Stenting Provides Better Early Outcomes vs Angioplasty Alone for PAD

In patients with PAD, stenting is associated with reduced postprocedural complications and amputation compared with angioplasty alone, according to a study published online May 28, 2015, ahead of print in the American Journal of Cardiology. Yet the choice of treatment had no impact on mortality.

Take Home:   Stenting Provides Better Early Outcomes vs Angioplasty Alone for PAD

Apurva O. Badheka, MD, of Yale School of Medicine (New Haven, CT), and colleagues looked at data from the Nationwide Inpatient Sample on 92,647 PAD patients who underwent stenting (52.1%) or angioplasty alone between 2006 and 2011. Indications and procedures were identified using diagnostic codes.

Unadjusted rates of overall periprocedural complications, in-hospital mortality, and a composite of overall complications or in-hospital mortality were lower with stenting than with angioplasty alone (P < .001 for all). Amputation also was less frequent after stenting (6.8% vs 12.8%; P < .001), a difference seen for below-knee, above-knee, and minor amputations.

Various complication types, including vascular, respiratory, renal, and infections, were all more common after angioplasty alone.

Propensity scoring to account for imbalances between the stenting and angioplasty groups resulted in 36,710 matched pairs (mean age 69.6 years; 45.6% female). Stenting remained associated with reduced rates of any complication, the composite of any complication or in-hospital mortality, and amputation, but there was no difference in the primary endpoint of mortality alone (table 1).

Table 1. In-Hospital Outcomes of Stenting vs Angioplasty Alone: Propensity-Matched Analysis

The reduction in amputation with stenting was observed across various high-risk subgroups, including elderly patients and those with acute or chronic limb ischemia, chronic total occlusions, a higher baseline burden of comorbidities, and emergent admissions. However, the amputation rate did not differ based on treatment among patients with iliac PAD, which the authors say is consistent with prior research.

Stenting’s benefits were accompanied by a greater average hospitalization cost compared with angioplasty alone ($21,009 vs $19,594; P < .001).

The authors also found a 12% variation in stenting rates across participating centers that did not relate to patient or hospital characteristics. Additional analysis “indicated that a randomly selected patient at any given hospital had nearly 1.9-fold higher odds of undergoing peripheral stenting compared to another identical patient at a different random hospital in the sample,” the authors report.

Stenting Worth the Extra Cost

Endovascular intervention has mostly overtaken surgery as the primary PAD treatment, with prior research showing similar technical success and long-term outcomes with both approaches but fewer periprocedural complications with minimally invasive techniques.

“Although angioplasty continues to be the primary endovascular modality for PAD in most centers, high rates of restenosis in long, complex lesions, especially in infra-inguinal interventions, have limited its long-term outcomes,” Dr. Badheka and colleagues write. “This is because angioplasty primarily involves controlled stretch injury of the vessel wall, which can lead to restenosis due to vessel wall recoil and neointimal hyperplasia. This might be especially true in femoropopliteal lesions where various mechanical compressive and torsional forces make endovascular management of PAD challenging.”

Early stents to address restenosis provided disappointing results, but newer stent designs, including self-expanding nitinol stents, have led to improved outcomes, the authors say.

“Our study adds to the current literature by demonstrating a significant advantage to endovascular stenting over angioplasty alone in terms of reduced postprocedural complications and, more importantly, reduced amputations rates,” they write.

Even though stenting was tied to a “marginal” increase in hospitalization costs, that disparity “must be counterweighed against substantial advantage in terms of superior clinical outcomes,” they add. “Indeed, PAD-related… limb loss/amputations and revascularizations represent a major financial burden on our healthcare system.”

Dr. Badheka and colleagues note some limitations of their analysis; these include potential coding errors and underreporting of secondary and comorbid diagnoses as well as the lack of information on long-term outcomes, detailed angiographic data, and newer DES or drug-coated balloons.

Panaich SS, Arora S, Patel N, et al. Comparison of in-hospital outcomes and hospitalization costs of peripheral angioplasty and endovascular stenting. Am J Cardiol. 2015;Epub ahead of print.

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Todd Neale is the Associate News Editor for TCTMD and a Senior Medical Journalist. He got his start in journalism at …

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  • Dr. Badheka reports no relevant conflicts of interest.