Study identifies ‘critical need’ for guidelines on appropriate use of atherectomy

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Caitlin W. Hicks

No data currently exist to support the use of atherectomy over other procedures for the treatment of peripheral arterial disease (PAD), and the healthcare expenditure associated with the procedure is substantial, write Caitlin W. Hicks MD, assistant professor of surgery at John Hopkins Medicine in Baltimore, et al in a new published study of physician practice patterns during peripheral vascular interventions (PVI) that appeared in JACC: Cardiovascular Interventions recently.

Hicks and colleagues plumbed Medicare beneficiaries undergoing first-time femoropopliteal PVI—including angioplasty, stenting, and atherectomy—for PAD between Jan. 1, 2019, and Dec. 31, 2019 in their analysis.

Of 58,552 patients who underwent index femoropopliteal PVI during the study period, 31,476 (53.8%) were treated with atherectomy, they find. Patients who underwent atherectomy were similar to those in the non-atherectomy group in terms of age and sex but were more frequently Black (17.1% vs. 13.9%) or Hispanic (4.6% vs. 2.6%) with a p<0.001, the authors found.

“Patients undergoing atherectomy were more frequently being treated for claudication (29.3% vs. 23.3%; p<0.001) and had a lower prevalence of end-stage renal disease (36.5% vs. 40.8%; p<0.001) and ever smoking (29.4% vs. 31.8%) than those in the non-atherectomy group.”

A total of 1,627 physicians were included in the study. Their use of femoropopliteal atherectomy during index PVI ranged from 0% to 100%, Hicks et al reported. Some 420 physicians, or 25.8%, performed atherectomy in 87.5%-plus of their cases. Another 133 physicians (8.2%) performed atherectomy in 100% of their index femoropopliteal PVI cases, they continue.

“High users of atherectomy were more frequently cardiologists (38.3% vs. 34.2%) or radiologists (14.1% vs. 6.9%) and less frequently vascular surgeons (34.1% vs. 48.2%) compared with atherectomy users in quartiles 1 to 3 (p<0.001),” they wrote.

“High atherectomy users had a higher median percentage of services delivered in an [ambulatory surgery center (ASC)] or [office-based lab (OBL)] (78.4% vs. 49.5%; p<0.001) and a higher median Medicare-allowed payment amount for index femoropopliteal PVI per patient ($11,071 vs. $532; p<0.001).”

In discussion, Hicks and colleagues noted patient characteristics associated with atherectomy use included claudication—rather than chronic limb-threatening ischemia (CLTI)—and diabetes.

“Patients with diabetes tend to have PAD with higher degrees of medial calcification compared with those without diabetes, suggesting that angioplasty and stenting technologies, which cause plaque disruption and displacement within the arterial wall, may not be as effective as debulking with atherectomy,” they commented.

“The association of atherectomy with claudication is more troublesome. Invasive interventions for claudication have not been shown to have better long-term outcomes compared with medical best medical management and supervised exercised therapy (SET) and indeed may be substantially worse.”

Yet, Hicks et al write, they found a subset of physicians with a high rate of intervention following an initial diagnosis of claudication.

Acknowledging limitations, the authors list their study’s data being limited to Medicare beneficiaries therefore may not be applicable to other populations. They also state they have not reported patient outcomes following intervention, writing, “the aim of our study was to describe practice patterns in the use of atherectomy for index femoropopliteal PVI rather than outcomes that have been previously described.”

Concluding, Hicks and colleagues point out a wide distribution pattern for atherectomy use in index PVI, with atherectomy used “more frequently for treating patients with claudication and diabetes and by nonvascular surgery specialists and physicians working primarily in ASCs and OBLs.”

They add: “There is a critical need for professional guidelines outlining the appropriate use of atherectomy to prevent overutilization of this technology, particularly in high-reimbursement settings.”

SOURCE: doi.org/10.1016/j.jcin.2021.01.004

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