Comparison of Atherectomy to Balloon Angioplasty and Stenting for Isolated Femoropopliteal Revascularization

Background: The use of atherectomy for lower extremity revascularization is increasing despite concerning reports about its long-term safety and effectiveness. This study compares the outcomes of atherectomy to percutaneous transluminal angioplasty (PTA) and stenting for treatment of isolated femoropopliteal disease.

Methods: All patients undergoing endovascular treatment of isolated femoropopliteal lesions in the Vascular Quality Initiative (2009-2018) were identified. Patients with concomitant open surgery, acute limb ischemia, or iliac or tibial intervention were excluded. Patients were divided into 3 treatment groups: atherectomy with or without PTA, PTA alone, and stenting alone. Propensity matching was performed based on age, gender, race, ambulatory status, diabetes, smoking, hypertension, coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure, dialysis, prior inflow bypass and intervention, prior major ipsilateral amputation, indication, length of treated lesion, American Society of Anesthesiologists class, and Trans-Atlantic Society Consensus II classification. The perioperative and one-year outcomes of the matched groups were compared.

Results: A total of 10,007 cases of atherectomy, 22,000 cases of PTA, and 27,579 cases of stenting of isolated femoropopliteal disease were identified. After matching, there were 6,372 procedures in atherectomy and PTA groups, respectively. Atherectomy was associated with higher likelihood of technical success (98.3% vs. 97.5%; P < 0.001) and shorter length of stay (1.8 ± 8.2 days vs. 2.7 ± 15.7 days; P < 0.001), but had increased rate of distal embolization (2% vs. 1.1%; P < 0.001) compared with PTA. At one year, atherectomy was associated with improved primary patency (84.2% vs. 82%; P = 0.047) and survival rate (91.1% vs. 90%; P = 0.044), but was also associated with a higher reintervention rate (15.7% vs 13.6%; P = 0.033) compared with PTA. There was no difference in the rates of major amputation, ambulatory status improvement, or ankle brachial index (ABI) improvement. In the second analysis, after matching, there were 6,877 procedures in the atherectomy and stenting groups, respectively. Atherectomy was associated with lower rate of dissection (3.7% vs. 8.2% <0 .001), lower rate of perforation (0.6% vs. 1.2%; P < 0.001), and a shorter length of stay (1.9 ± 8.1 vs. 2.9 ± 9.8 days; P < 0.001) than stenting. However, patients treated with atherectomy had a lower rate of technical success (98.3% vs. 99.2%; P < 0.001) and a higher rate of distal embolization (2% vs. 1.2%; P < 0.001) than stenting. At one year, atherectomy was associated with a higher rate of major ipsilateral amputation (5.3% vs. 4.1%; P = 0.046) and less improvement in ABI (0.19 ± 0.42 vs. 0.25 ± 0.4; P < 0.001) than stenting. There was no difference in rates of primary patency, survival, reintervention, and ambulatory status improvement at one year.

Conclusions: Atherectomy does not seem to confer any significant additional clinical benefit compared with balloon angioplasty or stenting. Further research is needed to justify its additional cost over other endovascular modalities.