We thank Agarwal et al for their interest in our manuscript. They cite a study by Lo et al that the number of outpatient procedures is on the rise. However, the outpatient procedural numbers that they quote are only half of the story because they represent only interventions performed for intermittent claudication. The same study by Lo et al reported that despite the increase, the inpatient endovascular interventions for critical limb ischemia are 2.7 times more than outpatient procedures. This is key because the outcomes evaluated in our study including inhospital mortality, amputation, and major complications are more likely to be encountered in sicker inpatients with critical limb ischemia. Our subgroup analysis further highlighted the value of hospital volume in predicting lower amputation rates in acute and critical limb ischemia and patients undergoing emergent/urgent admissions. Thus, we provide a better half of the story regarding lower extremity endovascular procedures in a possibly sicker inpatient population with more meaningful clinical outcomes.

However, we do agree with the need to further evaluate this hospital volume outcome relation in other national registries to confirm or refute our findings. Furthermore, we encourage other investigators to look into volume outcome relations for outpatient peripheral interventions.

This is important because despite being intuitive, the number of centers performing endovascular interventions continues to expand. There is lack of any statement on hospital volume in current competency guidelines on both outpatient and inpatient peripheral endovascular procedures. Our study adds valuable information in this regard.