Frequency of in-hospital adverse outcomes and cost utilization associated with cardiac resynchronization therapy defibrillator implantation in the United States.

BACKGROUND: The utilization of cardiac resynchronization therapy defibrillator (CRT-D) has increased significantly, since its initial approval for use in selected patients with heart failure. Limited data exist as for current trends in implant-related in-hospital complications and cost utilization. The aim of our study was to examine in-hospital complication rates associated with CRT-D and their trends over the last decade. METHODS AND RESULTS: Using the Nationwide Inpatient Sample, we estimated 378 248 CRT-D procedures from 2003 to 2012. We investigated common complications, including mechanical, cardiovascular, pericardial complications (hemopericardium, cardiac tamponade, or pericardiocentesis), pneumothorax, stroke, vascular complications (consisting of hemorrhage/hematoma, incidents requiring surgical repair, and accidental arterial puncture), and in-hospital deaths described with CRT-D, defining them by the validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. Mechanical complications (5.9%) were the commonest, followed by cardiovascular (3.6%), respiratory failure (2.4%), and pneumothorax (1.5%). Age (≥65 years), female gender (OR, 95% CI; P value) (1.08, 1.03-1.13; 0.001), and the Charlson score ≥3 (1.52, 1.45-1.60; <0.001) were significantly associated with increased mortality/complications. CONCLUSIONS: The overall complication rate in patients undergoing CRT-D has been increasing in the last decade. Age (≥65), female sex, and the Charlson score ≥3 were associated with higher complications. In patients who underwent CRT-D implantation, postoperative complications were associated with significant increases in cost.

Management of Hypertension in Patients with Aortic Valvular Stenosis.

Aortic stenosis (AS) has an increasing prevalence with age and is commonly associated with hypertension. While it has been established that hypertension is associated with increased mortality in patients with AS, further randomized control trials addressing the use of antihypertensives specifically in patients with AS are needed. The management of hypertension in patients with AS needs a cautious approach due to complex hemodynamic and structural changes involved. Comorbidities like coronary artery disease, heart failure and arrhythmias further dictate management of hypertension in patients with AS. The aim of this article is to review the various agents used in the management of hypertension in patients with AS.

Hospital Admissions for Chest Pain Associated with Cocaine Use in the United States.

BACKGROUND: The outcomes related to chest pain associated with cocaine use and its burden on the healthcare system are not well studied. METHODS: Data were collected from the Nationwide Inpatient Sample (2001-2012). Subjects were identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Primary outcome was a composite of mortality, myocardial infarction, stroke, and cardiac arrest. RESULTS: We identified 363,143 admissions for cocaine-induced chest pain. Mean age was 44.9 (±21.1) years with male predominance. Left heart catheterizations were performed in 6.7%, whereas the frequency of acute myocardial infarction and percutaneous coronary interventions were 0.69% and 0.22%, respectively. The in-hospital mortality was 0.09%, and the primary outcome occurred in 1.19% of patients. Statistically significant predictors of primary outcome included female sex (odds ratio [OR], 1.16; confidence interval [CI], 1.00-1.35; P = .046), age >50 years (OR, 1.24, CI, 1.07-1.43; P = .004), history of heart failure (OR, 1.63, CI, 1.37-1.93; P <.001), supraventricular tachycardia (OR, 2.94, CI, 1.34-6.42; P = .007), endocarditis (OR, 3.5, CI, 1.50-8.18, P = .004), tobacco use (OR, 1.3, CI, 1.13-1.49; P <.001), dyslipidemia (OR, 1.5, CI, 1.29-1.77; P <.001), coronary artery disease (OR, 2.37, CI, 2.03-2.76; P <.001), and renal failure (OR, 1.27, CI, 1.08-1.50; P = .005). The total annual projected economic burden ranged from $155 to $226 million with a cumulative accruement of more than $2 billion over a decade. CONCLUSION: Hospital admissions due to chest pain and concomitant cocaine use are associated with low rates of adverse outcomes. For the low-risk cohort in whom acute coronary syndrome has been ruled out, hospitalization may not be beneficial and may result in unnecessary cardiac procedures.

A Review of Hypertension Management in Atrial Fibrillation.

