Study Compares National Trends in Treatments for Claudication and Limb-Threatening Ischemia

October 4, 2011—The Society for Vascular Surgery (SVS) announced the publication of a study comparing the benefit of angioplasty versus bypass grafting as treatments for claudication and limb-threatening ischemia. The study was designed to determine national estimates for the costs, utilization, and outcomes of treatment for each procedure. Teviah Sachs, MD, et al published the findings in the Journal of Vascular Surgery (2011;54:1021–1031).

According to the SVS, the investigators used the Nationwide Inpatient Sample to identify 563,143 patients who underwent intervention for a well-defined level of atherosclerotic disease with claudication or limb-threatening ischemia between 1999 and 2007. Of these patients, 38% underwent percutaneous transluminal angioplasty (PTA), 50% underwent peripheral bypass grafting, and 6% underwent aortofemoral bypass.

Lead Investigator Marc Schermerhorn, MD, explained, “We compared demographics, costs, and comorbidities, as well as multivariable-adjusted outcomes of in-hospital mortality and major amputation. Additionally, we used the New Jersey State Inpatient and Ambulatory databases in order to better understand the influence of outpatient procedures on current volume and trends.”

The investigators found that average costs for PTA increased more than 60% for claudication ($8,670 to $14,084) and limb-threatening ischemia ($13,903 to $23,196) between 2001 and 2007. For bypass grafting, average costs increased 36% for both claudication ($9,322 to $12,681) and limb-threatening ischemia ($16,795 to $22,910). In 2007, the average cost per procedure of PTA was higher than bypass grafting for both claudication ($13,903 vs $12,681) and limb-threatening ischemia ($23,196 vs $22,910).

During the study, the number of patients per year undergoing PTA increased threefold for claudication (15,903 to 46,138) and limb-threatening ischemia (6,752 to 19,468). For bypass grafting, the procedures per year decreased approximately 40% for both claudication (13,625 to 9,108) and limb-threatening ischemia (25,575 to 13,762). In-hospital mortality was similar for PTA and bypass grafting groups for claudication (0.1% vs 0.2%) and limb-threatening ischemia (2.1% vs 2.6%). In-hospital amputation rates were significantly higher for patients who underwent PTA (7%) than bypass grafting (3.9%) or aortofemoral bypass (3%).

“PTA has altered the treatment paradigm for lower limb ischemia with an increase in costs and procedures,” commented Dr. Schermerhorn. “It is unclear if this represents an increase in patients or number of treatments per patient. Although mortality is slightly lower with PTA for all indications, amputation rates for limb-threat patients appear higher, as does the average cost. The mortality benefit with PTA may be ultimately lost, and average costs elevated, if multiple interventions are performed on the same patients.”

Dr. Schermerhorn believes that longitudinal studies are needed to determine the appropriateness of PTA for claudication and limb-threatening ischemia patients and that there should be an increased use of prospective registries to provide consensus on treatment options, reported the SVS.