Atherectomy overuse is a real problem

In this month’s Journal of Vascular Surgery, Nfor et al¹ have reported on the national trends of atherectomy use for infrainguinal peripheral vascular interventions (PVIs) using data from the Vascular Quality Initiative (VQI).¹ Overall, their results are not surprising—the use of atherectomy has been steadily increasing among VQI centers in the United States and has been most strongly associated with PVIs performed in office-based laboratory (OBL) settings. Similar results have been reported by a variety of other investigators in the past using Medicare claims data.^2–4 What is important is the overwhelming message of atherectomy overuse in the United States.

This is not an attack on physicians who work in OBLs. This is a statement of the facts, which I will summarized with supporting data.

Fact 1. Atherectomy use for infrainguinal PVI has been increasing rapidly in the United States.

A number of reports have shown the increased use of atherectomy to be true.^2–4 The report by Nfor et al¹ was limited in that the practices in the VQI represent a select group and do not represent national trends.¹ However, their data support previous work on this topic, showing a consistent increase in atherectomy PVI use over time.^2–4

Fact 2. No high-quality evidence is available that atherectomy improves outcomes compared with alternative endovascular therapies.

Most of the data evaluating the efficacy of atherectomy have shown similar patency outcomes compared with balloon angioplasty and stenting. Laser atherectomy has been shown to have efficacy for in-stent restenosis, and clinical consensus guidelines from the Society for Cardiovascular Angiography and Interventions have suggested rotational or orbital atherectomy might be a useful adjunct procedure for treating moderate to severely calcified lesions.⁵ Recent clinical outcomes data have suggested that atherectomy use is associated with more interventions in patients with claudication compared with other available endovascular technologies.⁶

Fact 3. Atherectomy is much more frequently used in OBL settings than in hospital-based settings.

Medicare claims data have shown significantly greater use of atherectomy for PVIs in OBL settings than in hospital-based settings.^7,8 A similar finding was shown in the VQI data. Without discussing the reason here, it is clear from the data that atherectomy use has been more prevalent in OBLs.

Fact 4. Reimbursement for atherectomy procedures is substantially higher than that for stenting and balloon angioplasty in the outpatient setting.

The present analysis extended from 2010 to 2019, with 2019 having the highest proportion of atherectomy use in the VQI. In 2019, Medicare physician reimbursement for femoropopliteal atherectomy performed in a non-facility setting was $12,444 when performed with or without balloon angioplasty and $16,033 when performed with concomitant stenting. In comparison, physician reimbursment was $3,628 and $10,793 for balloon angioplasty and stenting, respectively in the same setting.⁹

Based on these facts, the routine use of atherectomy for infrainguinal PVI is suspicious at best. Certainly, cases exist for which atherectomy has proven helpful, such as calcific disease, popliteal lesions that cannot or should not be stented, and recalcitrant lesions. However, the data have shown the use of atherectomy in up to 100% of PVI cases by some physicians,⁷ and that is not right. These high atherectomy users are not all non–evascular surgery offenders, either. They include a combination of vascular surgery, cardiology, radiology, and general surgery physicians.⁷ As a field, vascular surgeons need to come together and unite on this issue. If we do not police ourselves regarding the appropriate use of high-cost technologies, the Centers for Medicare and Medicaid will most certainly do it for us.