Atrial fibrillation (AF) is one of the commonest arrhythmias in clinical practice and has major healthcare and economic implications. It is a growing epidemic with prevalence all set to double to 12 million by 2050. After adjusting for other associated conditions, hypertension confers a 1.5- and 1.4-fold risk of developing AF, for men and women respectively. Furthermore, in patients with AF, the presence of hypertension has a cumulative effect on the risk of stroke. Growing evidence suggests reversal or attenuation of various structural and functional changes predisposing to AF with the use of antihypertensive medications. Randomized trials have shown major reduction in the risk of stroke and heart failure with blood pressure reduction. However, such trials are lacking in AF patients specifically. The Joint National Committee-8 guidelines have not addressed the threshold or goal BP for patients with known AF. Furthermore, "J-shaped" or "U-shaped" curves have been noted during hypertension management in patients with AF with published data demonstrating worse outcomes in patients with strict BP control to <110/60 mmhg similar to coronary artery disease. In this review, we outline the available literature on management of hypertension in patients with AF as well as the role of individual anti-hypertensive medications in reducing the incidence of AF Fig. 1.

Etiologies and Predictors of 30-Day Readmission and In-Hospital Mortality During Primary and Readmission After Transcatheter Aortic Valve Implantation.

There are sparse data on the etiologies and predictors of readmission after transcatheter aortic valve implantation (TAVI). The study cohort was derived from the National Readmission Data 2013, a subset of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. TAVI was identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. The coprimary outcomes were 30-day readmissions and in-hospital mortality during primary admission and readmission. Hierarchical 2-level logistic models were used to evaluate study outcomes. Our analysis included 5,702 (weighted n = 12,703) TAVI procedures. About 1,215 patients were readmitted (weighted n = 2,757) within 30 days during the study year. Significant predictors of readmission included transapical access (OR, 95% CI, p value) (1.23, 1.10 to 1.38, <0.01), diabetes (1.18, 1.06 to 1.32, p 0.004), chronic lung disease (1.32, 1.18 to 1.47, <0.01), renal failure (1.43, 1.24 to 1.65, <0.01), patients discharged to facilities (1.28, 1.14 to 1.43, <0.01), and those who had lengthier hospital stays during primary admission (length of stay >10 days: 3.06, 2.22 to 4.22, <0.01). Female gender (1.39, 1.16 to 1.68, <0.01), blood transfusion (1.88, 1.55 to 2.29, <0.01), use of vasopressors (3.63, 2.50 to 5.28, <0.01), hemodynamic support (6.39, 5.20 to 7.85, <0.01) and percutaneous coronary intervention (1.89, 1.30 to 2.74, 0.01) during primary admission were significant predictors of in-hospital mortality. Age and transapical access were significant predictors of in-hospital mortality during readmission. In conclusion, heart failure, pneumonia, and bleeding complications are among important etiologies of readmission in patients after TAVI. Patients who underwent transapical TAVI and those with slower in-hospital recovery and co-morbidities such as chronic lung disease and renal failure are more likely to be readmitted to the hospital.

Comparison of Outcomes of Transcatheter Aortic Valve Replacement Plus Percutaneous Coronary Intervention Versus Transcatheter Aortic Valve Replacement Alone in the United States.

Transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) has emerged as a less-invasive therapeutic option for high surgical risk patients with aortic stenosis and coronary artery disease. The aim of this study was to determine the outcomes of TAVR when performed with PCI during the same hospitalization. We identified patients using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes from the Nationwide Inpatient Sample between the years 2011 and 2013. A total of 22,344 TAVRs were performed between 2011 and 2013. Of these, 21,736 (97.3%) were performed without PCI (TAVR group) while 608 (2.7%) along with PCI (TAVR + PCI group). Among the TAVR + PCI group, 69.7% of the patients had single-vessel, 22.2% had 2-vessel, and 1.6% had 3-vessel PCI. Drug-eluting stents were more commonly used than bare-metal stents (72% vs 28%). TAVR + PCI group witnessed significantly higher rates of mortality (10.7% vs 4.6%) and complications: vascular injury requiring surgery (8.2% vs 4.2%), cardiac (25.4% vs 18.6%), respiratory (24.6% vs 16.1%), and infectious (10.7% vs 3.3%), p <0.001% for all, compared with the TAVR group. The mean length of hospital stay and cost of hospitalization were also significantly higher in the TAVR + PCI group. The propensity score-matched analysis yielded similar results. In conclusion, performing PCI along with TAVR during the same hospital admission is associated with higher mortality, complications, and cost compared with TAVR alone. Patients would perhaps be better served by staged PCI before TAVR.

