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Regional Variation in Practice Patterns and Outcome of Infrapopliteal Peripheral Intervention for Critical Limb Ischemia
Mark Perry1, Mrinal Shukla1, Peter Callas2, Daniel Bertges1.
1University of Vermont Medical Center, Burlington, VT, USA, 2University of Vermont College of Medicine, Burlington, VT, USA.

Objectives
To analyze regional variation in practice patterns and outcome of peripheral vascular intervention (PVI) for infrapopliteal occlusive disease in patients with critical limb ischemia (CLI).
Methods
Patients (N= 12,125) undergoing infrapopliteal PVI on 12,946 limbs for CLI in the Vascular Quality Initiative were studied from 2010 to 2016. Major amputation rates were analyzed by the Kaplan-Meier method according to treatment type including angioplasty (PTA, N= 9,566), atherectomy + angioplasty (ATHER, N= 1,297), tibial stenting (STENT, N= 864) and multiple interventions (MULT, N= 1,219). Multivariate analysis was used to generate adjusted hazard ratios (aHR) for factors independently associated with major amputation. Differences in major amputation rates and these factors were compared across regions.
Results
There were 5,784 (45%) interventions at the tibial-peroneal level and 7,162 (55%) multilevel interventions. Regional variation was noted in infrapopliteal treatment types with no difference in major amputation rate across the 4 treatment types (log rank P =0.50). Angioplasty accounted for an average of 75% of the interventions (range 52 - 91%), atherectomy for 10% (range 2 - 26%), stenting for 6% (range 1 - 24%), and multiple interventions for 9% (range 0 - 23%). The average major amputation rate was 11%, ranging from 6% - 20% (P <0.001) (Figure 1). The following variables were independently associated with major amputation; age (aHR=.84, 95% CI 0.80-0.89), gender (aHR=0.83, 0.72-0.95), race – African American versus Caucasian (aHR=1.22, 1.05-1.42), body mass index (BMI) (aHR=0.94, 0.89-0.98), tibial vs multilevel intervention (aHR=0.86, 0.76-0.97), urgency (aHR=1.40, 1.23-1.60), insulin dependent diabetes(aHR=1.39, 1.17-1.66), and dialysis (aHR=1.67, 1.45-1.92). These independent factors varied across regions with high and low amputation rates.
Conclusion
Major amputation after PVI for CLI was similar across all types of infrapopliteal treatment indicating either correct patient selection or clinical equivalence of peripheral devices. The significant regional variation in major amputation rates is likely related to regional differences in patient characteristics.
Figure 1. Regional variation in amputation rate for tibial interventions


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