Outcomes Of Peripheral Vascular Intervention And Atherectomy In The ESRD Population
Shaunak Adkar, MD PhD, Venita Chandra, MD, Ronald Dalman, MD, Manuel Garcia-Toca, MD, Michael D. Sgroi, MD.
Stanford University, Stanford, CA, USA.
OBJECTIVES: Atherectomy is being increasingly utilized for the treatment of infrainguinal peripheral arterial disease (PAD). As patients with end stage renal disease (ESRD) often present with calcified vasculature, atherectomy in this population may provide improved revascularization compared with other peripheral interventions. Outcomes after atherectomy have not yet been described within this population. The purpose of this study is to compare the outcomes of peripheral vascular intervention with and without atherectomy in the ESRD patient with critical limb threatening ischemia (CLTI).
METHODS: Data was obtained from the Vascular Quality Initiative data files. Patients with ESRD and CLTI were identified and separated into cohorts based on the application of atherectomy at the time of each procedure. Patient and procedure-related characteristics, 30-day mortality, and long-term post-operative outcomes were compared using Pearson chi-squared and Wilcoxon rank sum tests.
RESULTS: From 2010 to 2020, we identified 9037 patients with ESRD and CLTI undergoing peripheral vascular intervention, of which 532 (5.9%) underwent atherectomy. 30-day mortality did not significantly vary in patients undergoing atherectomy compared to other interventions (5.8% vs. 6.2%, p=0.75). Rate of amputation during admission was significantly lower (0.1% vs. 15.6%, p<0.001) in the atherectomy cohort. Analysis of long-term follow-up data revealed increased overall rates of mortality in the atherectomy cohort (54% vs. 46%, p<0.001), but similar rates of re-intervention (17.8% vs 18.8%, p=0.88) and amputation (20.1% vs. 19.6%, p=0.53). However, median time to mortality was greater in the atherectomy cohort (355 days vs. 262 days, p<0.001), as was time to re-intervention (226 days vs. 177 days, p<0.001). Likewise, median time to amputation was greater in the atherectomy cohort (215 days vs. 125 days, p<0.001). While we found no difference in primary or secondary patency on long-term follow-up, primary-assisted patency was significantly greater in the atherectomy cohort (13.7% vs. 7.0%, p<0.001).
CONCLUSIONS: Atherectomy in the ESRD patient with CLTI demonstrates delay in time to amputation or re-intervention, but inevitably similar long-term outcome of amputation. The severity of disease and comorbid conditions likely also leads to the high mortality rates in both cohorts. A cost-effectiveness analysis would need to be performed to further evaluate the validity and value of atherectomy as an adjunct to peripheral interventions.
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