Outcomes and Costs of Lower Extremity Peripheral Vascular Interventions With Intravascular Ultrasound

The benefits of intravascular ultrasound (IVUS) during coronary angiography are established. However, the utility of IVUS in lower extremity peripheral vascular interventions (PVIs) is not clear. This study aimed to evaluate the outcomes and associated costs of IVUS during PVIs in the VISION database. The Medicare-linked VISION database (2017-2019) for lower extremity PVI for atherosclerotic disease was reviewed. Patients were grouped as PVI-IVUS and PVI alone based on adjunctive IVUS use. The outcomes evaluated were major amputation and reinterventions. Medicare costs, charges, and payments for the index procedure were reviewed. Multivariable Cox regression was used to compare outcomes and to identify predictors of outcomes. There were 13,499 patients during the study period with a low rate of IVUS use (3.5%). The median follow-up was 350 days (interquartile range, 145-638 days). Patient demographics and characteristics are described in Table I. IVUS was more commonly used for claudication (41.6% vs 32.4%; P < .001) and in the outpatient setting (68.6% vs 48.4%; P < .001), whereas PVI alone (67.6% vs 58.7%; P < .001) was performed for chronic limb-threatening ischemia. IVUS was more likely to be used for treatment of lesions ≥15 cm in length (51.7% vs 40.5%; P < .001) and for Trans-Atlantic Inter-Society Consensus (TASC) C and D lesions (50.6% vs 25.8%; P < .001). Moreover, there was increased use of atherectomy and stenting together (25.7% vs 6.1%; P < .001) in the PVI-IVUS group. There was a lower rate of amputations (6.1% vs 12.8%; P < .001) with IVUS and higher reinterventions (43.3% vs 33.9%; P < .001) at 1 year. On multivariable regression, IVUS did not independently impact major amputation. However, IVUS was independently associated with increased reinterventions (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.13-1.554). Other predictors of reinterventions were TASC-D lesions (HR, 1.27; 95% CI, 1.14-1.41), TASC-C lesions (HR, 1.23; 95% CI, 1.10-1.38), and atherectomy and stenting together (HR, 1.23; 95% CI, 1.08-1.39). The total costs ($15,421.71 vs $10,789.58; P < .001) and Medicare payments ($12,480.64 vs $9.195.65; P < .001) for the index procedure were significantly higher for the PVI-IVUS group in the outpatient setting (Table II). In the VISION database, lower extremity PVI with IVUS was performed in patients with more complex anatomy without independently impacting amputations. IVUS use was associated with increased costs and reinterventions. Further research is needed to guide IVUS use during PVI to optimize patient care and justify costs.Table ICharacteristics of the cohortPatient characteristicsPVI (n = 13,021)PVI-IVUS (n = 478)P-valueAge, years72 (65-80)72 (66-79).43Female sex5303 (40.7)203 (42.5).45White race10,131 (77.9)358 (75.1).003Black race2338 (18.0)84 (17.6).003Other race537 (4.1)35 (7.3).003Hypertension11,751 (90.7)417 (88.0).05Diabetes7648 (58.8)262 (54.8).09Congestive heart failure3464 (26.6)89 (18.6)<.001Coronary artery disease4762 (36.6)167 (35.1).5Chronic obstructive pulmonary disease3448 (26.5)97 (20.3).002Former smoker5824 (44.8)216 (45.2).1Current smoker3247 (25.0)136 (28.5).1Prior coronary intervention4763 (37.0)154 (34.2).23Prior carotid intervention913 (7.1)49 (10.9).002Ambulatory7861 (61.8)316 (66.2).05Claudication4179 (32.4)197 (41.6)<.001Chronic limb-threatening ischemia8720 (67.6)277 (58.4)<.001Inpatient PVI6717 (51.6)150 (31.4)<.001Outpatient PVI6304 (48.4)328 (68.6)<.001TASC A2418 (18.6)41 (8.6)<.001TASC B2707 (20.8)82 (17.2)<.001TASC C2163 (16.6)92 (19.2)<.001TASC D2854 (21.9)150 (31.4)<.001Treatment length, cm<.001 <155114 (39.3)165 (34.5) ≥155273 (40.5)247 (51.7)Treatment type<.001 Plain balloon angioplasty4913 (37.7)47 (9.8) Stent5280 (40.5)168 (35.1) Atherectomy2035 (15.6)140 (29.3) Atherectomy and stenting793 (6.1)123 (25.7)Treatment level<.001 Aortoiliac2041 (15.7)89 (18.7) Femoral-popliteal5428 (41.7)164 (34.4) Tibial2255 (17.3)50 (10.5) Multilevel3286 (25.3)174 (36.5)IVUS, Intravascular ultrasound; PVI, peripheral vascular intervention; TASC, Trans-Atlantic Inter-Society Consensus.Data are presented as number (%) or median (interquartile range). Open table in a new tab Table IIOutcomes and Medicare costs of lower extremity peripheral vascular intervention (PVI)Outcomes and costsPVI (n = 13,021)PVI-IVUS (n = 478)P-value1-year outcomesa Reinterventions33.9 (32.9-34.8)43.3 (38.2-48.8)<.0001 Major amputation12.8 (12.2-13.5)6.1 (3.9-9.2)<.0001 Mortality20.8 (20.0-21.6)13.5 (10.4-17.4).001Total Medicare costs Payment for index procedure, $Inpatient24,404.51 (18,631.9-34,011.7)24,733.31 (19,303.28-36,658.36).41Outpatient9.195.65 (8070.71-11,617.87)12,480.64 (9253.89-14,766.06)<.001 Cost for index procedure, $Inpatient26,319.60 (20,468.50- 36,208.98)26,737.86 (20,629.71-38,682.10).56Outpatient10,789.58 (9661.23-13,608.82)15,421.71 (11,021.50-17,463.03)<.001 Charge for index procedure, $Inpatient122,571.00 (81,078.00-190,884.70)167,617.01 (111,290.00-258,995.39)<.001Outpatient52,785.72 (36,999.89-75,793.50)61,250.38 (38,380.75-99,931.35)<.001IVUS, Intravascular ultrasound.Data are presented as median (interquartile range) or percent (95% confidence interval).aTime-to-event analysis. 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