The migration of revascularization procedures for lower extremity peripheral arterial occlusive disease continues from the inpatient to the outpatient setting and especially to OBLs. Increased use of atherectomy in all segments of the lower extremity arterial system has been observed, particularly in OBLs, without substantial evidence in the literature of increased efficacy compared with standard angioplasty with or without stenting. Generous Medicare reimbursement for in-office atherectomy procedures is likely contributing to the volume shifts observed.

Outpatient use of atherectomy for peripheral arterial disease has grown rapidly and outcomes are poorly understood. We analyzed outcomes of atherectomy done for claudication, comparing office and hospital outpatient settings. Analysis of Medicare Part B claims data was performed for incident femoral-popliteal or tibial-peroneal atherectomy from 2012 to 2014. Longitudinal analysis assessed services 18 months before, during, and up to 18 months after the incident peripheral vascular intervention (PVI). Differences between office-based and hospital outpatient-based settings were assessed using χ and Fisher exact tests. Comparing procedure settings, significant differences in race (femoral-popliteal: P = .04, tibial-peroneal: P = .001), chronic renal failure (femoral-popliteal: P = .002), and hypertension (femoral-popliteal: P = .01, tibial-peroneal: P = .006) were found. Nine hundred twenty-four patients undergoing femoral-popliteal atherectomy were analyzed (262 office based, 662 hospital outpatient based); 42.7% of office-based and 36.9% of hospital outpatient-based femoral-popliteal atherectomy patients had repeat PVI within 18 months ( P = .10). Major amputation was performed in 2.3% and 3.2% of patients in office and hospital outpatient settings, respectively ( P = .47). Four hundred twenty-three patients undergoing tibial-peroneal atherectomy were analyzed (202 office based, 221 hospital outpatient based); 46.5% of office-based and 38.9% of hospital outpatient-based tibial-peroneal atherectomy patients had repeat PVI within 1 year ( P = .11). Major amputation was performed in 5.0% and 8.1% of patients in office and hospital outpatient settings, respectively ( P = .19). Our study demonstrates higher than expected rates of major amputation for patients undergoing peripheral arterial atherectomy with regard to previously reported rates. Further studies may be required to prove the efficacy and safety of atherectomy for occlusive disease in the femoral-popliteal and tibial-peroneal segments to ensure outcomes are not worse than the natural history of medically managed claudicants.

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Kaplan-Meier analysis was used to determine freedom from mortality and primary patency. The secondary aim was to identify predictive risk factors for mortality and reintervention. Results: At 5 years, freedom from mortality was 60%. Mean length of time from procedure to death was 1281.6 (61599) days. Primary patency at 5 years was 89% (Fig). No neurologic events occurred at 30 days. Two patients suffered a stroke in long-term follow-up. The reintervention rate was 8% (n ¼ 4), with an assisted primary patency rate of 100%. No stent occlusions occurred in this series. Eleven of 14 patients died of recurrent, active index, or other distinct primary cancer. Mortality and need for reintervention were not predicted by type of cancer, TNM stage at initial diagnosis, indication for surgery (irradiation, neck dissection, or both), preoperative symptom status, or preoperative demographic variables. Conclusions: Based on the results in this series, CAS in these patients can be performed with low long-term rates of neurologic events and need for reintervention. However, the survival of patients with head and neck cancer undergoing CAS in this cohort is reduced compared with published outcomes of other large series undergoing CAS for all indications. In this specific population of patients, a more critical analysis of the patient's overall prognosis, especially as it relates to cancer, should be undertaken before offering CAS. Fig. Kaplan-Meier curves for stent patency and patient survival.