Atherectomy Offers no Benefits Over Balloon Angioplasty in Tibial Interventions for Critical Limb Ischemia

Abstract

Endovascular adjuncts, like atherectomy, have been developed in order to improve outcomes for patients undergoing endovascular treatment for peripheral arterial disease (PAD). The true impact of atherectomy on endovascular outcomes remains to be determined, and no data exist on the influence of atherectomy on tibial interventions. Our study compares the early and late outcomes of tibial intervention with angioplasty vs atherectomy. We completed a retrospective review of all tibial interventions between 2008 and 2010. Preprocedural, procedural, and postprocedural data were collected using paper and electronic systems. Factors affecting patient outcomes were analyzed using single and multivariate analysis, Cox regression analysis, and Kaplan-Meier life-table curves. Primary outcomes were primary, primary assisted, and secondary patency rates, as well as limb salvage and survival. After review, 480 tibial interventions were completed for 421 limbs, 418 (87%) presented with critical limb ischemia (CLI) and 62 (13%) with claudication. A total of 192 isolated tibial interventions were completed, and 288 multisegment interventions were completed. The CLI cohort of 418 limbs was selected for analysis. These patients were a mean age of 71 years, with a mean follow-up time of 16 ± 15 months (range, 0-59 months). Moat patients (60%) were men, with predominant risk factors of hypertension (92%), tobacco use (64%), diabetes (72%), hyperlipidemia (65%), and chronic kidney disease (39%). Of the 418 limbs, 339 underwent percutaneous transluminal angioplasty (PTA): 333 PTA alone and six PTA+stent. The remaining 79 limbs received atherectomy (33 laser, 13 directional, 33 orbital) alone or in conjunction with PTA (11 atherectomy only, 68 atherectomy+PTA). The groups did not differ significantly in age, sex, risk factors, occlusion vs stenosis, or technical success. The atherectomy group had significantly more TransAtlantic Inter-Society Consensus (TASC) B lesions (54% vs 38%, P = .013), and the PTA group had significantly more TASC D lesions (25% vs 13%, P = .049). TASC A and C lesions did not differ significantly between the two groups. No significant differences existed with respect to the early (30-day) outcomes of loss of patency (11% vs 13%, P = .70), complications (9% vs 13%, P = .41), or major amputation (17% vs 13%, P = .34). Furthermore, there was no difference between treatment groups in symptomatic relief at first follow-up (61% vs 65%, P = .53) or Rutherford score improvement (70% vs 69%, P = .81). Kaplan-Meier analysis revealed no difference in primary outcomes of PTA vs atherectomy at the 12-month and 36-month assessments: primary patency (69% and 55% vs 61% and 46%, P = .15), primary assisted patency (83% and 71% vs 85% and 67%, P = .80), secondary patency (94% and 89% vs 95% and 89%, P = .89), limb salvage (79% and 70% vs 81% and 77%, P = .49), or survival (77% and 56% vs 80% and 50%). The adjunctive use of atherectomy offered no improvement over PTA in early or late outcomes in patients with CLI who underwent endovascular tibial interventions. Considering the additional cost and increased procedural time, these findings put into question the routine use of adjunctive atherectomy.