Objectives: The use of atherectomy in lower extremity arterial disease has gained popularity despite no available data demonstrating superiority to angioplasty or stenting for femoral-popliteal occlusive disease. Additionally, rates of embolization from atherectomy have not been previously well-characterized, and the use of embolic protection devices (EPD) has been variable, leaving questions about the safety of atherectomies that are performed in lower-acuity settings such as office-based laboratories (OBL). There are important lesion characteristics to consider when weighing the risk of distal embolization and device usage as well as cost and utilization factors. We sought to describe current trends in atherectomy and EPD use in lower extremity interventions to better characterize practice patterns in the inpatient and outpatient interventional settings.
Methods: We conducted a retrospective matched cohort study with data form the Vascular Quality Initiative (VQI) database from 2016-2019 to analyze endovascular interventions performed for femoral-popliteal occlusive disease. Primary outcomes were atherectomy and EPD use and a propensity-matched multivariate logistic regression was used to evaluate the relationship between these outcomes and intervention setting.
Results: Among 29,382 peripheral vascular interventions (PVI) that met inclusion criteria, 6,136 procedures performed on 3,049 matched pairs were included in the final analysis. An EPD was used during 500 (8.1%) of procedures and 3,198 (50.6%) atherectomies were performed. Among these atherectomy cases, 12.9% used EPD while only 3.0% of non-atherectomy cases used an EPD. Multivariable analysis adjusted for patient and lesion characteristics showed that atherectomy was performed much more frequently in Office-Based Laboratories (OBL), OR
16.52 (CI 14.50-18.86, p<0.001. Procedures performed in an OBL setting were significantly less likely to have an EPD used, OR 0.08 (0.07-0.11, p<0.001).
Conclusions: Our findings suggest that atherectomy is much more likely to be performed in the non-hospital/OBL setting. At the same time, the use of EPD is dramatically decreased in this clinical environment, highlighting the inconsistent use of safety devices across inpatient and outpatient procedure settings. These trends persisted after adjustment for patient and lesion characteristics suggesting that external factors other than clinical patient characteristics drive decision-making in both use of atherectomy devices and EPD. Further inquiry to elucidate these driving factors may be important to ensure the safety and ethical treatment of patients receiving lower extremity interventions in the fast-growing OBL setting.