Temporal Trends, Predictors, and Outcomes of In-Hospital Gastrointestinal Bleeding Associated With Percutaneous Coronary Intervention.

Since the introduction of new antiplatelet and anticoagulant agents in the last decade, large-scale data studying gastrointestinal bleeding (GIB) in patients undergoing percutaneous coronary intervention (PCI) are lacking. Using the Nationwide Inpatient Sample, we identified all hospitalizations from 2006 to 2012 that required PCI. Temporal trends in the incidence and multivariate predictors of GIB associated with PCI were analyzed. A total of 4,376,950 patients underwent PCI in the United States during the study period. The incidence of GIB was 1.1%. Mortality rate in the GIB group was significantly higher (9.71% vs 1.1%, p <0.0001). Although the incidence of GIB remained stable during the study period (0.97% in 2006 to 1.19% in 2012), in-hospital mortality rate increased significantly from 7.9% in 2006 to 10.78% in 2012, with a peak of 12% in 2010. The GIB group had a longer median length of stay (5.80 vs 1.57 days) and an increased median cost of hospitalization ($26,564 vs $16,879). The predictors of GIB included cardiovascular co-morbidities such as acute myocardial infarction, cardiogenic shock, atrial fibrillation, congestive heart failure, valvular heart diseases, and a history of transient ischemic attack/stroke. Gastrointestinal co-morbidities including diverticulosis, esophageal cancer, stomach cancer, small intestine cancer, large intestine cancer, rectosigmoid cancer, gastrointestinal ulcer, and liver disease were predictors of GIB. Interestingly, a lower risk of GIB was associated with obese patients and patients with private insurance. A higher risk of GIB was noted in urgent versus elective admissions and weekend versus weekday admissions. In conclusion, the incidence of GIB in patients who underwent PCI remained stable from 2006 to 2012; however, the in-hospital mortality increased significantly. Identifying patients at higher risk for GIB is critically important to develop preventive strategies to reduce morbidity and mortality.

Comparison of In-Hospital Mortality, Length of Stay, Postprocedural Complications, and Cost of Single-Vessel Versus Multivessel Percutaneous Coronary Intervention in Hemodynamically Stable Patients With ST-Segment Elevation Myocardial Infarction (from Nationwide Inpatient Sample [2006 to 2012]).

The primary objective of our study was to evaluate the in-hospital outcomes in terms of mortality, procedural complications, hospitalization costs, and length of stay (LOS) after multivessel percutaneous coronary intervention (MVPCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). The study cohort was derived from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database, years 2006 to 2012. Percutaneous coronary interventions (PCI) performed during STEMI were identified using appropriate International Classification of Diseases, Ninth Revision, diagnostic and procedural codes. Patients in cardiogenic shock were excluded. Hierarchical mixed-effects logistic regression models were used for categorical dependent variables such as in-hospital mortality and composite of in-hospital mortality and complications, and hierarchical mixed-effects linear regression models were used for continuous dependent variables such as cost of hospitalization and LOS. We identified 106,317 (weighted n = 525,161) single-vessel PCI and 15,282 (weighted n = 74,543) MVPCIs. MVPCI (odds ratio, 95% confidence interval [CI], p value) was not associated with significant increase in in-hospital mortality (0.99, 0.85 to 1.15, 0.863) but predicted a higher composite end point of in-hospital mortality and postprocedural complications (1.09, 1.02 to 1.17, 0.013) compared to single-vessel PCI. MVPCI was also predictive of longer LOS (LOS +0.19 days, 95% CI +0.14 to +0.23 days, p <0.001) and higher hospitalization costs (cost +$4,445, 95% CI +$4,128 to +$4,762, p <0.001). MVPCI performed during STEMI in hemodynamically stable patients is associated with no increase in in-hospital mortality but a higher rate of postprocedural complications and longer LOS and greater hospitalization costs compared to single-vessel PCI.

