Introduction:
Restoring circulation to patients with symptomatic lower extremity peripheral arterial disease (PAD) is traditionally achieved with open surgery. However, endovascular techniques have enhanced the armamentarium available to patients. No long-term, population-based results exist on which of these provides the optimal approach to symptomatic PAD.
Methods:
We identified patients who underwent an inpatient endovascular or open lower extremity revascularization for PAD (including those with claudication and limb threat) for 2006 through 2009 from the Centers for Medicare & Medicaid Services Chronic Conditions Warehouse, a 5% national sample of Medicare beneficiaries. The primary outcome was amputation free survival. The secondary outcome was the relative rate of subsequent intervention. Propensity score matching ensured similar baseline characteristics amongst cohorts.
Results:
Among 14,685 eligible patients, 5,928 endovascular revascularization patients and 5,928 open revascularization patients were included in a matched analysis. Patients undergoing endovascular repair had improved amputation free survival compared to open repair at 30-days (7.4 vs. 8.9%, p=0.002). This benefit persisted over the long-term: At 4-years, 49% of endovascular patients had died or received major amputation compared to 54% of open patients (p<0.001). An endovascular procedure was associated with a risk-adjusted 19% decreased risk of amputation or death compared to open over the study period (hazard ratio: 0.84; 95% confidence interval, 0.79-0.89; p<0.001). The rate of subsequent intervention at 30-days was 7.4% greater for the endovascular versus the open revascularization cohort. At 4-years, this difference remained stable at 8.6%.
Conclusions:
Using a population-based dataset, we show that an endovascular approach is associated with improved amputation free survival over the long-term. Moreover, we show a modest initial increase in the risk of reintervention after endovascular procedures; the differential rate of reintervention for endovascular patients was less than 10% over four years. The observed benefit associated with endovascular intervention may have significant implications for the millions of patients with PAD.
Long‐Term Prognostic Risk in Lower Extremity Peripheral Arterial Disease as a Function of the Number of Peripheral Arterial Lesions
