Infrainguinal Angioplasty for Claudication: A Population-Level Analysis

Todd R. Vogel, MD, Leonard T. Su, MD, Rebecca Gaston-Symons, Alexander W. Clowes, MD and David R. Flum, MD
The Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, WA

Objective: With the increased availability of infrainguinal percutaneous transluminal angioplasty (PTA) the traditional management for claudication may be evolving, with little data to support the practice change. This study evaluated changes in the use and short term outcomes of PTA among patients with peripheral vascular disease (PVD).
Methods: We performed a retrospective cohort study using a Washington State hospital discharge database (CHARS) which allows tracking of subsequent hospitalizations for each subject. Cases included all patients undergoing peripheral angioplasty (ICD-9 procedure codes for angioplasty with codes for PVD) from 1995-2004 (renal, mesenteric, and carotid interventions were excluded). Patients having PTA for claudication were compared to those having PTA for other infrainguinal diagnoses. The main outcome measures were readmission, reintervention (angiography, angioplasty/stent, surgical revascularization, or amputation), and death within 30 days.
Results: 2013 patients (mean age 69.5±11.1, 53.7% male) underwent PTA for claudication (51.5%), rest pain (12.57%), ulceration (23.1%), or not otherwise specified (12.9%). There was a 620% increase in the overall use of PTA with a 632% increase in claudicants. PTA was performed primarily at urban, non-academic institutions (62.8 vs. 37.2%, p<0.001). PTA was performed at 43 hospitals with 7 contributing 50% of the cases. Patients undergoing PTA for claudication were younger (67.5±10.5 vs. 71.4±11.5, p<0.001), more likely male (58.3% vs. 47.5%, p<0.001), and had a lower co morbidity index (0.68 vs. 1.13, p<0.001). Most patients undergoing PTA were Medicare eligible, but among patients less than 65 (n=662) the indication for PTA was claudication more often when patients had commercial insurance versus other or no insurance (67.5% vs. 45.2%, p<0.001). Claudicants had shorter lengths of stay (2.4±2.2 vs. 5.3±5.8 days, p<0.001), lower in hospital death (0.8% vs. 3.2%, p<0.001), and a lower 30-day mortality (1.3% vs. 4.8%, p<0.001). Claudicants 30-day readmission rate was 10.2% (n=106) and 27.4% of those readmitted required reintervention with no amputations among claudicants.
Conclusion: There has been a dramatic increase in the use of PTA for PVD in Washington State in the last decade. Although non-interventional management of claudication is the standard of care we found that most patients (51.5%) undergoing PTA were claudicants. Claudicants were more likely to receive PTA in urban non-academic medical centers, to have commercial insurance, and to be younger and healthier. PTA for claudication had a higher than expected morbidity with a 10% 30-day readmission rate and of those readmitted greater than 25% required a second procedure. Given the absence of evidence based guidelines for PTA in claudication, future studies are needed to evaluate the factors involved in its use and associated outcomes.