Strategies for lower extremity peripheral artery disease compared


Researchers from Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, US, have published a new study in the July issue of the Journal of Vascular Surgery about the trends in lower extremity endovascular interventions, lower extremity bypass surgery and major above and below the knee amputations in Medicare beneficiaries (Part B claims). The study was done between 1996 and 2006.

Philip P Goodney, from the DHMC section of vascular surgery, noted that endovascular interventions were now performed much more commonly than bypass surgery in the treatment of lower extremity peripheral artery disease. Across the United States, more than three endovascular interventions replaced every single decline in lower extremity bypass surgery over the last 10 years.

“During the study period, per 100,000 patients, bypass surgery rates decreased from 219 to 126 procedures (43%); endovascular interventions increased from 138 to 455 procedures (230%), and the rate of lower extremity amputation rates fell by 28% from 263 to 188,” said Goodney.

Increased numbers in endovascular interventions per 100,000 patients was due to growth in peripheral angioplasty (from 135 to 337 procedures) and percutaneous atherectomy (from three to 118 procedures), according to researchers, who added that percutaneous atherectomy is a particularly new, expensive and relatively untested treatment – however its rate has increased by more than 4100%.

“We suspect new procedures may have translated into better outcomes, given the significant decline in amputation rates. However, other aspects of health care provided to patients at risk for amputation have changed along with the rates of surgical and endovascular procedures,” added Goodney. “Medicare patients are much more likely to receive medical and podiatric care, such as cholesterol monitoring, diabetic foot examinations and blood glucose monitoring aimed at preventing amputation now than they were 10 years ago. Our future work aims to determine if amputation rates are falling because of better medical care, changes in revascularization strategies or a combination of the two.”

Goodney said that larger and broader clinical trials should occur to compare bypass and endovascular interventions in patients with claudication and critical limb ischaemia. These trials would further evaluate what medical steps can be taken and resources should be used to obtain the best functional outcomes in patients with peripheral artery disease, and to prevent death and disability from lower extremity amputation.