Comparison and Trends of Endovascular, Surgical and Hybrid Revascularizations and the Influence of Comorbidity in 1 Million Hospitalizations Due to Peripheral Artery Disease in Germany Between 2009 and 2018

Objective: To analyze trends and differences of endovascular, surgical and hybrid revascularization approaches and the impact of comorbidity on characteristics, costs, and outcome of in-patients with peripheral artery disease (PAD) of the lower extremity.

Methods: Analyzing data provided by the Research Data Center of the German Federal Statistical Office, we included all hospitalizations due to PAD Fontaine IIb (Rutherford 2-3) or higher in Germany between 2009-2011 and 2016-2018. According to the individually performed procedures encoded by the Operation and Procedure Classification System, we divided hospitalizations by revascularization procedures into sole endovascular, sole surgical, hybrid, two-step and no revascularization. Patient's comorbidity was assessed using the linear van Walraven comorbidity score (vWs).

Results: 1,067,671 hospitalizations (mean age 71.3 ± 11.1 years; 60.1% male) were analyzed. Between 2009-2011 and 2016-2018, reimbursement costs rose by 28.0% from €2.72 billion (€5,350/case) to €3.49 billion (€6,238/case). The share of hospitalizations with any revascularization increased by 8.9% (67.7-73.7%) driven by an increase in two-step (+ 63.3%), hybrid (+ 58.2%) and sole endovascular revascularizations (+ 32.6%), while sole surgical approaches declined (- 18.2%). Hospitalizations of more comorbid patients (vWs ≥ 20) rose by 46.8% (21,444-31,478 cases), showed an overproportionate increase in costs of 124.6% (+ €1,750/case) and were associated with more individual procedures (+ 90.6%).

Conclusions: In-patient treatment of PAD patients shows increasing numbers of hybrid and sole endovascular revascularizations and more patients with higher comorbidity, while sole surgical interventions and in-hospital mortality decrease. Consequently, associated costs are surging especially in more comorbid patients due to an increasing number of performed procedures and escalation of therapy.