Mohan Sathish, Flahive Julie M, Arous Edward J, Judelson Dejah R, Aiello Francesco A, Schanzer Andres, Simons Jessica P
Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
J Vasc Surg. 2018 Dec;68(6):1806-1816. doi: 10.1016/j.jvs.2018.03.417. Epub 2018 Jun 21.
Peripheral atherectomy has been shown to have technical success in single-arm studies, but clinical advantages over angioplasty and stenting have not been demonstrated, leaving its role unclear. We sought to describe patterns of atherectomy use in a real-world U.S. cohort to understand how it is currently being applied.
The Vascular Quality Initiative was queried to identify all patients who underwent peripheral vascular intervention from January 2010 to September 2016. Descriptive statistics were performed to analyze demographics of the patients, comorbidities, indication, treatment modalities, and lesion characteristics. The intermittent claudication (IC) and critical limb ischemia (CLI) cohorts were analyzed separately.
Of 85,605 limbs treated, treatment indication was IC in 51% (n = 43,506) and CLI in 49% (n = 42,099). Atherectomy was used in 15% (n = 13,092) of cases, equivalently for IC (15%; n = 6674) and CLI (15%; n = 6418). There was regional variation in use of atherectomy, ranging from a low of 0% in one region to a high of 32% in another region. During the study period, there was a significant increase in the proportion of cases that used atherectomy (11% in 2010 vs 18% in 2016; P < .0001). Compared with nonatherectomy cases, those with atherectomy use had higher incidence of prior peripheral vascular intervention (IC, 55% vs 43% [P < .0001]; CLI, 47% vs 41% [P < .0001]), greater mean number of arteries treated (IC, 1.8 vs 1.6 [P < .0001]; CLI, 2.1 vs 1.7 [P < .0001]), and lower proportion of prior leg bypass (IC, 10% vs 14% [P < .0001]; CLI, 11% vs 17% [P < .0001]). There was lower incidence of failure to cross the lesion (IC, 1% vs 4% [P < .0001]; CLI, 4% vs 7% [P < .0001]) but higher incidence of distal embolization (IC, 1.9% vs 0.8% [P < .0001]; CLI, 3.0% vs 1.4% [P < .0001]) and, in the CLI cohort, arterial perforation (1.4% vs 1.0%; P = .01).
Despite a lack of evidence for atherectomy over angioplasty and stenting, its use has increased across the United States from 2010 to 2016. It is applied equally to IC and CLI populations, with no identifiable pattern of comorbidities or lesion characteristics, suggesting that indications are not clearly delineated or agreed on. This study places impetus on further understanding of the optimal role for atherectomy and its long-term clinical benefit in the management of peripheral arterial disease.
在单臂研究中，外周血管斑块旋切术已显示出技术上的成功，但与血管成形术和支架置入术相比，其临床优势尚未得到证实，其作用仍不明确。我们试图描述美国一个真实队列中斑块旋切术的使用模式，以了解其目前的应用情况。
查询血管质量倡议数据库，以确定2010年1月至2016年9月期间接受外周血管介入治疗的所有患者。进行描述性统计分析患者的人口统计学特征、合并症、适应症、治疗方式和病变特征。分别对间歇性跛行（IC）和严重肢体缺血（CLI）队列进行分析。
在治疗的85605条肢体中，治疗适应症为IC的占51%（n = 43506），为CLI的占49%（n = 42099）。15%（n = 13092）的病例使用了斑块旋切术，IC组（15%；n = 6674）和CLI组（15%；n = 6418）使用比例相同。斑块旋切术的使用存在地区差异，从一个地区的0%到另一个地区的32%不等。在研究期间，使用斑块旋切术的病例比例显著增加（2010年为11%，2016年为18%；P <.0001）。与未使用斑块旋切术的病例相比，使用斑块旋切术的患者既往外周血管介入治疗的发生率更高（IC组，55%对43% [P <.0001]；CLI组，47%对41% [P <.0001]），平均治疗动脉数量更多（IC组，1.8对1.6 [P <.0001]；CLI组，2.1对1.7 [P <.0001]），既往腿部搭桥手术的比例更低（IC组，10%对14% [P <.0001]；CLI组，11%对17% [P <.0001]）。病变通过失败的发生率更低（IC组，1%对4% [P <.0001]；CLI组，4%对7% [P <.0001]），但远端栓塞的发生率更高（IC组，1.9%对0.8% [P <.0001]；CLI组，3.0%对1.4% [P <.0001]），在CLI队列中，动脉穿孔的发生率也更高（1.4%对1.0%；P =.01）。
尽管缺乏证据表明斑块旋切术优于血管成形术和支架置入术，但从2010年到2016年，其在美国的使用有所增加。它在IC和CLI人群中的应用相同，没有可识别的合并症或病变特征模式，这表明适应症尚未明确界定或达成共识。这项研究促使人们进一步了解斑块旋切术在周围动脉疾病管理中的最佳作用及其长期临床益处。
