Cost Analysis of Target Lesion Revascularisation in Patients With Femoropopliteal In Stent Re-Stenosis or Occlusion: The COSTLY-TLR Study

OBJECTIVE

To report the cost of target lesion revascularisation procedures (TLR) for femoropopliteal peripheral artery disease (PAD) following stenting, from a healthcare payer's perspective.

METHODS

European multicentre study involving consecutive patients requiring femoropopliteal TLR (January 2017 - December 2021). The primary outcome was overall cost (euros) associated with a TLR procedure from presentation to discharge. Exact costs per constituent, clinical characteristics, and early outcomes were reported.

RESULTS

This study included 482 TLR procedures (retrospectively, 13 hospitals, six countries): 56% were female, mean age was 75 ± 2 years, 61% were Rutherford class 5 or 6, 67% had Tosaka class 3 disease, and 16% had common femoral or iliac involvement. A total of 52% were hybrid procedures and 6% involved open surgery only. Technical success was 70%, 30 day mortality rate was 1%, and the 30 day major amputation rate was 4%. Most costs were for operating time during the TLR (healthcare professionals' salaries, indirect and estate costs), with a mean of: €21 917 ± €2 110 for all procedures; €23 337 ± €8 920 for open procedures; €12 903 ± €3 108 for endovascular procedures; and €22 806 ± €3 977 for hybrid procedures. In a regression analysis, procedure duration was the main parameter associated with higher overall TLR costs (coefficient, 2.77; standard error, 0.88; p < .001). The mean cost per operating minute of TLR (indirect, estate costs, all salaried staff present included) was €177 and the mean cost per night stay in hospital (outside intensive care unit) was €356. The mean cost per overnight intensive care unit stay (minimum of 8 hours per night) was €1 193.

CONCLUSION

The main driver of the considerable peri-procedure costs associated with femoropopliteal TLR was procedure time.

A Cost-Consequence Analysis Comparing Balloon-Expandable Covered Stents for the Management of Aortoiliac Occlusive Disease

PURPOSE

To compare procedural and long-term costs associated with the use of Balloon-Expandable Covered Stents (BECS) in the management of Aortoiliac Occlusive Disease (AIOD).

MATERIALS AND METHODS

A cost-consequence model was developed to simulate the intra- and post-operative management of patients with AIOD from the perspective of private health-payers. The study assessed the costs of the LifeStream (BD, Franklin Lakes, New Jersey), iCAST/Advanta V12 (Getinge, Goteborg, Sweden), BeGraft Peripheral (Bentley, Hechingen, Germany), and Viabahn Balloon Expandable (VBX) (W.L. Gore, Flagstaff, Arizona) BECS devices. Device costs were identified from the Australian Prosthesis List, whereas clinical outcomes of BECS were estimated from a systematic review of the literature. Costs were calculated over 24 and 36 month time horizons and reported in US dollars.

RESULTS

Long-term, per-patient cost of each device at 24 and 36 months was $6253/$6634 for the LifeStream; $6359/$6869 for the iCAST/Advanta V12; $4806 (data available to 24 months) for the BeGraft Peripheral; and $4839/$5046 for the Viabahn VBX, respectively. Most of the cost difference was attributed to the number of stents required per treated limb and frequency of clinically-driven target lesion revascularization events.

CONCLUSIONS

Best-available clinical evidence and economic modeling demonstrates that the BeGraft Peripheral and Viabahn VBX were of similar cost and the least costly options at 24 months, whereas at 36 months, the lowest cost BECS option for the treatment of AIOD was the Viabahn VBX.

CLINICAL IMPACT

This analysis supports economically informed decision-making for health-payers managing systems that care for patients with AIOD. Stent length and avoiding reintervention were identified as key areas of cost-saving for future BECS development.

Daly/Cost comparison in the management of peripheral arterial disease at 17 Belgian hospitals

OBJECTIVE

Peripheral arterial disease (PAD) is a manifestation of atherosclerosis that affects the lower extremities and afflicts more than 200 million people worldwide. Because of limited resources, the need to provide quality care associated with cost control is essential for health policies. Our study concerns an interhospital comparison among seventeen Belgian hospitals that integrates the weighting of quality indicators and the costs of care, from the hospital perspective, for a patient with this pathology in 2018.

METHODS

The disability-adjusted life years (DALYs) were calculated by adding the number of years of life lost due to premature death and the number of years of life lost due to disability for each in-hospital stay. The DALY impact was interpreted according to patient safety indicators. We compared the hospitals using the adjusted values ​​of costs and DALYs for their case mix index, obtained by relating the observed value to the predicted value obtained by linear regression.

RESULTS

We studied 2,437 patients and recorded a total of 560.1 DALYs in hospitals. The in-hospital cost average [standard deviation (SD)] was €8,673 (€10,893). Our model identified the hospitals whose observed values were higher than predicted; six needed to reduce the costs and impacts of DALYs, six needed to improve one of the two factors, and four seemed to have good results. The average cost (SD) for the worst performing hospitals amounted to €27,803 (€28,358).

CONCLUSIONS

Studying the costs of treatment according to patient safety indicators permits us to evaluate the entire chain of care using a comparable unit of measurement.

Outcomes and use of healthcare resources after an intervention for chronic limb-threatening ischaemia

BACKGROUND

The fate of patients with chronic limb-threatening ischaemia undergoing revascularization or a primary amputation is unclear. The aim of this study was to assess the postoperative outcomes and post-procedural healthcare resource use/costs over 1 year after revascularization or a primary amputation for chronic limb-threatening ischaemia.

METHODS

The UK Kent Integrated Dataset, which links primary, community, and secondary care for 1.6 million people, was interrogated. All patients with a new diagnosis of chronic limb-threatening ischaemia undergoing revascularization or a major amputation between January 2016 and January 2019 (3 years) were identified. Postoperative events across all healthcare settings and post-procedure healthcare resource use were analysed over 1 year (until the end of 2019).

