Temporal Trends, Practice Variation, and Outcomes of Intravascular Lithotripsy vs Atherectomy Use for Peripheral Arterial Intervention in the United States

Background Peripheral intravascular lithotripsy (IVL) has emerged as a novel alternative to atherectomy for calcium modification. However, little is known about its uptake and associated outcomes in real-world practice. We aimed to assess temporal trends, practice variation, and outcomes of peripheral IVL vs atherectomy use in the US. Methods Using the Centers for Medicare & Medicaid Services data, we identified 423,315 endovascular revascularization procedures involving the femoropopliteal or tibial artery in 2019-2024 for temporal trend and practice variation analyses. Within this sample, we identified 47,238 patients aged ≥66 years who underwent IVL or atherectomy in 2021-2024 for comparative analyses. Associations of IVL vs atherectomy with in-hospital and long-term outcomes were assessed after 1:1 propensity score matching. Results IVL use increased steadily following Centers for Medicare & Medicaid Services coverage in 2020 Q3, reaching 10.2% in 2024 Q4 (difference, 10.2%; 95% CI, 9.7-10.7). Concurrently, atherectomy use decreased from 38.5% in 2020 Q2 to 31.6% in 2024 Q4 (difference, −6.9%; 95% CI, −8.0 to −5.8]). During 2023-2024, 85.5% of hospitals used IVL in <20% of cases, whereas atherectomy use varied more widely across hospitals. IVL, compared with atherectomy, was associated with a lower risk of arterial thrombosis/embolism (1.3% vs 3.2%; OR, 0.40; 95% CI, 0.31-0.53]), a reduced need for stenting (19.2% vs 21.1%; OR, 0.89; 95% CI, 0.8 to −0.97]), and a lower risk of a composite of major amputation, surgical revascularization, or death (38.6 vs 39.7 per 100 person-years; HR, 0.93;[95% CI, 0.89-0.98]). Conclusions IVL use has increased steadily, alongside a decrease in atherectomy use. Hospital-level variation in IVL use was modest, in contrast to the greater variation in atherectomy use. IVL was associated with more favorable outcomes compared with atherectomy.