Date of Award

January 2020

Document Type

Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Yawei Zhang

Abstract

Introduction. Atherectomy utilization has increased despite recent reports raising concerns about its effectiveness. The objective of this thesis is twofold. The first compares the outcomes of atherectomy to percutaneous transluminal angioplasty (PTA) and stenting for the treatment of isolated femoropopliteal disease. The second investigates the utilization patterns of orbital (OA), laser (LA), and excisional atherectomy (EA) and compares their outcomes.

Methods. All patients undergoing endovascular revascularization in the Vascular Quality Initiative (VQI) Peripheral Vascular Interventions (PVI) files from 2009-2018 were identified. Patients undergoing isolated femoropopliteal revascularization were categorized into three treatment groups: atherectomy, PTA alone, and stenting alone. Propensity score matching was used to obtain balanced groups to compare perioperative and 1-year outcomes. All patients undergoing atherectomy in the VQI PVI files from 2010-2016 were further identified. Utilization of atherectomy and each modality (OA, LA, or EA) were obtained. Characteristics and outcomes of patients treated for isolated femoropopliteal and isolated tibial disease by the different atherectomy modalities were separately compared.

Results. A total of 10,007 atherectomy, 22,000 PTA, and 27,579 stenting of isolated femoropopliteal disease were identified. After matching, 6,372 treatment pairs were created between the atherectomy and PTA groups. Compared to PTA, atherectomy was associated with higher likelihood of technical success (98.3% vs 97.5%; P <.001) and shorter length of stay (1.8 ± 8.2 vs 2.7 ± 15.7 days; P <.001) but had a higher rate of distal embolization (2.0% vs 1.1%; P<.001). At one year, atherectomy was associated with improved primary patency (84.2% vs 82.0%; P=.047) and rate of survival (91.1% vs 90.0%; P=.044), but atherectomy was associated with a higher reintervention rate (15.7% vs 13.6%; P=.033) compared to PTA. After matching, 6,877 treatment pairs were created between the atherectomy and stenting groups. Compared to stenting, atherectomy was associated with a lower rate of perforation (0.6% vs 1.2%; P<.001), a lower rate of dissection (3.7% vs 8.2%; P <.001), and a shorter length of stay (1.9 ± 8.1 vs 2.9 ± 9.8 days; P <.001). However, in comparison to stenting, atherectomy was associated with lower rate of technical success (98.3% vs. 99.2%; P <.001) and higher rate of distal embolization (2.0% vs 1.2%; P <.001). At one year, atherectomy was associated with a higher rate of major ipsilateral amputation (5.3% vs 4.1%; P= .046) and less improvement in ABI (0.19 ± 0.42 vs 0.25 ± 0.40; P <.001) compared to stenting.

As a share of all PVI, atherectomy use increased from 10.3% in 2010 to 25.6% in 2018. In the treatment of isolated femoropopliteal disease, there were no significant differences in 1-year primary patency, reintervention, major amputation, improvement in ambulatory status, or survival among the different modalities of atherectomy. In isolated tibial revascularization, EA was associated with the highest improvement in 1-year primary patency (88.1%). After adjusting for confounders, EA remained associated with improved 1-year primary patency compared to OA (OR = 2.59, [1.177-5.683]), and EA remained associated with a lower rate of 1-year major ipsilateral amputation compared to LA (OR = 0.29, [0.088-0.947]).

Conclusions. Atherectomy utilization has increased driven primarily by OA. Despite its higher cost over other endovascular modalities, atherectomy does not seem to confer any significant additional clinical benefit over standard PTA or stenting. EA seems to have improved long-term outcomes compared to OA and LA in the treatment of isolated tibial disease, but no difference was found in the treatment of isolated femoropopliteal disease. These differences warrant further investigation into the comparative effectiveness of atherectomy modalities in various vascular beds.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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