Endovascular Management of Severe Peripheral Artery Disease Isolated to the Popliteal Artery Shows Comparable Outcomes Regardless of Treatment Modality.

Background: While the use of endovascular intervention for peripheral artery disease has expanded in recent years, there remains relatively few studies focused on the endovascular treatment of isolated popliteal artery occlusive disease. The popliteal artery presents a particular challenge for endovascular intervention due to the constant flexion at the knee. We sought to assess the outcomes for endovascular management of isolated popliteal artery occlusive disease based on type of intervention performed.

Methods: The Vascular Quality Initiative (VQI) database was queried for patients with isolated popliteal artery occlusive disease who underwent endovascular intervention from January 2011 to December 2019. Patients were excluded from analysis if they did not have Medicare Fee-For-Service entitlement, had a history of prior intervention in the ipsilateral limb, or had vessels treated in addition to the popliteal artery. Patients were stratified into groups based on their initial presenting symptom (claudication versus chronic limb-threatening ischemia (CLTI)) and were analyzed by endovascular procedure performed (plain old balloon angioplasty (POBA) versus adjunctive stent/atherectomy). The POBA group underwent only plain balloon angioplasty, whereas the adjunctive stent/atherectomy group underwent any type of balloon angioplasty and adjunctive stenting or atherectomy or both. The primary outcome was amputation-free survival, a composite outcome of freedom from major amputation and/or death.

Results: A total of 1,740 patients met criteria for analysis who underwent endovascular intervention for isolated popliteal artery occlusive disease. Among patients with claudication, the amputation-free survival rate was significantly higher at 1 year and 3 years for patients treated with adjunctive stent/atherectomy than POBA (1 year: 94.2% vs. 88.9%, P = 0.03; 3 years: 83.0% vs. 76.6%, P = 0.04). This difference appeared to be driven by mortality, as mortality was significantly better for adjunctive stent/atherectomy than POBA (1 year: 4.6% vs. 10.2%, P = 0.01; 3 years: 15.4% vs. 23.3%, P = 0.02), whereas major amputation rates were not significantly different. However, multivariable analysis showed that use of adjunctive stent/atherectomy was not independently associated with improved amputation-free survival (adjusted hazard ratio 0.74, 95% confidence interval 0.48-1.16, P = 0.19). In the CLTI group, amputation-free survival rates were not significantly different for patients treated with adjunctive stent/atherectomy compared to POBA (1 year: 65% vs. 64.6%, P = 0.78; 3 years: 47.1% vs. 42.6%, P = 0.30). Reintervention rates were not statistically different when stratified by use of adjunctive therapies in either the claudication or CLTI groups.

Conclusions: Our results suggest that across all patients with isolated popliteal artery occlusive disease, amputation-free survival rates were comparable regardless of endovascular treatment modality. As expected, amputation-free survival for patients presenting with claudication was favorable compared to those with CLTI and was driven primarily by mortality. Reintervention rates were similar across all patients regardless of treatment modality. This study underscores the clinical challenge of treating isolated popliteal artery occlusive disease and stresses the need for further study of adjunctive modalities in treating complex lesions.