Use of Atherectomy During Index Peripheral Vascular Interventions

Abstract

Objectives: The aim of this study was to describe physician practice patterns and examine physician-level factors associated with the use of atherectomy during index revascularization for patients with femoropopliteal peripheral artery disease.

Background: There are minimal data to support the routine use of atherectomy over angioplasty and/or stenting for the endovascular treatment of peripheral artery disease.

Methods: Medicare fee-for-service claims (January 1 to December 31, 2019) were used to identify all beneficiaries undergoing elective first-time femoropopliteal peripheral vascular intervention (PVI) for claudication or chronic limb-threatening ischemia. Hierarchical logistic regression was used to evaluate patient- and physician-level characteristics associated with atherectomy.

Results: A total of 58,552 patients underwent index femoropopliteal PVI by 1,627 physicians. There was a wide distribution of physician practice patterns in the use of atherectomy, ranging from 0% to 100% (median 55.1%). Independent characteristics associated with atherectomy included treatment for claudication (vs. chronic limb-threatening ischemia; odds ratio [OR]: 1.51), patient diabetes (OR: 1.09), physician male sex (OR: 2.08), less time in practice (OR: 1.41 to 2.72), nonvascular surgery specialties (OR: 2.78 to 5.71), physicians with high volumes of femoropopliteal PVI (OR: 1.67 to 3.51), and physicians working primarily at ambulatory surgery centers or office-based laboratories (OR: 2.19 to 7.97) (p ≤ 0.03 for all). Overall, $266.8 million was reimbursed by Medicare for index femoropopliteal PVI in 2019. Of this, $240.6 million (90.2%) was reimbursed for atherectomy, which constituted 53.8% of cases.

Conclusions: There is a wide distribution of physician practice patterns for the use of atherectomy during index PVI. There is a critical need for professional guidelines outlining the appropriate use of atherectomy in order to prevent overutilization of this technology, particularly in high-reimbursement settings.

Keywords: atherectomy; endovascular; femoropopliteal disease; peripheral artery disease; peripheral vascular interventions.

Figure 1.. National distribution of physicians by their atherectomy rate for index femoropopliteal peripheral vascular interventions (PVI) in 2019.

The 1,627 physicians included in the analysis had a wide distribution of use of femoropopliteal atherectomy during index PVI, ranging from 0% (i.e. never used atherectomy as the initial procedure) to 100% (always used atherectomy as the initial procedure).

Central Illustration

Based on 2019 Medicare data, we found a wide distribution of physician practice patterns for use of atherectomy during index peripheral vascular interventions. Atherectomy accounted for 90.2% of Medicare payments to physicians for index femoropopliteal PVI procedures in 2019, despite accounting for only 53.8% of cases. High rates of atherectomy were more common in patients with claudication and diabetes, and for procedures performed in ambulatory surgical centers (ASC) and office-based laboratories (OBL).