RESULTS

Overall, 4252 patients with a new diagnosis of chronic limb-threatening ischaemia were identified (65 per cent were male and the mean age was 73 years) between January 2016 and January 2019, of whom 579 (14 per cent) underwent an intervention (studied population); 296 (7 per cent) had an angioplasty, 75 (2 per cent) had bypass surgery, 141 (3 per cent) had a primary major lower limb amputation, 11 had a thrombo-embolectomy (0.3 per cent), and 56 had an endarterectomy (1.3 per cent). Readmissions (median of 2) were similar amongst different procedures within 1 year; bypass surgery was associated with more hospital appointments (median of 4 versus 2; P = 0.002). Patients undergoing a primary amputation had the highest number of cardiovascular events and 1-year mortality. In a linear regression model, index procedure type and Charlson co-morbidity index score were not predictors of appointments in primary/secondary care, community care visits, or readmissions after discharge. There were no statistically significant differences regarding post-procedural healthcare costs between procedures over 1 year.

CONCLUSION

Revascularization is not associated with more hospital, primary/community care appointments or increased post-procedural healthcare costs over 1 year when compared with primary amputation, in people with chronic limb-threatening ischaemia.

Editor's Choice - Infra-inguinal Endovascular Revascularisation and Bypass Surgery for Chronic Limb Threatening Ischaemia: a Retrospective European Multicentre Cohort Study with Propensity Score Matching

OBJECTIVE

The aim of this study was to compare the long term efficacy of lower limb bypass with that of endovascular treatment (EVT) in patients with chronic limb threatening ischaemia (CLTI).

METHODS

This retrospective, multicentre study evaluated the outcomes of patients with CLTI who underwent first time infra-inguinal bypass or EVT. The primary outcome was to compare amputation free survival (AFS) rates between the two propensity score matched groups. The secondary outcome was to compare wound healing within the first six months. Major adverse events were compared according to the type of revascularisation.

RESULTS

Overall, 793 patients fulfilled the eligibility criteria, from whom 236 propensity score matched pairs were analysed. The mean follow up was 52 months. The 236 bypass procedures included 190 autogenous bypass grafts (80.5%), 151 (64.0%) of which were infrapopliteal. Among the 236 EVT procedures, the target lesion was the femoropopliteal segment in 81 patients (34.3%), the femoropopliteal and infrapopliteal segments in 101 patients (42.8%), and the infrapopliteal segment in 54 patients (22.9%). AFS was significantly better in the bypass group at five years (60.5 ± 3.6%) compared with the EVT group (35.3 ± 3.6%) (p < .001). Major amputation occurred in 61 patients (25.8%) in the bypass group and 85 patients (36.0%) in the EVT group (HR 0.66, 95% CI 0.47 - 0.92; p = .014). The probability of healing was significantly better in the bypass group at six months compared with the EVT group (p = .003). The median length of stay was shorter for the EVT group (4 days) than for the bypass group (8 days) (p = .001). Urgent re-intervention and re-admission rates were high and did not differ significantly between the groups.

CONCLUSION

This study has shown that lower limb bypass surgery offered a significantly higher probability of AFS and wound healing compared with EVT in patients with CLTI.

Pre-clinical investigation of liquid sirolimus for local drug delivery

Introduction

Sirolimus is currently being explored as an alternative drug to paclitaxel for the treatment of peripheral artery disease (PAD). To date, sirolimus has only been used as drug coatings for stents and balloons and no studies have yet demonstrated the delivery of sirolimus in liquid form. The purpose of this pilot study was to investigate the feasibility of the delivery of liquid sirolimus into arterial segments in a benchtop peripheral artery bioreactor.

Methods

The feasibility to deliver liquid therapy was first tested on four drug delivery devices using a fluorescently tagged liquid drug and an ex vivo porcine artery benchtop model. The four devices included the Bullfrog micro-infusion device, ClearWay RX catheter, Occlusion perfusion catheter (OPC), and the targeted adjustable pharmaceutical administration system (TAPAS). Penetration of the fluorescently tagged drug was measured via microscopic imaging and quantification of the depth of drug penetration into all device-treated tissue. Based on the penetration outcome, we then selected a single device to deliver liquid sirolimus into the ex vivo porcine artery model undergoing physiological flow and pressure conditions. The liquid sirolimus-treated arteries were collected from the ex vivo bioreactor at 1- and 24-hour post-delivery and arterial drug retention analyzed by liquid chromatography-tandem mass spectrometry.

Results

Fluorescent microscopy demonstrated that drug delivery with the OPC had greater drug penetration into the medial wall as compared to other devices (OPC: 234 ± 161 µm; TAPAS: 127 ± 68 µm; ClearWay: 118 ± 77 µm; Bullfrog: 2.12 ± 3.78 µm; p = 0.098). The results of the ex vivo flow-circuit bench top model showed that the OPC device successfully delivered the liquid sirolimus at 1-hour (5.17 ± 4.48 ng/mg) and 24-hour (0.78 ± 0.55 ng/mg).

Conclusions

These results demonstrate for the first time the ability to deliver liquid sirolimus directly to the medial layer of an artery via a liquid delivery catheter.

Association of Sarcopenia With Mortality in Patients With Chronic Limb-Threatening Ischemia Undergoing Endovascular Revascularization

INTRODUCTION

Chronic limb-threatening ischemia (CLTI) is the most severe form of peripheral artery disease and leads high mortality. Sarcopenia, characterized by the loss of muscle mass or poor muscle quality, is associated with adverse clinical outcomes. This study aimed to investigate the association between sarcopenia and the long-term outcomes in patients with CLTI after endovascular revascularization.

