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National Outcomes of Lower Extremity Angioplasty and Bypass Procedures for Claudication or Limb Threat

Ami Jhaveri, Allen Hamdan, Frank Pomposelli, Kristina Giles, Suzanne Dahlberg, Marc Schermerhorn.
Beth Israel Deaconess Medical Center, Boston, Mass.

OBJECTIVES: Percutaneous transluminal angioplasty (PTA) is increasingly being utilized for the treatment of lower extremity peripheral vascular disease (PVD). Still, there is little data comparing its effectiveness to surgical bypass. The purpose of this study is to compare national outcomes and trends of bypass surgery and angioplasty.

METHODS: Lower extremity procedures were identified from the National Inpatient Sample database from 1994-2005 by ICD-9 procedural codes for lower extremity angioplasty or bypass combined with primary diagnosis codes for atherosclerosis with claudication or limb threat (rest pain, ulcer, or gangrene). We also measured procedure volumes over time, and in-hospital mortality and amputation rates.

RESULTS: We identified 39,036 hospitalizations involving lower extremity revascularizations (Table). Total volume of procedures have increased for both claudication and limb threat. While bypass procedures for claudication have been on a steady decline, PTA for claudication has increased and overtook bypass in 2001. Angioplasty for limb threat has also steadily increased and approximated bypass procedures in 2005. Mortality was slightly higher with bypass than PTA for claudication (0.75% vs. 0.27%; p=.003; RR=2.7; 95%CI=1.4-5.4) and was similar for limb threat (3.0% vs. 2.7%; p=0.18; RR=1.1; 95%CI=0.95-1.3). The amputation rate was higher in the bypass group for claudication (0.86% vs. 0.12%; p<0.0001; RR=7.3; 95%CI=2.9-18.5) but lower for limb threat (8.7% vs. 12.3%; p<0.0001, RR=0.70; 95%CI=0.65-0.76).
CONCLUSIONS: Interventions for PVD are increasing over time despite a decrease in bypass procedures due to an even larger increase in PTA volume. Contrary to the general perception that angioplasty is associated with a lower mortality compared with bypass, we did not find this to be the case in patients with limb threat. Further work with data allowing risk-adjustment, and assessment of re-intervention rates and long-term limb salvage will clarify the appropriate role of PTA and bypass in the treatment of claudication and limb threat.

AUTHOR DISCLOSURES: A. Jhaveri, None; A. Hamdan, None; F. Pomposelli, None; K. Giles, None; S. Dahlberg, None; M. Schermerhorn, None.

*Combined=Lower extremity bypass and angioplasty performed during same hospitalization.
**Limb threat=includes rest pain, ulceration or gangrene.