RS10 - Infrapopliteal Peripheral Vascular Interventions for Claudication Are Associated with Poor Long-Term Outcomes Regardless of Anatomic and Disease Severity

Thursday, June 15, 2023

8:51 AM – 8:58 AM ET

Submitting & Presenting Author(s)

Sanuja Bose, MD

Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine
Baltimore, Maryland

Co-Author(s)

CD

Chen Dun, MS

Baltimore, Maryland
AK

Alana C. Keegan

Johns Hopkins University School of Medicine
Baltimore, Maryland
KM

Katherine M. McDermott

Department of Surgery, Johns Hopkins Hospital
Baltimore, Maryland
DS

David P. Stonko

Department of Surgery, Johns Hopkins Hospital
Baltimore, Maryland
James H. Black, III, MD

Professor and Chief
Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine
Baltimore, Maryland
JC

Jesse A. Columbo

Assistant Professor of Surgery
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire
Michael S. Conte, MD

Professor and Chief, Division of Vascular and Endovascular Surgery
University of California San Francisco
San Francisco, California
SD

Sarah A. Deery

Maine Medical Center
PG

Philip P. Goodney, MD, MS

The Dartmouth Institute
Lebanon, New Hampshire
Jessica P. Simons, MD

Associate Professor of Surgery
University of Massachusetts Medical School
Worcester, Massachusetts
Jeffrey J. Siracuse, MD, MBA

Professor of Surgery and Radiology
Boston University School of Medicine
Boston, Massachusetts
KW

Karen Woo, MD, PhD

Associate Professor
University of California Los Angeles School of Medicine
Los Angeles, California
MM

Martin A. Makary

Professor
Department of Surgery, Johns Hopkins University School of Medicine
Baltimore, Maryland

Senior Author(s)

Caitlin W. Hicks, MD, MS (she/her/hers)

Associate Professor
Johns Hopkins University School of Medicine
Baltimore, Maryland

Objectives: The use of infrapopliteal peripheral vascular interventions (PVI) in the treatment of claudication has been controversial. We have previously shown that infrapopliteal PVI for claudication is associated with poor long-term outcomes among Medicare beneficiaries, but could not account for anatomic characteristics using an administrative dataset. Here, we aimed to show that infrapopliteal PVI is persistently associated with poor long-term outcomes in patients with claudication when compared with isolated femoropopliteal PVI, even after accounting for anatomic and disease severity characteristics.

Methods: We identified all patients who underwent an index infrainguinal PVI for an indication of claudication between 2004 and 2020 in the Vascular Quality Initiative and Vascular Implant Surveillance and Interventional Outcomes Network (VQI-VISION). Our primary outcomes were conversion to chronic limb threatening ischemia (CLTI) and any repeat PVI. Kaplan-Meier curves and multivariable Cox proportional hazards models were used to assess the association of infrapopliteal PVI with long-term outcomes after adjusting for baseline patient characteristics (demographics, socioeconomic status, comorbidities, medications, site of service, treatment type performed) and anatomic/disease severity characteristics (ankle brachial index, femoropopliteal TASC classification, ambulation) and clustering by treating physician.

Results: Of 13,824 patients (mean age 72.1±0.1 years, 40.9% female, 19.6% nonwhite/Hispanic) who underwent an index PVI for claudication, 2,565 (18.6%) underwent an infrapopliteal PVI, including 10.5% (n=1,423) with one infrapopliteal PVI and 8.5% (n=1,141) with ≥2-vessel infrapopliteal PVI. Median follow-up was 3.1 years (IQR 1.6-5.5 years). The estimated 3-year rates of conversion to CTLI (31.3% vs. 20.0%) and repeat PVI (42.4% vs. 34.3%) were higher for patients who underwent any infrapopliteal PVI vs. those who underwent an isolated femoropopliteal PVI (both, P< 0.001; Fig 1). After adjusting for baseline and anatomic characteristics, index infrapopliteal PVI was associated with a higher risk of conversion to CLTI (aHR 1.45, 95% CI 1.29-1.63) and repeat PVI (aHR 1.25, 95% CI 1.14-1.36) than isolated femoropopliteal PVI. These associations remained significant with any number of infrapopliteal vessels treated, as well as among patients stratified by TASC classification (all, P< 0.001; Fig 2).

Conclusions: The use of infrapopliteal PVI for claudication is common and associated with worse long-term outcomes compared to the use of isolated femoropopliteal PVI, even after accounting for anatomic characteristics of peripheral artery disease. Infrapopliteal PVI performed for claudication is harmful, and should not be part of the treatment paradigm for claudication.