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Rate of endovascular procedures for PAD increasing in kidney disease
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New data indicate that the use of endovascular revascularization for peripheral artery disease increased nearly threefold, whereas surgical revascularization significantly decreased, in patients with end-stage renal disease who are on dialysis.
Using data from the Healthcare Cost and Utilization Project of the National Inpatient Sample files from 2002 to 2012, Pranav S. Garimella, MD, MPH, from the University of California, San Diego, and colleagues compared outcomes between endovascular and surgical revascularization strategies for PAD in patients on dialysis.
The researchers identified 106,605 hospitalizations for PAD revascularization — of which 77,049 (72.3%) were for endovascular procedures and 29,556 (26.7%) were for surgical procedures. From 2002 to 2012, the number of endovascular procedures increased from 3,255 (44% of all procedures) to 7,838 (84%), but surgical procedures decreased from 3,822 (56%) to 1,311 (16%).
Differences in mortality, complications
Mortality decreased by about 50% for both endovascular (7.6% vs. 3.2%) and surgical procedures (5.8% vs. 2.9%) from 2002 to 2012. Further, after multivariable adjustment, odds for death remained similar for surgical vs. endovascular procedures (adjusted OR = 1.05; 95% CI, 0.85-1.29).
From 2002 to 2012, the incidence of major amputations decreased from 6.7% to 5.8% after surgery and from 10.2% to 7% after endovascular revascularization. Minor amputations after endovascular revascularization increased from 8.5% to 12.9% but did not change significantly after surgery. However, after multivariable adjustment, the odds of amputation were 1.6-fold higher (95% CI, 1.4-1.75) with surgery vs. endovascular revascularization.
Although the incidence of overall complications in patients undergoing endovascular procedures increased from 12.8% to 13.5%, it nearly doubled from 13.7% to 26.7% in those undergoing surgery. Additionally, the researchers found a 1.8-fold higher adjusted odds of overall complications (95% CI, 1.6-2.02) with surgery vs. endovascular procedures.
The median length of hospital stay was 10 days for patients undergoing endovascular revascularization and did not significantly change over time. For those undergoing surgical procedures, the median length of stay was 12.9 days and decreased during the study period (P = .01).
Potential contributing factors
In an accompanying editorial, Hans-Henning Eckstein, MD, and colleagues from the Technical University of Munich noted that the increase in endovascular procedures in this patient population may reflect changes in clinical practice as well as in this particular patient population itself.
For instance, the average age of patients on dialysis has increased, as has the prevalence of PAD. Significant strides have also been made in endovascular techniques, such that a trend toward an “endovascular first” approach has emerged. Moreover, patients undergoing surgery may have more advanced disease and the presence of end-stage renal disease may affect the outcomes of surgery, according to the editorialists. However, they noted that the relatively unchanged rate of complications and decrease in mortality over time in light of the increasing disease severity speaks to the progress that has been made in surgical techniques and perioperative management as well.
“Taking these points altogether, the study most indirectly demonstrates that we already have achieved a significant improvement for our patients with PAD on hemodialysis,” they wrote. “There is substantial further investigation needed beyond this descriptive analysis. But hopefully, we will find that where the danger is, the savings will grow!” – by Melissa Foster
Disclosure s : Eckstein reports he has received research funding from Bayer. Garimella reports he has received speaker honoraria from Lifeline Vascular (DaVita). Please see the study and editorial for all other authors’ relevant financial disclosures.
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