Septal Ablation and Hypertrophic Obstructive Cardiomyopathy: 7 Years US Experience.

BACKGROUND: Septal ablation (SA) is a key modality for left ventricular outflow tract gradient reduction in hypertrophic obstructive cardiomyopathy (HOCM) patients with refractory symptoms. The primary objective of our study was to evaluate post-procedural mortality, complications, length of stay (LOS), and cost of hospitalization following SA. METHODS: We queried the Nationwide Inpatient Sample (NIS) between 2005 and 2011 using the ICD9 procedure code of 37.34 for ablation of heart tissue. Only adult patients with HOCM (ICD-9-CM: 425.1) were included. Patients with any arrhythmia diagnosis or open surgical ablation procedure code were excluded. Hierarchical mixed effects models were generated in order to identify the independent multivariate predictors of outcomes. RESULTS: A total of 358 SAs were available for analysis. There was no reported mortality during the study period; permanent pacemaker implantation rate was 8.7%. Highest hospital volume tertile (OR, 95%CI, P- value) predicted significantly lower post-procedural complications (0.51, 0.26-0.98, P = 0.04). Univariate analysis of highest versus lowest tertile of hospital volume showed significant decrease in LOS (2.6 days vs. 3.8 days, P<0.01) and non-significant decrease hospitalization costs (16,800$ vs. 19,500$, P = 0.29). CONCLUSIONS: SA is a safe procedure and associated with low peri- procedural mortality rate. A higher burden of baseline comorbidities is associated with worse outcomes while higher annual hospital volume is associated with lower rate of post-procedural complications, length of stay, and cost of care following SA.

Influence of same-day admission on outcomes following transcatheter aortic valve replacement.

BACKGROUND: Since elective transcatheter aortic valve replacements (TAVRs) can be performed on the day of admission, i.e., Day 0, or on the next day of admission, i.e., Day 1, we sought to investigate if there is an advantage to either approach. METHODS: We performed a retrospective cohort study, using the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample database of 2012 and identified subjects undergoing endovascular (Transfemoral/Transaortic) TAVRs using the ICD-9-CM procedure code of 35.05. The cohort was divided based on the day of the TAVR performed, i.e., Day 0 or 1. The cost of the hospitalization and length of stay were the primary outcomes, with in-hospital mortality and procedural complications as the secondary outcomes. We identified a total of 843 TAVRs. Propensity matched models were created. The mean age of the study cohort was 82 years. RESULTS: In a propensity-matched dataset, TAVRs performed on Day 0 were associated with a lower cost ($51,126 ± 1184 vs $57,703 ± 1508, p < 0.0001) and length of stay (mean days, standard error: 5.87 ± 0.25 vs 7.20 ± 0.29, p < 0.001) compared to Day 1. In-hospital mortality plus complication rates were relatively similar with no difference between Days 0 and 1 (31.5% vs 34.1%, p = 0.47, respectively). CONCLUSIONS: Endovascular TAVRs performed on the same day of admission are associated with lower hospitalization costs and length of stay, and similar mortality and complication rates compared to those performed on the next day of admission.

Influence of hospital volume and outcomes of adult structural heart procedures.

Hospital volume is regarded amongst many in the medical community as an important quality metric. This is especially true in more complicated and less commonly performed procedures such as structural heart disease interventions. Seminal work on hospital volume relationships was done by Luft et al more than 4 decades ago, when they demonstrated that hospitals performing > 200 surgical procedures a year had 25%-41% lower mortality than those performing fewer procedures. Numerous volume-outcome studies have since been done for varied surgical procedures. An old adage "practice makes perfect" indicating superior operator and institutional experience at higher volume hospitals is believed to primarily contribute to the volume outcome relationship. Compelling evidence from a slew of recent publications has also highlighted the role of hospital volume in predicting superior post-procedural outcomes following structural heart disease interventions. These included transcatheter aortic valve repair, transcatheter mitral valve repair, septal ablation and septal myectomy for hypertrophic obstructive cardiomyopathy, left atrial appendage closure and atrial septal defect/patent foramen ovale closure. This is especially important since these structural heart interventions are relatively complex with evolving technology and a steep learning curve. The benefit was demonstrated both in lower mortality and complications as well as better economics in terms of lower length of stay and hospitalization costs seen at high volume centers. We present an overview of the available literature that underscores the importance of hospital volume in complex structural heart disease interventions.

