Infrapopliteal Endovascular Interventions for Claudication Are Associated with Poor Long-Term Outcomes in Medicare-Matched Registry Patients

Sanuja Bose, Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD.
Katherine M. McDermott, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
Chen Dun, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
Jialin Mao, Department of Population Health Sciences, Weill Cornell Medical College, New York, NY.
Alex J. Solomon, Medical Center Radiologists, Norfolk, VA.
James H. Black, Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD.
Jesse A. Columbo, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Michael S. Conte, University of California San Francisco Medical Center, San Francisco, CA.
Sarah E. Deery, Maine Medical Center, Portland, ME.
Philip P. Goodney, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Rohan Kalathiya, Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD.
Corey A. Kalbaugh, Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN.
Jeffrey J. Siracuse, Division of Vascular and Endovascular Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.

Abstract

BACKGROUND: There are limited data supporting or opposing the use of infrapopliteal peripheral vascular interventions (PVI) for the treatment of claudication. OBJECTIVES: We aimed to evaluate the association of infrapopliteal PVI with long-term outcomes compared with isolated femoropopliteal PVI for the treatment of claudication. METHODS: We conducted a retrospective analysis of all patients in the Medicare-matched Vascular Quality Initiative database who underwent an index infrainguinal PVI for claudication from January 2004-December 2019 using Cox proportional hazards models. RESULTS: Of 14,261 patients (39.9% female; 85.6% age ≥65 years, 87.7% non-Hispanic white) who underwent an index infrainguinal PVI for claudication, 16.6% (N=2,369) received an infrapopliteal PVI. The median follow-up after index PVI was 3.7 years (IQR 2.1-6.1). Compared to patients who underwent isolated femoropopliteal PVI, patients receiving any infrapopliteal PVI had a higher 3-year cumulative incidence of conversion to CLTI (33.3% vs. 23.8%; P<0.001); repeat PVI (41.0% vs. 38.2%; P<0.01); and amputation (8.1% vs. 2.8%; P<0.001). After risk-adjustment, patients undergoing infrapopliteal PVI had a higher risk of conversion to CLTI (aHR 1.39, 95% CI, 1.25-1.53); repeat PVI (aHR 1.10, 95% CI, 1.01-1.19); and amputation (aHR 2.18, 95% CI, 1.77-2.67). Findings were consistent after adjusting for competing risk of death; in a 1:1 propensity-matched analysis; and in subgroup analyses stratified by TASC disease, diabetes, and end-stage kidney disease. CONCLUSIONS: Infrapopliteal PVI is associated with worse long-term outcomes than femoropopliteal PVI for claudication. These risks should be discussed with patients.