD and outcomes.

Results

Among 1189 patients enrolled, 378 patients (31.8%) had CKD. At 1 year, patients with CKD had higher rates of MAVE (34.6% vs 25.6%), all‐cause mortality (11.9% vs 5.5%), and major amputation (5.9% vs 2.6%) when compared with patients without CKD (all P < .05). After adjustment, patients with CKD had higher risks of 1‐year MAVE (HR 1.30, 95% CI 1.04‐1.64; P = .023) and all‐cause mortality (HR 1.88, 95% CI 1.22‐2.91; P = .005) when compared with patients without CKD. There was no statistically significant difference in risk of major amputations (HR 1.70, 95% CI 0.91‐3.17; P = .094).

Conclusions

Despite high procedural success and low amputation rates, patients with CKD remain at greater risk for MAVE and all‐cause mortality after PVI. Further research is needed to determine treatment strategies to mitigate substantial mortality risk in this vulnerable population.

Failed Prior Endovascular Interventions Do Not Affect 30-day Cardiovascular or Limb-related Outcomes of Infrainguinal Bypasses for Chronic Limb Threatening Ischemia

BACKGROUND

It is often hypothesized that failed prior endovascular intervention could adversely affect the outcome of subsequent infrainguinal bypass in the corresponding limb. However, this perception is not well supported in the literature because of conflicting data. The aim of this study is to address this controversial issue via analysis of a multicenter prospectively collected database.

METHODS

Patients who underwent infrainguinal bypass for chronic limb threatening ischemia (CLTI) were identified in the targeted American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2017. These patients were stratified into 4 groups: first time femoral-popliteal bypass, femoral-popliteal bypass after failed prior endovascular revascularization, first time femoral-tibial bypass, and femoral-tibial bypass after failed prior endovascular revascularization. Thirty-day outcomes including mortality, graft patency, major amputations, and major organ dysfunction were measured.

RESULTS

We identified 7,044 patients who underwent surgical bypasses for CLTI. Patients were mostly well matched among the 4 groups except for differences in sex, hypertension, and preoperative renal function. In terms of major adverse cardiovascular events and major adverse limb events, femoral-popliteal or femoral-tibial bypasses after failed prior endovascular intervention had comparable 30-day outcomes to first-time bypasses. However, patients with failed prior endovascular intervention had increased rates of postoperative wound infection, required significantly more blood transfusions, and had longer operative time.

CONCLUSIONS

Failed prior endovascular intervention does not adversely affect 30-day outcomes of subsequent infrainguinal bypass surgery in mortality, limb salvage, or other major cardiovascular complications.

Practice Patterns of Vascular Surgery's "1%"

BACKGROUND

Public focus on health care spending has increased attention on variation in practice patterns and overutilization of high-cost services. Mainstream news reports have revealed that a small number of providers account for a disproportionate amount of total Medicare payments. Here, we explore variation in Medicare payments among vascular surgeons and compare practice patterns of the most highly reimbursed surgeons to the rest of the workforce.

METHODS

2016 Medicare Provider Utilization Data were queried to identify procedure, charge, and payment data to vascular surgeons, identified by National Provider Identification taxonomy. Commonly performed services (>10/year) were stratified into categories (endovascular, open surgery, varicose vein, evaluation and management, etc.). Practice patterns of vascular surgeons comprising the top 1% Medicare payments (n = 31) were compared with the remainder of the workforce (n = 3,104).

RESULTS

In 2016, Medicare payments to vascular surgeons totaled $589 M. 31 vascular surgeons-1% of the workforce-received $91 million (15% of total payments). Practice patterns of the 1% differed significantly from the remainder of vascular surgeons (P < 0.05), with endovascular procedures accounting for 85% of their reimbursement. Specifically, the 1% received 49% of total Medicare payments for atherectomy ($121 M), 98% of which were performed in the office setting.

CONCLUSIONS

One percentage of vascular surgeons receive an inordinate amount of total Medicare payments to the specialty. This discrepancy is due to variations in volume, utilization, and site of service. Disproportionate use of outpatient atherectomy in a small number of providers, for example, raises concerns regarding appropriateness and overutilization. Given current scrutiny over health care spending, these findings should prompt serious discussion regarding the utility of personal and societal self-regulation.