Percutaneous Coronary Intervention: Relationship Between Procedural Volume and Outcomes.

Percutaneous coronary intervention (PCI) is an integral treatment modality for acute coronary syndromes (ACS) as well as chronic stable coronary artery disease (CAD) not responsive to optimal medical therapy. This coupled with studies on the feasibility and safety of performing PCI in centers without on-site surgical backup led to widespread growth of PCI centers. However, this has been accompanied by a recent steep decline in the volume of PCIs at both the operator and hospital level, which raises concerns regarding minimal procedural volumes required to maintain necessary skills and favorable clinical outcomes. The 2011 ACC/AHA/SCAI competency statement required PCI be performed by operators with a minimal procedural volume of >75 PCIs annually at high-volume centers with >400 PCIs per year, a number which was relaxed in the 2013 ACC/AHA/SCAI update to >50 PCIs/operator/year in hospitals with >200 PCIs annually to coincide with reduction in national PCI volume. Recent data suggests that many hospitals do not meet these thresholds. We review data on the importance of volume as a vital quality metric at both an operator and hospital level in determining procedural outcomes following PCI.

Impact of Glycoprotein IIb/IIIa Inhibitors Use on Outcomes After Lower Extremity Endovascular Interventions From Nationwide Inpatient Sample (2006-2011).

OBJECTIVE: The aim of our study was to study the impact of glycoprotein IIb/IIIa inhibitors (GPI) on in-hospital outcomes. BACKGROUND: There is paucity of data regarding the impact of GPI on the outcomes following peripheral endovascular interventions. METHODS: The study cohort was derived from Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database between the years 2006 and 2011. Peripheral endovascular interventions and GPI utilization were identified using appropriate ICD-9 Diagnostic and procedural codes. Two-level hierarchical multivariate mixed models were created. The study outcomes were: primary (in-hospital mortality and amputation studied separately) and secondary (composite of in-hospital mortality and postprocedural complications). Hospitalization costs were also assessed. RESULTS: GPI utilization (OR, 95% CI, P-value) was independently predictive of lower amputation rates (0.36, 0.27-0.49, <0.001). There was no significant difference in terms of in-hospital mortality (0.59, 0.31-1.14, P 0.117), although GPI use predicted worse secondary outcomes (1.23, 1.03-1.47, 0.023). Following propensity matching, the amputation rate was lower (3.2% vs. 8%, P < 0.001), while hospitalization costs were higher in the cohort that received GPI ($21,091 ± 404 vs. 19,407 ± 133, P < 0.001). CONCLUSIONS: Multivariate analysis revealed GPI use in peripheral endovascular interventions to be suggestive of an increase in composite end-point of in-hospital mortality and postprocedural complications, no impact on in-hospital mortality alone, significantly lower rate of amputation, and increase in hospitalization costs. © 2016 Wiley Periodicals, Inc.

Gender, Race, and Health Insurance Status in Patients Undergoing Catheter Ablation for Atrial Fibrillation.

Catheter ablation for atrial fibrillation (AF) has emerged as a popular procedure. The purpose of this study was to examine whether there exist differences or disparities in ablation utilization across gender, socioeconomic class, insurance, or race. Using the Nationwide Inpatient Sample (2000 to 2012), we identified adults hospitalized with a principal diagnosis of AF by ICD 9 code 427.31 who had catheter ablation (ICD 9 code-37.34). We stratified patients by race, insurance status, age, gender, and hospital characteristics. A hierarchical multivariate mixed-effect model was created to identify the independent predictors of AF ablation. Among an estimated total of 3,508,122 patients (extrapolated from 20% Nationwide Inpatient Sample) hospitalized with a diagnosis of AF in the United States from the year 2000 to 2012, 102,469 patients (2.9%) underwent catheter ablations. The number of ablations was increased by 940%, from 1,439 in 2000 to 15,090 in 2012. There were significant differences according to gender, race, and health insurance status, which persisted even after adjustment for other risk factors. Female gender (0.83 [95% CI 0.79 to 0.87; p <0.001]), black (0.49 [95% CI 0.44 to 0.55; p <0.001]), and Hispanic race (0.64 [95% CI 0.56 to 0.72; p <0.001]) were associated with lower likelihoods of undergoing an AF ablation. Medicare (0.93, 0.88 to 0.98, <0.001) or Medicaid (0.67, 0.59 to 0.76, <0.001) coverage and uninsured patients (0.55, 0.49 to 0.62, <0.001) also had lower rates of AF ablation compared to patients with private insurance. In conclusion we found differences in utilization of catheter ablation for AF based on gender, race, and insurance status that persisted over time.