METHODS

We retrospectively reviewed the medical records of all patients with CLTI who underwent endovascular revascularization between January 2015, and December 2021. The skeletal muscle area was calculated at the third lumbar vertebra from computed tomography images using the manual trace method and normalized to patient height. Sarcopenia was defined as a third lumbar skeletal muscle index of <40.8 cm2/m2 in males and <34.9 cm2/m2 in females. The Kaplan-Meier and Cox proportional hazards regression analyses were used for survival analysis and to evaluate the association between sarcopenia and mortality.

RESULTS

A total of 137 patients (90 men; mean age 71.7 ± 9.6 y) were enrolled for the study, of whom 56 (40.8%) had sarcopenia. The 3-year overall survival rate in patients with CLTI who underwent endovascular revascularization was 71.2%. The sarcopenic group had a significantly worse 3-year overall survival rate than the nonsarcopenic group (55.3% versus 78.6%, P = 0.001). Multivariate Cox proportional hazard regression analyses revealed that sarcopenia (hazard ratio, 2.262; 95% confidence interval, 1.132-4.518; P = 0.021) and dialysis (hazard ratio, 3.021; 95% confidence interval, 1.337-6.823; P = 0.008) were independently associated with increased risk of all-cause mortality, whereas technical success had significantly opposing correlation with mortality. (hazard ratio, 0.400, 95% confidence interval, 0.194-0.826, P = 0.013).

CONCLUSIONS

Sarcopenia can be highly prevalent in patients with CLTI who undergo endovascular revascularization, and is independently associated with long-term mortality. These results may help risk stratification to assist in personalized assessment and clinical decision-making.

Comparative Analysis of Endovascular Intervention and Endarterectomy in Patients with Femoral Artery Disease: A Systematic Review and Meta-Analysis

Peripheral artery disease is a prevalent illness affecting more than 200 million people worldwide. A commonly used technique to manage the condition has been open endarterectomy. However, in recent times, a shift towards minimally invasive techniques has resulted in endovascular intervention as a popular alternative. This review aims to assess the safety and efficacy of endovascular intervention when compared with endarterectomy. A systematic review of the articles published in PubMed, Ovid, Embase, and Scopus within the last 10 years was conducted. The PRISMA guidelines were adhered to, and the Newcastle-Ottawa and NICE quality assessment scales were used. A meta-analysis of proportions was performed using the RStudio software (RStudio Team (2021). RStudio: Integrated Development Environment for R, PBC, Boston, MA, USA). Twenty-six studies were included, with a total of 7126 patients (endovascular, 2496; endarterectomy, 4630). Technical success was greater for endarterectomy than endovascular intervention with an odds ratio of 0.38; 95% CI [0.27–0.54]. In terms of safety as well endovascular intervention was better than endarterectomy with an odds ratio of 0.22; 95% CI [0.15 to 0.31] for wound infection. Endovascular intervention is a safe and effective procedure; however, it cannot be considered superior to endarterectomy.

Association of Chronic Kidney Disease with perioperative outcomes following acute lower limb revascularization

Background

There is a paucity of data examining the impact of advancing chronic kidney disease stages on outcomes following revascularization for acute limb ischemia. The present study examined the association of chronic kidney disease with in-hospital mortality, amputation, and resource utilization following revascularization for acute limb ischemia using a nationally representative cohort.

Methods

The 2016–2018 National Inpatient Sample was queried to identify all adult hospitalizations with lower extremity acute limb ischemia requiring surgical and/or endovascular interventions. Patients were grouped according to the presence of chronic kidney disease and its severity: no chronic kidney disease, chronic kidney disease 1–3 (chronic kidney disease stages 1 through 3), chronic kidney disease 4–5 (chronic kidney disease stages 4 through 5), and end-stage renal disease. Multivariable logistic and linear models were used to evaluate association of chronic kidney disease stage with outcomes of interest.

Results

Of an estimated 82,610 patients meeting study criteria, 14.8% had chronic kidney disease (chronic kidney disease 1–3: 63.4%, chronic kidney disease 4–5: 12.1%, end-stage renal disease: 24.5%). Compared to those with chronic kidney disease, chronic kidney disease patients were on average older, were more frequently female, and had a higher median Elixhauser Comorbidity Index. Increasing severity of chronic kidney disease was associated with a stepwise increase in unadjusted mortality rates (4.7% in no chronic kidney disease to 12.6% in end-stage renal disease, P < .001). Following risk adjustment, only end-stage renal disease was associated with increased odds of mortality (adjusted odds ratio 3.10, 95% confidence interval 2.28–4.22) and limb amputation (adjusted odds ratio 1.99, 95% confidence interval 1.59–2.48) compared to patients with no chronic kidney disease. Similarly, advancing chronic kidney disease stage conferred increased odds of prolonged length of stay and greater hospitalization costs.

Conclusion

Advanced renal dysfunction demonstrated inferior perioperative outcomes and greater health care expenditures in the study population. These findings imply that quality improvement efforts in acute limb ischemia revascularization should target patients with chronic kidney disease 4–5 and end-stage renal disease.

Comparison and Trends of Endovascular, Surgical and Hybrid Revascularizations and the Influence of Comorbidity in 1 Million Hospitalizations Due to Peripheral Artery Disease in Germany Between 2009 and 2018

Objective

To analyze trends and differences of endovascular, surgical and hybrid revascularization approaches and the impact of comorbidity on characteristics, costs, and outcome of in-patients with peripheral artery disease (PAD) of the lower extremity.

Methods

Analyzing data provided by the Research Data Center of the German Federal Statistical Office, we included all hospitalizations due to PAD Fontaine IIb (Rutherford 2–3) or higher in Germany between 2009–2011 and 2016–2018. According to the individually performed procedures encoded by the Operation and Procedure Classification System, we divided hospitalizations by revascularization procedures into sole endovascular, sole surgical, hybrid, two-step and no revascularization. Patient’s comorbidity was assessed using the linear van Walraven comorbidity score (vWs).

