Author + information
- Rym El Khoury1,
- Jose L. Cataneo1,
- Juan A. Paredes1,
- Alexander M. Schwartz2,
- Chad E. Jacobs1,
- John V. White1 and
- Lewis B. Schwartz1
“Failure-to-cross” still complicates 5-20% of percutaneous peripheral interventions (PPIs) for peripheral arterial disease. Extended efforts to cross long, occlusive lesions can utilize significant hospital and practitioner resources. The hospital is typically reimbursed for this effort, as facility fees and materials are charged by the hour and per use. However, given the lack of a CPT code for “failure-to-cross,” practitioners are rarely appropriately compensated. The purpose of this study is to analyze the predictors, technical details, outcomes, and cost of “failures-to-cross.”
PPIs over two years at a single institution were retrospectively reviewed. Clinical and financial data were compared between successful therapeutic interventions, crossing failures, and diagnostic angiograms without attempted intervention.
A total of 146 consecutive PPIs were identified; the rate of “failure-to-cross” was 11.6%. Patients with “failure-to-cross” were more likely to be male (82% vs. 59%, p=0.08) and have poorer arterial outflow (53% vs. 30% single-vessel runoff, p=0.07) although, compared to successful interventions, the incidences of critical limb ischemia (82% vs. 70%, p=0.34) and infrapopliteal disease were similar (47% vs. 31%, p=0.20). “Failure-to-cross” and successful procedures utilized similar fluoroscopy (27±10 vs. 24±14 min, p=0.52), room time (106±98 vs. 103±44 min, p=0.84) and contrast dye volume (73±37 vs. 96±54 ml, p=0.12). As expected, “failure-to-cross” interventions incurred higher hospital charges and costs compared to non-interventional diagnostic angiograms (charges $13,311±6067 vs. $7690±1942, p<0.01; costs $5289±2099 vs. $2826±1198, p<0.01) but the operators were reimbursed at the same low rate as a purely diagnostic procedure (average charge $7360; average reimbursement $992). At 1 year, the 17 patients with crossing failures had undergone either repeat endovascular procedures with success (n=2), surgical bypass grafting (n=5), extremity amputation (n=4), or no additional intervention without limb loss (n=6).
Patients whose lesions cannot be crossed fare worse than patients undergoing successful interventions. Hospital costs and charges reflect the high technical difficulty and resource utilization of extended attempts at endovascular therapy. However, for practitioners, crossing lesions during PPI is truly a “pay-for-performance” procedure in that only successful procedures are adequately reimbursed.