Management Strategies and Outcomes of ST-Segment Elevation Myocardial Infarction Patients Transferred After Receiving Fibrinolytic Therapy in the United States.

Fibrinolytic therapy is still used in patients with ST-segment elevation myocardial infarction (STEMI) when the primary percutaneous coronary intervention cannot be provided in a timely fashion. Management strategies and outcomes in transferred fibrinolytic-treated STEMI patients have not been well assessed in real-world settings. Using the Nationwide Inpatient Sample from 2008 to 2012, we identified 18 814 patients with STEMI who received fibrinolytic therapy and were transferred to a different facility within 24 hours. The primary outcome was in-hospital mortality. Secondary outcomes included gastrointestinal bleeding, bleeding requiring transfusion, intracranial hemorrhage (ICH), length of stay, and cost. The patients were divided into 3 groups: those who received medical therapy alone (n = 853; 4.5%), those who underwent coronary artery angiography without revascularization (n = 2573; 13.7%), and those who underwent coronary artery angiography with revascularization (n = 15 388; 81.8%). Rates of in-hospital mortality among the groups were 20% vs 6.6% vs 2.1%, respectively (P < 0.001); ICH was 8.5% vs 1.1% vs 0.6%, respectively (P < 0.001); and gastrointestinal bleeding was 1.1% vs 0.4% vs 0.4%, respectively (P = 0.011). Multivariate analysis identified increasing age, higher Charlson Comorbidity Index score, cardiogenic shock, cardiac arrest, and ICH as the independent predictors of not performing coronary artery angiography and/or revascularization in patients with STEMI initially treated with fibrinolytic therapy. The majority of STEMI patients transferred after receiving fibrinolytic therapy undergo coronary angiography. However, notable numbers of patients do not receive revascularization, especially patients with cardiogenic shock and following a cardiac arrest.

In-Hospital Outcomes of Atherectomy During Endovascular Lower Extremity Revascularization.

Contemporary data on clinical outcomes after utilization of atherectomy in lower extremity endovascular revascularization are sparse. The study cohort was derived from Healthcare Cost and Utilization Project nationwide inpatient sample database from the year 2012. Peripheral endovascular interventions including atherectomy were identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes. The subjects were divided and compared in 2 groups: atherectomy versus no atherectomy. Two-level hierarchical multivariate mixed models were created. The coprimary outcomes were in-hospital mortality and amputation; secondary outcome was a composite of in-hospital mortality and periprocedural complications. Hospitalization costs were also assessed. Atherectomy utilization (odds ratio, 95% CI, p value) was independently predictive of lower in-hospital mortality (0.46, 0.28 to 0.75, 0.002) and lower amputation rates (0.83, 0.71 to 0.97, 0.020). Atherectomy use was also predictive of significantly lower secondary composite outcome of in-hospital mortality and complications (0.79, 0.69 to 0.90, 0.001). In the propensity-matched cohort, atherectomy utilization was again associated with a lower rate of amputation (11.18% vs 12.92%, p = 0.029), in-hospital mortality (0.71% vs 1.53%, p 0.001), and any complication (13.24% vs 16.09%, p 0.001). However, atherectomy use was also associated with higher costs ($24,790 ± 397 vs $22635 ± 251, p <0.001). Atherectomy use in conjunction with angioplasty (with or without stenting) was associated with improved in-hospital outcomes in terms of lower amputation rates, mortality, and postprocedural complications.