The routine application of atherectomy for femoropopliteal disease cannot be justified based on available evidence

Kawaji et al1Kawaji Q. Dun C. Walsh C. Sorber R. Stonko D. Abularrage C. et al.Index atherectomy peripheral vascular interventions performed for claudication are associated with more re-interventions than non-atherectomy interventions.J Vasc Surg. 2022 Mar 8; 76: 489-498Scopus (2) Google Scholar examined patients from Medicare fee-for-service claims from 2019 to determine the midterm results of first time percutaneous endovascular interventions for claudication. Remarkably, of 15,246 patients, 59.7% were treated with atherectomy versus nonatherectomy. Of atherectomy patients, 48.9% required a repeat percutaneous intervention, compared with 29.8% of nonatherectomy patients (median follow-up, 603 days). High-end physician atherectomy users were most likely to reintervene and more likely to use repeat atherectomy. What has been the motivating factor for the liberal application of atherectomy? In 2011, changes to the Common Procedural Terminology coding increased the profitability for interventionalists performing atherectomy, particularly in an outpatient setting. These changes were followed with an exponential increase in the application of atherectomy.2Mukherjee D. Hashemi H. Contos B. The disproportionate growth of office based atherectomy.J Vasc Surg. 2017; 65: 495-500Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar This study and others confirm that atherectomy is used commonly in more than 50% of percutaneous procedures in the United States.3Siricuse J.J. Woodson J. Ellis R.P. Farber A. Roddy S.P. Kalesan B. et al.Intermittent claudication treatment patterns in the commercially insured non-Medicare population.J Vasc Surg. 2012; 74: 499-504Abstract Full Text Full Text PDF Scopus (7) Google Scholar By comparison, atherectomy makes up less than 4% of interventions in Japan, Eastern Europe, and Canada, where there is less financial motivation.2Mukherjee D. Hashemi H. Contos B. The disproportionate growth of office based atherectomy.J Vasc Surg. 2017; 65: 495-500Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar What are the data to support this paradigm shift? They are sorely lacking. There is no significant Level 1 evidence and previous metanalyses and reviews have failed to distinguish any durable benefits over traditional endovascular treatments.4Gupta R. Siada S. Lai S. Al-Musawi M. Malgor E.A. Jacobs D.L. et al.Critical appraisal of the contemporary use of atherectomy to treat femoral-popliteal atherosclerotic disease.J Vasc Surg. 2022; 75: 697-708Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 5Wu Z. Huang Q. Pu H. Qin J. Wang X. Ye K. et al.Atherectomy combined with balloon angioplasty versus balloon angioplasty alone for de novo femoral-popliteal arterial diseases: a systemic review and meta-analysis of randomized controlled trials.Eur J Vasc Surg. 2021; 62: 65-73Abstract Full Text Full Text PDF Scopus (5) Google Scholar, 6Ambler G. Radwan R. Hayes P. Twine C. Atherectomy for peripheral vascular disease.Cochrane Database Syst Rev. 2014; 3: CD006680PubMed Google Scholar Now, this study as well as others from large databases demonstrate that in general, atherectomy patients suffer inferior midterm outcomes compared with patients treated with nonatherectomy interventions.7Bath J. Lawrence P. Zhao Y. Neal D. Zhao Y. Smith J.B. et al.Endovascular interventions for claudication do not meet minimum standards for the Society for Vascular Surgery efficacy guidelines.J Vasc Surg. 2021; 73: 1693-1700Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Furthermore, these inferior results come at an increased cost to our health care system ($9427 vs $1551 per patient in this study). Further investigation is necessary to determine which subset of patients benefit from atherectomy over less expensive endovascular therapies. Until such information is available, the routine use of atherectomy is not justifiable and should be actively discouraged. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Index atherectomy peripheral vascular interventions performed for claudication are associated with more reinterventions than nonatherectomy interventionsJournal of Vascular SurgeryVol. 76Issue 2PreviewDespite limited evidence supporting atherectomy alone over stenting/angioplasty as the index peripheral vascular intervention (PVI), the use of atherectomy has rapidly increased in recent years. We previously identified a wide distribution of atherectomy practice patterns among US physicians. The aim of this study was to investigate the association of index atherectomy with reintervention. Full-Text PDF