Results

1,067,671 hospitalizations (mean age 71.3 ± 11.1 years; 60.1% male) were analyzed. Between 2009–2011 and 2016–2018, reimbursement costs rose by 28.0% from €2.72 billion (€5,350/case) to €3.49 billion (€6,238/case). The share of hospitalizations with any revascularization increased by 8.9% (67.7–73.7%) driven by an increase in two-step (+ 63.3%), hybrid (+ 58.2%) and sole endovascular revascularizations (+ 32.6%), while sole surgical approaches declined (− 18.2%). Hospitalizations of more comorbid patients (vWs ≥ 20) rose by 46.8% (21,444–31,478 cases), showed an overproportionate increase in costs of 124.6% (+ €1,750/case) and were associated with more individual procedures (+ 90.6%).

Conclusions

In-patient treatment of PAD patients shows increasing numbers of hybrid and sole endovascular revascularizations and more patients with higher comorbidity, while sole surgical interventions and in-hospital mortality decrease. Consequently, associated costs are surging especially in more comorbid patients due to an increasing number of performed procedures and escalation of therapy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00270-022-03136-9.

Doença arterial obstrutiva periférica: um estudo comparativo entre revascularizações abertas e endovasculares realizadas em caráter de urgência no sistema público de saúde do Brasil entre 2010 e 2020

RESUMO Contexto A doença arterial obstrutiva periférica apresenta alta prevalência, sendo associada a elevado risco de eventos cardiovasculares. A intervenção cirúrgica ou endovascular faz-se necessária na isquemia crítica do membro. Objetivos Avaliar a distribuição de realização de revascularizações abertas e endovasculares nas diferentes regiões do Brasil, analisando os custos para o sistema de saúde e a mortalidade relacionada a esses procedimentos. Métodos Foi realizado um estudo epidemiológico observacional transversal descritivo para avaliar as cirurgias abertas e endovasculares realizadas no sistema público de saúde do Brasil entre 2010 e 2020. Os dados foram coletados através do Departamento de Informática do SUS (Datasus). Resultados No período analisado, foram registradas 83.218 internações para realização de cirurgias abertas e endovasculares, com um custo total de R$ 333.989.523,17. Houve predominância das internações para os procedimentos percutâneos (56.132) em relação aos cirúrgicos convencionais (27.086). As Regiões Sudeste e Sul concentraram a maior parte do total de procedimentos realizados no país (83%), enquanto a Região Norte foi a que apresentou a menor taxa de internação. Observou-se uma tendência decrescente para os procedimentos abertos, e uma tendência crescente para os endovasculares. A média de permanência hospitalar foi menor nos procedimentos endovasculares (5,3 dias) em relação aos abertos (10,2 dias). Além disso, notou-se uma maior taxa de mortalidade hospitalar relacionada à revascularização aberta em relação à endovascular (5,24% versus 1,56%). Conclusões As técnicas endovasculares consistiram em uma abordagem dominante no tratamento cirúrgico da isquemia crítica, apresentando menor taxa de mortalidade hospitalar e menor tempo de internação quando comparada às cirurgias abertas.

Peripheral artery disease: a comparison of urgent open and endovascular revascularizations on the public health system in Brazil, from 2010 to 2020

ABSTRACT Background Peripheral artery disease (PAD) has high prevalence and is associated with high risk of cardiovascular events. Surgical or endovascular intervention is necessary in chronic limb-threatening ischemia. Objectives To evaluate the distribution of open and endovascular revascularizations in different regions of Brazil, analyzing the health system costs and mortality related to these procedures. Methods A descriptive, cross-sectional, observational, epidemiological study was carried out to evaluate open and endovascular surgeries performed on the SUS public healthcare system in Brazil, from 2010 to 2020. Data were collected from the SUS Department of Informatics (Datasus). Results Over the period analyzed, 83,218 admissions for open and endovascular surgeries were registered, with a total cost of R$ 333,989,523.17. There were more hospital admissions for percutaneous procedures (56,132) than for conventional surgery (27,086). Most of the procedures (83%) were performed in the country’s Southeast and South regions, while the North region had the lowest number of procedures. Over the period evaluated, there was a decreasing trend for open procedures and an increasing trend for endovascular procedures. The average hospital stay was shorter for endovascular procedures (5.3 days) than for open surgery (10.2 days). The analysis of mortality related to these procedures revealed a higher rate of in-hospital mortality associated with open revascularization than with endovascular (5.24% vs. 1.56%). Conclusions Endovascular techniques constituted the primary approach for revascularization treatment in critical limb-threatening ischemia, with a lower in-hospital mortality rate and shorter hospital stay when compared to open surgeries.

The Burden of Patients With Lower Limb Amputations in a Community Safety-net Hospital

BACKGROUND

The functional disability after amputation is tremendous and imposes a high economic burden on patients and health systems. The current literature on the costs of amputation has been limited to the index hospitalization or a short time window around the amputation procedure, which covers a small percentage of the total costs.

METHODS

We conducted a retrospective cohort study of patients who underwent lower extremity amputations at a single urban public level 1 trauma hospital. Resource utilization and healthcare costs 1 year before and 1 year after the index amputation were examined. Hospitalization costs were estimated using cost center-based cost-to-charge ratios for the 2-year follow-up.

RESULTS

The sample comprised 90 patients (73 men and 17 women) with a mean age of 55.9 years (SD, 9.9). Most amputations were secondary to diabetes (74%) and vascular disease in the absence of diabetes (22%). During the 2-year window around the index amputation, patients had an average of 2.7 admissions (SD, 2.3), mean index length of stay of 14.6 days (SD, 22.3), and a mean cumulative length of stay of 31.3 days (SD, 43.4). The patients had a mean of 2.3 (SD, 3.2) additional procedures performed on their amputated limb. Twenty-one patients (23%) required additional proximal amputations, with an average change of 2.2 (SD, 1.6) levels. The mean cost, per patient, of the index hospitalization was $51,481. Over the 2-year period, the mean cost of hospitalizations was $114,292 per patient with a total cost, summed over the cohort, of $10,286,250. Approximately 64% of the total cost went uncompensated.

