Outcomes mixed for endovascular vs. surgical revascularization in CTO PAD
Endovascular intervention conferred less in-hospital mortality but more postprocedural complications compared with surgical revascularization in patients with peripheral artery disease due to chronic total occlusion, new data suggest.
Recently, emerging technologies in the endovascular intervention of PAD, such as interventional imaging with IVUS and OCT, and intervention with drug-coated balloons and drug-eluting stents, have shown superior endovascular outcomes, Mohamed Zghouzi, MD, of the Detroit Medical Center, and colleagues wrote. However, the outcome of intervention compared with surgery in patients with PAD due to CTO remains unknown.
This knowledge gap led the researchers to examine national trends and in-hospital outcomes in patients with PAD and CTO. They identified 168,420 patients with PAD and CTO in the National Inpatient Sample database who received limb revascularization from 2007 to 2014.
More than half of patients (58.9%) received endovascular intervention, with those receiving the procedure younger, more likely to be women and Black patients, and less likely to be white patients (P < .001 for all) compared with those who had surgery.
According to results, endovascular intervention conferred lower in-hospital mortality compared with surgery (1.2% vs. 1.7%; adjusted OR = 0.54; 95% CI, 0.5-0.59). However, the interventional procedure also increased the risks for vascular complications (2.9% vs. 1.8%; aOR = 1.77; 95% CI, 1.64-1.92), major bleeding (7.4% vs. 5.2%; aOR = 1.44; 95% CI, 1.38-1.51), acute kidney injury (9.7% vs. 8.1%; aOR = 0.93; 95% CI, 0.89-0.96) and major amputation (4.4% vs. 3.7%; aOR = 0.9; 95% CI, 0.85-0.95).
In a subgroup analysis of patients with critical limb ischemia, researchers observed a decrease in mortality with endovascular intervention (1.4% vs. 1.9%; aOR = 0.56; 95% CI, 0.5-0.63). No differences in the incidence of acute kidney injury or major amputation were reported in the CLI subgroup, although intervention was linked to higher rates of vascular complications (2.4% vs. 1.4%; aOR = 1.9; 95% CI, 1.69-2.13) and major bleeding events (6.8% vs. 5.8%; aOR = 1.18; 95% CI, 1.11-1.25).
Regarding the higher rate of complications observed with endovascular intervention in this study, researchers wrote that the cause is likely the complex nature of the procedure and CTO lesions.
“Also, we believe that the patients in the endovascular group have more comorbidities likely to the fact that they are high surgical risk and poor candidates for surgical intervention upon their inpatient hospital stay,” they wrote. “Therefore, periprocedural CTO lesion assessment with CTA, angiogram and microcatheter increases lesion crossing's success rate, considering different crossing and treatment strategies if initial attempts fail. The procedure should be performed in centers that have the capabilities with the required types of equipment and expert operators.”
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