Atherectomy Plus Angioplasty Reduces Mortality, Amputation Risk But Adds Hefty Initial Price


Real-world data from a large registry show conclusive evidence that atherectomy in conjunction with angioplasty can have tangible survival and limb-saving benefits for patients with peripheral arterial disease (PAD), the caveat being that it costs more.

Next Step: Atherectomy Plus Angioplasty Reduces Mortality, Amputation Risk But Adds Hefty Initial Price

“Despite supportive data for the use of atherectomy devices, most [prior studies] have been limited due to their small sample sizes, lack of comparative arms or clinical endpoints, and restricted patient populations or lesion complexities,” write Apurva O. Badheka, MD, of The Everett Clinic (Everett, WA), and colleagues.

In their study of more than 13,000 PAD patients (56.2% men) from the Nationwide Inpatient Sample who did (23.2%) or did not (76.8%) receive atherectomy in 2012, those who underwent the procedure were more likely to have a greater comorbidity burden. Most patients also received balloon angioplasty or stenting, with only 2.3% treated by atherectomy alone. The majority of atherectomies were performed in large and urban teaching hospitals.

The findings were published online December 7, 2015, ahead of print in the American Journal of Cardiology.

Less Mortality, Amputation

Overall, atherectomy led to fewer complications (13.2% vs 16.3%; P < .001) and less amputation (11.5% vs 13.4%; P < .001) compared with patients who did not receive it.

After propensity matching, atherectomy was associated with lower amputation, in-hospital mortality, and complication rates. However, costs were higher with the added procedure.

Propensity-Matched Outcomes in PAD Patients

On multivariate analysis, older age predicted in-hospital mortality (OR 1.42 by 10-year increase; 95% CI 1.21-1.66), and higher baseline comorbidity predicted both in-hospital mortality (OR 4.60; 95% CI 2.48-8.52) and amputation (OR 4.78; 95% CI 3.89-5.87). Nonelective procedures were also associated with worse outcomes.

But atherectomy use lowered the risks of mortality, amputation, and the combined outcome of in-hospital mortality and complications. The best outcomes were seen when atherectomy was added to either angioplasty or stenting, and the worst outcomes were seen with atherectomy alone.

In the subgroups of patients with chronic limb ischemia, angioplasty, and those with higher baseline comorbidity, atherectomy use predicted less amputation, though the increased cost persisted.

Does It Save to ‘Shave’?

Between-hospital atherectomy rates varied by 24% and were not affected by individual patient or hospital characteristics. This is not surprising, according to the authors, because of the current “lack of substantial literature and/or definitive guidelines for use of atherectomy.” Additionally, the variation reflects hospital preference and “perhaps calls for further literature to clarify benefits of atherectomy in peripheral revascularization,” they write.

The most tangible benefit of atherectomy “is in improving acute procedural success,” the researchers state, adding that maximal value can only be grasped with adjunctive balloon angioplasty or stenting.

With regard to vascular complications after atherectomy, Badheka and colleagues say the rate “was comparable to prior literature”—11.3% in DEFINITIVE LE vs 9.5% here.

But cost is still an issue, and convincing hospitals that atherectomy is worth the initial added cost can only be done through further study and comparison with potential future savings, the authors say. “Long-term follow-up studies with risk-adjusted cost analysis accounting for repeat hospitalizations, mortality, and revascularizations would shed more light on the cost-benefit ratio of atherectomy,” they write.

Also, future research should focus on newer devices used since 2012 and the newer DES and drug-coated balloons, which have “also provided excellent patency outcomes,” the researchers add. 


Source: 
Panaich SS, Arora S, Patel N, et al. In-hospital outcomes of atherectomy during endovascular lower extremity revascularization. Am J Cardiol. 2015;Epub ahead of print.


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