DISCUSSION

Over a 2-year window, amputees endured multiple procedures, readmissions, and reamputations, leading to high healthcare costs. Further research into resource-conscious interventions and programs is needed to control the burdens faced by amputees and the health systems that care for them.

In-patient care trends in peripheral artery disease in the German healthcare system over the past decade

OBJECTIVES

To analyze trends of in-hospital treatment of patients admitted due to peripheral artery disease (PAD) from 2009 to 2018 with special focus on comorbidities, revascularization procedures, resulting costs, and outcome.

METHODS

Using data from the research data center of the German Federal Statistical Office, we included all hospitalizations due to PAD Fontaine stage IIb or higher from 2009 to 2018. To analyze comorbidities, Elixhauser diagnostic groups and linear van Walraven score (vWS) were assessed.

RESULTS

A total of 1.8 million hospitalizations resulting in €10.3 billion in reimbursement costs were included. From 2009 to 2018, the absolute number of hospitalizations due to PAD increased by 13.3% (163,547 to 185,352). The average cost per hospitalization increased by 20.8% from €5,261 to €6,356. The overall in-hospital mortality decreased from 3.1 to 2.6%. Median vWS of all PAD cases increased by 3 points (2 to 5). The number of percutaneous transluminal angioplasties (PTA) increased by 43.9% while some surgical procedures such as bypasses and embolectomies decreased by 30.8% and 6.8%, respectively. Many revascularization procedures showed a disproportionate increase of those performed in vessels below the knee for example in PTA (+ 68.5%) or in endarterectomies (+ 38.8%).

CONCLUSIONS

This decade-long nationwide analysis shows a rising number of hospitalizations due to PAD with more comorbid patients resulting in increasing reimbursement costs. Interventions are shifting from surgical to endovascular approaches with a notable trend towards interventions in smaller vessels below the knee.

KEY POINTS

• The number of hospitalizations due to peripheral artery disease is rising and it is associated with increasing reimbursement costs. • Admitted patients are older and show an increasing number of comorbidities while overall in-hospital mortality is decreasing. • Revascularization procedures are shifting from surgical to endovascular approaches and show a trend towards intervention in smaller vessels below the knee. • Major amputations are decreasing while the number of minor amputations is increasing.

Reduction in Acute Limb Ischemia with Rivaroxaban versus Placebo in Peripheral Artery Disease after Lower Extremity Revascularization: Insights from VOYAGER PAD

Background: Patients with peripheral artery disease (PAD) are at heightened risk of acute limb ischemia (ALI), a thrombotic event associated with amputation, disability, and mortality. Prior lower extremity revascularization (LER) is associated with increased ALI risk in chronic PAD. However, the pattern of risk, clinical correlates, and outcomes after ALI early after LER are not well-studied, and effective therapies to reduce ALI post-LER are lacking. Methods: VOYAGER PAD (NCT02504216) randomized patients with PAD undergoing LER to rivaroxaban 2.5 mg twice daily or placebo on a background of low-dose aspirin. The primary outcome was a composite of ALI, major amputation of vascular cause, myocardial infarction, ischemic stroke, or cardiovascular death. ALI was prospectively ascertained and adjudicated by a blinded committee. The cumulative incidence of ALI was calculated using Kaplan Meier estimates, and Cox proportional-hazards models were used to generate hazard ratios and associated confidence intervals. Analyses were performed as intention-to-treat. Results: Among 6,564 patients followed for a median of 2.3 years, 382 (5.8%) had a total of 508 ALI events. In placebo patients, the 3-year cumulative incidence of ALI was 7.8%. After multivariable modeling, prior LER, baseline ABI <0.50, surgical LER, and longer target lesion length were associated with increased risk of ALI. Incident ALI was associated with subsequent all-cause mortality (HR 2.59, 95% CI 1.98-3.39) and major amputation (HR 24.87, 95% CI 18.68-33.12). Rivaroxaban reduced ALI relative to placebo by 33% (absolute risk reduction 2.6% at 3 years, HR 0.67, 95% CI 0.55-0.82, P=0.0001), with benefit starting early (HR 0.45, 95% CI 0.24-0.85, P=0.0068 at 30 days). Benefit was present for severe ALI (associated with death, amputation, or prolonged hospitalization and ICU stay, HR 0.58, 95% CI 0.40-0.83, P=0.003) and regardless of LER type (surgical vs endovascular revascularization, p-interaction=0.42) or clopidogrel use (p-interaction=0.59). Conclusions: After LER for symptomatic PAD, ALI is frequent, particularly early after LER, and is associated with poor prognosis. Low-dose rivaroxaban plus aspirin reduces ALI after LER, including ALI events associated with the most severe outcomes. The benefit of rivaroxaban for ALI appears early, continues over time, and is consistent regardless of revascularization approach or clopidogrel use.

The Potential Benefits and Costs of an Intensified Approach to Low Density Lipoprotein Cholesterol Lowering in People with Abdominal Aortic Aneurysm

OBJECTIVE

The aims of this study were to assess the incidence of major vascular events (MVE) and peripheral vascular events (PVE) in people with a small asymptomatic abdominal aortic aneurysm (AAA) and model the theoretical benefits and costs of an intensified low density lipoprotein cholesterol (LDL-C) lowering programme.

METHODS

A total of 583 participants with AAAs measuring 30 - 54 mm were included in this study. The control of LDL-C and prescription of lipid lowering drugs were assessed by dividing participants into approximately equal tertiles depending on their year of recruitment into the study. The occurrence of MVE (myocardial infarction, stroke, cardiovascular death, and coronary or non-coronary revascularisation) and PVE (non-coronary revascularisation, AAA repair, and major amputation) were recorded prospectively, and the incidence of these events was calculated using Kaplan-Meier analysis. The relative risk reduction reported for these events in a previous randomised control trial (RCT) was then applied to these figures to model the absolute risk reduction and numbers needed to treat (NTT) that could theoretically be achieved with a mean LDL-C lowering of 1 mmol/L. The maximum allowable expense for a cost effective intensive LDL-C lowering programme was estimated using a cost utility analysis.

