Infrapopliteal Peripheral Vascular Interventions for Claudication Are Associated With Poor Long-term Outcomes Regardless of Anatomical and Disease Severity

Abstract

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 anatomical 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 anatomical and disease severity characteristics. 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. Our primary outcomes were conversion to chronic limb-threatening ischemia 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 anatomical/disease severity characteristics (ankle brachial index, femoropopliteal TASC classification, ambulation) and clustering by treating physician. Of 13,824 patients (mean age, 72.1 ± 0.1 years; 40.9% female; 19.6% non-White/Hispanic) who underwent an index PVI for claudication, 2565 (18.6%) underwent an infrapopliteal PVI, including 10.5% (n = 1423) with one infrapopliteal PVI and 8.5% (n = 1141) with two or more vessel infrapopliteal PVI. Median follow-up was 3.1 years (interquartile range, 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 < .001) (Fig 1). After adjusting for baseline and anatomical characteristics, index infrapopliteal PVI was associated with a higher risk of conversion to chronic limb-threatening ischemia (adjusted hazard ratio, 1.45; 95% CI, 1.29-1.63) and repeat PVI (adjusted hazard ratio, 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 < .001) (Fig 2). 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 anatomical characteristics of peripheral artery disease. Infrapopliteal PVI performed for claudication is harmful, and should not be part of the treatment paradigm for claudication.Fig 2Forest plot depicting the adjusted* hazard ratios of infrapopliteal peripheral vascular intervention (PVI) with conversion to chronic limb-threatening ischemia (CLTI) and repeat PVI, overall, by number of infrapopliteal vessels treated, and among subgroups stratified by TASC classification.View Large Image Figure ViewerDownload Hi-res image Download (PPT)