Contemporary outcomes of infrapopliteal atherectomy with angioplasty versus balloon angioplasty alone for critical limb ischemia

Objective: Limited data exist comparing atherectomy (At) with balloon angioplasty for infrapopliteal peripheral arterial disease. The objective of this study was to compare the outcomes of infrapopliteal At with angioplasty vs angioplasty alone in patients with critical limb ischemia. Methods: This is a retrospective, single-center, longitudinal study comparing patients undergoing either infrapopliteal At with angioplasty or angioplasty alone for critical limb ischemia, between January 2014 and October 2017. The primary outcome was primary patency rates. Secondary outcomes were reintervention rates, assisted primary patency, secondary patency, major adverse cardiac events, major adverse limb events, amputation-free survival, overall survival, and wound healing rates. Data were analyzed in multivariate generalized linear models with log rank tests to determine survival in Kaplan-Meier curves. Results: There were 342 infrapopliteal interventions, 183 percutaneous balloon angioplasty (PTA; 54%), and 159 atherectomies (At) with PTA (46%) performed on 290 patients, with a mean age of 67 +/- 12 years; 61% of the patients were male. The PTA and At/PTA groups had similar demographics, tissue loss (79% vs 84%; P = .26), ischemic rest pain (21% vs 16%; P = .51), mean follow-up (19 +/- 9 vs 20 +/- 9 months; P = .32), mean number of vessels treated (1.7 +/- 0.8 vs 1.9 +/- 0.8; P = .08) and the mean lesion length treated (6.55 +/- 5.00 cm vs 6.02 +/- 4.00 cm; P = .08), respectively. Similar 3-month (96 +/- 1% vs 94 +/- 1%), 6-month (85 +/- 2% vs 86 +/- 3%), 12-month (68 +/- 3% vs 69 +/- 4%), and 18-month (57 +/- 4% vs 62 +/- 4%) primary patency rates were seen in the two groups (P = .87). At/PTA patients had significantly higher reintervention rates as compared with the PTA patients (28% vs 16%; P = .02). Similar assisted primary patency rates (67 +/- 4% vs 69 +/- 4%; P = .78) and secondary patency rates (61 +/- 4% vs 66 +/- 4%; P = .98) were seen in the PTA and At/PTA groups at 18 months. The 30-days major adverse cardiac event rates (3% vs 2%; P = .13) and 30-day major adverse limb event rates (5% vs 4%; P = .2) were similar in both groups. Wound healing rates (72 +/- 3% vs 75 +/- 2%; P = .12), 1-year amputation-free survival (68 +/- 4.1% vs 70 +/- 2%; P = .5), and 1-year overall survival (76 +/- 4% vs 78 +/- 4%; P = .39) rates did not differ in the PTA and At/PTA groups. THE At/PTA group had higher local complication rates (7 [4%] vs 1 [0.5%]; P = .03) Conclusions: At with angioplasty provides similar patency rates compared with angioplasty alone for infrapopliteal peripheral arterial disease, but associated with higher reintervention and local complication rates. Further appropriately designed studies are required to determine the exact role of At in this subset of patients.