RESULTS

At entry, only 28.5% of participants had an LDL-C of < 1.8 mmol/L and only 18.5% were prescribed a high potency statin (atorvastatin 80 mg or rosuvastatin 40 mg). The five year incidences of MVE and PVE were 38.1% and 44.7%, respectively. It was estimated that if the mean LDL-C of the cohort had been reduced by 1 mmol/L, this could have reduced the absolute risk of MVE and PVE by 6.5% (95% CI 4.4 - 8.7; NNT 15) and 5.3% (95% CI 1.4 - 7.5; NNT 19), respectively. It was estimated that the maximum allowable expense for a cost effective LDL-C lowering programme would be between $1 239 AUD (€768) and $1 582 AUD (€981) per person per annum over a five year period.

CONCLUSION

People with a small asymptomatic AAA are at high risk of MVE and PVE. This study provides evidence of the possible benefits and allowable expense for a cost effective intensive LDL-C lowering programme in this population.

Fabrication of Highly Oriented Cylindrical Polyacrylonitrile, Poly(lactide-co-glycolide), Polycaprolactone and Poly(vinyl acetate) Nanofibers for Vascular Graft Applications

Small-diameter vascular grafts fabricated from synthetic polymers have found limited applications so far in vascular surgeries, owing to their poor mechanical properties. In this study, cylindrical nanofibrous structures of highly oriented nanofibers made from polyacrylonitrile, poly (lactide-co-glycolide) (PLGA), polycaprolactone (PCL) and poly(vinyl acetate) (PVAc) were investigated. Cylindrical collectors with alternate conductive and non-conductive segments were used to obtain highly oriented nanofibrous structures at the same time with better mechanical properties. The surface morphology (orientation), mechanical properties and suture retention of the nanofibrous structures were characterized using SEM, mechanical tester and universal testing machine, respectively. The PLGA nanofibrous cylindrical structure exhibited excellent properties (tensile strength of 9.1 ± 0.6 MPa, suture retention strength of 27N and burst pressure of 350 ± 50 mmHg) when compared to other polymers. Moreover, the PLGA grafts showed good porosity and elongation values, that could be potentially used for vascular graft applications. The combination of PLGA nanofibers with extracellular vesicles (EVs) will be explored as a potential vascular graft in future.

Outcomes of bypass and endovascular interventions for advanced femoropopliteal disease in patients with premature peripheral artery disease

OBJECTIVE

Patients with premature peripheral artery disease (PAD), defined as age ≤50 years at presentation, have had poor outcomes with open and endovascular lower extremity revascularization. It is unclear whether either strategy is associated with better outcomes because comparative studies have been limited to case series in this patient population. The aim of the present study was to compare the outcomes of patients with premature PAD who had undergone bypass or endovascular revascularization for advanced femoropopliteal disease. Our hypothesis was that open bypass would provide superior long-term outcomes compared with endovascular intervention for patients with premature advanced femoropopliteal PAD.

METHODS

All the patients with premature PAD who had undergone isolated femoropopliteal lower extremity revascularization and included in the Vascular Quality Initiative infrainguinal bypass and peripheral vascular intervention files were reviewed from 2003 through 2019. Propensity score matching (1:1) was performed between patients who had undergone femoropopliteal bypass and endovascular interventions for isolated femoropopliteal Trans-Atlantic Classification System C or D lesions. The 1-year outcomes, including reintervention, patency, major amputation, and mortality, were analyzed.

RESULTS

Of the 2538 included patients, 902 had undergone isolated femoropopliteal endovascular intervention and 1636 had undergone femoropopliteal bypass. The endovascular intervention group were more likely to have diabetes (68.9% vs 54.0%; P < .001), coronary artery disease (31.0% vs 23.0%; P < .001), renal failure requiring dialysis (14.2% vs 7.2%; P < .001), and claudication (45.1% vs 36.6%; P < .001) compared with the bypass group. After propensity score matching, 466 patients were in each group with no significant differences in the baseline characteristics. Perioperative morbidity was higher with femoropopliteal bypass compared with endovascular intervention (12.0% vs 7.9%; P = .038); however, the rates of major amputation and mortality were not different. At 1 year, patients who had undergone femoropopliteal bypass were less likely to require reintervention (17.0% vs 25.2%; P = .012). However, no differences were found in major amputation (7.7% vs 7.9%; P = .928) or mortality (5.2% vs 5.2%; P = 1.00). Propensity score matching was also performed between femoropopliteal bypass with the great saphenous vein and isolated femoropopliteal endovascular interventions, and the outcomes were similar.

CONCLUSIONS

For patients with premature PAD and advanced femoropopliteal disease, bypass surgery decreased the reintervention rate at 1 year but was associated with increased perioperative morbidity and hospital length of stay compared with endovascular therapy. No differences were found in major amputation or mortality between the two strategies.

Outcomes and Costs of Open and Endovascular Revascularisation for Chronic Limb Ischaemia in an Australian Cohort

OBJECTIVE

The costs of open and endovascular revascularisation to treat peripheral artery disease (PAD) have not been fully established. This study examined the costs of both the index admission and any readmissions to hospital within 30 days of discharge for people having revascularisation at a single centre in Australia.

METHODS

This was a retrospective analysis of prospectively collected data. Eligible participants were those presenting with chronic limb ischaemia requiring revascularisation between 2002 and 2017. Generalised linear modelling was used to estimate mean (95% confidence interval [95% CI]) hospital costs for the index and readmission hospital treatments.

