PeripheralAtherectomy Practice Patterns in the United States
Sathish Mohan, MD, MPH, Julie M. Flahive, MS, Edward J. Arous, MD, Dejah R. Judelson, MD, Francesco A. Aiello, MD, Andres Schanzer, MD, Jessica P. Simons, MD, MPH.
University of Massachusetts, Worcester, MA, USA.
OBJECTIVES: Peripheral atherectomy is shown to have technical success in single-arm studies, but clinical advantages over angioplasty and stenting have not been demonstrated, leaving its role unclear. We sought to describe adoption patterns of atherectomy in a real-world cohort to understand current practice. METHODS: The Vascular Quality Initiative (VQI) was queried to identify all patients who underwent peripheral vascular intervention (PVI), 1/2010-9/2016. Descriptive statistics were performed to analyze patient demographics, comorbidities, indication, treatment modalities used, and lesion characteristics. The intermittent claudication (IC) and critical limb ischemia (CLI) cohorts were analyzed separately. RESULTS: Of 85,605 limbs treated, treatment indication was IC in 51% (n=43,506) and CLI in 49% (n=42,099). Atherectomy was used in 15% (n= 13,092) of cases, equivalently for IC (15%, n=6674), and for CLI (15%, n=6418). There was significant regional variation in use of atherectomy, ranging from 0-32%. During the study period, there was a significant increase in the proportion of cases that utilized atherectomy (11% in 2010 vs 18% in 2016; p<.0001; Figure). Compared to non-atherectomy cases, those with atherectomy use had higher incidence of prior PVI (IC: 55% vs 43%, p<.0001; CLI: 47% vs 41%, p<.0001), greater mean number of arteries treated (IC: 1.8 vs 1.6, p<.0001; CLI: 2.1 vs 1.7, p<.0001), and lower proportion of prior leg bypass (IC: 10% vs 14%, p<.0001; CLI: 11% vs 17%, p<.0001). There was lower incidence of failure to cross the lesion (IC: 1% vs 4%, p<.0001; CLI: 4% vs 7%, p<.0001), but higher incidence of distal embolization (IC: 1.9% vs. 0.8%, p<.0001; CLI: 3.0% vs 1.4%, p<.0001), and in the CLI cohort, arterial perforation (1.4% vs 1.0%, p=0.01). CONCLUSIONS: Despite a lack of evidence for atherectomy over angioplasty and stenting, its use has increased across the US from 2010 to 2016. It is applied equally to IC and CLI populations, with no identifiable pattern of comorbidities or lesion characteristics, suggesting that indications are not clearly delineated or agreed upon. This study places impetus on further understanding the optimal role for atherectomy and its long term clinical benefit in the management of peripheral artery disease. 
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