RESULTS

A total of 302 participants presenting with intermittent claudication (n=219; 72.5%) or chronic limb threatening ischaemia (n=83; 27.5%) treated by open (n=116; 38.4%) or endovascular (n=186; 61.6%) revascularisation were included. Forty-eight (48) (15.9%) participants were readmitted within 30 days of discharge from their index admission. The mean estimated index admission hospital cost was AUD$13,827 (95% CI, $11,935-$15,818) per person. This cost was significantly greater for open as compared to endovascular revascularisation (p<0.001). The mean estimated hospital cost was AUD$15,324 ($10,944-$19,966) per person readmitted. When comparing participants treated before and after 2010, the total hospital costs decreased, mainly due to decreased lengths of hospital stay for open procedures.

CONCLUSIONS

In this study the hospital costs were less for endovascular than open revascularisation of chronic limb ischaemia. Costs decreased over time. Readmission is an important contributor to the overall costs of peripheral revascularisation.

A comparison of revascularization methods for peripheral arterial disease in diabetics: Changing trends in lower extremity revascularization from 2008 to 2014

OBJECTIVES

This study examined the current demographic and outcome trends regarding endovascular and open revascularization for people with diabetes.

METHODS

The National Inpatient Sample database was utilized to identify diabetic patients who underwent lower extremity revascularization and amputation procedures between 2008 and 2014. International Classification of Diseases 9th edition codes were used to identify the procedures, diagnoses, and comorbidities.

RESULTS

We identified 38,143 diabetic patients who underwent endovascular revascularization and 25,415 who underwent open revascularization between 2008 and 2014. The number of endovascular and open revascularization procedures decreased steadily by 17.5% and 12.43% during the study period, respectively. The total charges for the endovascular procedure were greater than the open procedure ($98,761 vs. $80,782, p ≤ 0.001) despite similar median length of stay (5 days (inner quartile range (IQR) = 1-10) vs. 5 days (IQR = 3-10), p ≤ 0.001). Compared to open, the in-patient amputation rate for endovascular patients has been increasing faster for both minor (11.75% vs. 0.37%) and major amputations (3.08% vs. 0.19%). Although the post-procedure amputation rates between endovascular and open procedures were increased for endovascular patients (odds ratio [OR] = 1.71, confidence interval [CI] = 1.35-2.18, p ≤ 0.001) in 2008, by 2014 the risk of major amputation was doubled in endovascular patients (OR = 2.88, CI = 2.27-3.64, p ≤ 0.001). African Americans were more likely to undergo minor amputation than Whites (p ≤ 0.001). Lastly, diabetic patients with uncontrolled diabetes, systemic infection, weight loss, congestive heart failure, gangrene, and end-stage renal disease were more likely to undergo endovascular repair.

CONCLUSIONS

As more medically complex patients undergo endovascular revascularization, endovascular revascularization for diabetic patients is becoming associated with higher total cost despite similar length of stay, minor amputation, and major amputation rates. Further studies are needed to continuously evaluate the post-procedural outcomes and cost effectiveness of this trend.

Long-term outcomes following endovascular and surgical revascularization for peripheral artery disease: a propensity score-matched analysis

AIMS

Peripheral artery disease (PAD) revascularization can be performed by either endovascular or open surgical approach. Despite increasing use of endovascular revascularization, it is still uncertain which strategy yields better long-term outcomes.

METHODS AND RESULTS

This retrospective cohort study evaluated patients hospitalized with PAD in Australia and New Zealand who underwent either endovascular or surgical revascularization between 2008 and 2015, and compared procedures using a propensity score-matched analysis. Hybrid interventions were excluded. The primary endpoint was mortality or major adverse limb events (MALE), defined as a composite endpoint of acute limb ischaemia, urgent surgical or endovascular reintervention, or major amputation, up to 8 years post-hospitalization using time-to-event analyses 75 189 patients fulfilled eligibility (15 239 surgery and 59 950 endovascular), from whom 14 339 matched pairs (mean ± SD age 71 ± 12 years, 73% male) with good covariate balance were identified. Endovascular revascularization was associated with an increase in combined MALE or mortality [hazard ratio (HR) 1.13, 95% confidence interval (CI): 1.09-1.17, P < 0.001]. There was a similar risk of MALE (HR 1.04, 95% CI: 0.99-1.10, P = 0.15), and all-cause urgent rehospitalizations (HR 1.01, 95% CI: 0.98-1.04, P = 0.57), but higher mortality (HR 1.16, 95% CI: 1.11-1.21, P < 0.001) when endovascular repair was compared to surgery. In subgroup analysis, these findings were consistent for both claudication and chronic limb-threatening ischaemia presentations.

CONCLUSION

Although the long-term risk of MALE was comparable for both approaches, enduring advantages of surgical revascularization included lower long-term mortality. This is at odds with some prior PAD studies and highlights contention in this space.

The Effect of Patient and Hospital Characteristics on Total Costs of Peripheral Bypass in New York State

INTRODUCTION

With the aging U.S. population, peripheral vascular procedures will become increasingly common. The objective of this study is to characterize the factors associated with increased total costs after peripheral bypass surgery.

METHODS

Data for 34,819 patients undergoing peripheral bypass surgery in NY State were extracted using the Statewide Planning and Research Cooperative System (SPARCS) database for years 2009-2017. Patient demographics, All Patient Refined Diagnostic Related Groups (APR) severity score, mortality risk, hospital volume, and length of stay data were collected. Primary outcomes were total costs and length of stay. Data were analyzed using univariate and multivariate analysis.

RESULTS

28.1% of peripheral bypass surgeries were performed in New York City. 7.9% of patients had extreme APR severity of illness whereas 32.0% had major APR severity of illness. 6.3% of patients had extreme risk of mortality and 1 in every 5 patients (20%) had major risk of mortality. 24.9% of patients were discharged to a facility. The mean length of stay (LOS) was 9.9 days. Patient LOS of 6-11 days was associated with +$2,791.76 total costs. Mean LOS of ≥ 12 days was associated with + $27,194.88 total costs. Multivariate analysis revealed risk factors associated with an admission listed in the fourth quartile of total costs (≥$36,694.44) for peripheral bypass surgery included NYC location (2.82, CI 2.62-3.04), emergency surgery (1.12, CI 1.03-1.22), extreme APR 2.08, 1.78-2.43, extreme risk of mortality (2.73, 2.34-3.19), emergency room visit (1.68, 1.57-1.81), discharge to a facility (1.27, CI 1.15-1.41), and LOS in the third or fourth quartile (11.09, 9.87-12.46).

CONCLUSION

The cost of peripheral bypass surgery in New York State is influenced by a variety of factors including LOS, patient comorbidity and disease severity, an ER admission, and discharge to a facility.

Differences in outcomes for hospitalizations of systemic and non-systemic infections associated with vascular and cardiac grafts and devices: a population-based study

BACKGROUND

Use of vascular and cardiac devices has expanded and is associated with a relative, though disproportionate, increase in device-associated infections.

AIM

To describe the association between cardiac/vascular device infections and outcomes in those with, and without systemic infections.

METHODS

We used the 2016 National Inpatient Sample and the International Classification of Diseases - 10^th revision codes to identify hospitalized individuals with vascular and cardiac device infections. Linear and logistic regression models were utilized to compare outcomes of death, length of stay (LOS) and hospitalization costs between individuals with and without systemic infection.

FINDINGS

There were a total of 65,110 hospitalizations associated with device infections with a mean age of 61.3 ± 15.9 years (standard deviation); 28,650 (44%) had systemic infections. Elixhauser comorbidity scores of three or greater were observed in 91.2% of individuals with systemic infections along with a higher prevalence of diabetes, renal disease and heart failure. The primary outcome of mortality was observed in 3965 individuals with an odds ratio of 3.97 (95% confidence interval (CI), 2.92-3.95) in those with systemic infections compared with those without. Mean LOS was 3.44 days longer (95% CI, 2.92-3.95) and mean cost was US$11,776 greater (95% CI, US$9826-12,727) in the systemic infection cohort.

CONCLUSION

Systemic cardiac and vascular device infections were associated with increased mortality, LOS and costs. Considering the increasing use of these life-saving devices, further work is needed to identify those at risk for infectious complications, particularly systemic infection, in order to enhance preventative strategies and improve health outcomes.

The cost-effectiveness of intensive low-density lipoprotein cholesterol lowering in people with peripheral artery disease

BACKGROUND

People with peripheral artery disease are at a high risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Randomized controlled trials suggest that intensive lowering of low-density lipoprotein cholesterol (LDL-C) with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors is an effective strategy to prevent these events. This study estimated the potential benefit and cost-effectiveness of administrating PCSK9 inhibitors to a cohort of participants with peripheral artery disease.

METHODS

A total of 783 participants with intermittent claudication (IC; n = 582) or chronic limb-threatening ischemia (CLTI; n = 201) were prospectively recruited from three hospitals in Australia. Serum LDL-C was measured at recruitment, and the occurrence of MACE and MALE was recorded over a median (interquartile range) follow-up of 2.2 years (0.3-5.7 years). The potential benefit of administering a PCSK9 inhibitor was estimated by calculating the absolute risk reduction and numbers needed to treat (NNT) based on relative risk reductions reported in published randomized trials. The incremental cost-effectiveness ratio per quality-adjusted life year gained was estimated.

RESULTS

Intensive LDL-C lowering was estimated to lead to an absolute risk reduction in MACE of 6.1% (95% confidence interval [CI], 2.0-9.3; NNT, 16) and MALE of 13.7% (95% CI, 4.3-21.5; NNT, 7) in people with CLTI compared with 3.2% (95% CI, 1.1-4.8; NNT, 32) and 5.3% (95% CI, 1.7-8.3; NNT, 19) in people with IC. The estimated incremental cost-effectiveness ratios over a 10-year period were $55,270 USD and $32,800 USD for participants with IC and CLTI, respectively.

CONCLUSIONS

This analysis suggests that treatment with a PCSK9 inhibitor is likely to be cost-effective in people with CLTI.

Treatment of bypass failure in patients with chronic limb threatening ischemia – open surgery vs. percutaneous mechanical thrombectomy

Summary: Background: Lower limb bypass occlusion in patients with chronic limb threating ischemia remains a challenge. We can choose between different treatment options: open surgery, local thrombolysis, thrombectomy/atherectomy devices. In this pilot study, we compare clinical outcomes and treatment costs between open surgery (OS) and percutaneous mechanical thrombectomy (pMTH). Patients and methods: This pilot study represents a retrospective analysis of hospital data of 48 occluded bypasses admitted from 2013 to 2018. Only patients presenting with severe ischemia and recrudescence of symptoms (Rutherford 4–6) were included in the current analysis. Two cohorts of patients were analysed: patients who underwent OS and patients that underwent pMTH. Primary clinical outcomes were one-year cumulative patency and limb salvage rates. Total cost was calculated as a sum of intra- and post-operative costs. To weigh clinical benefits against the economic consequences of OS versus pMTH a cost-effectiveness framework was adopted. Results: We analysed a series of 48 occluded bypasses 17 treated with open surgery and 31 with pMTH. Procedural success was 100% in both groups. When comparing one-year death rates ( p-value = .22) and re-occlusion rates ( p-value = .43), no statistically significant differences were observed between the two cohorts. Mean patency duration in the surgery cohort was significantly shorter ( p-value < .05). Primary patency (OS 41.2% vs. pMTH 48.4%) and limb salvage rate (OS 88.2% vs. pMTH 90.3%) at one year are similar in both groups. The total cost of surgery was substantially higher (OS 10,159€ vs. pMTH 8,401€) Conclusions: This pilot study, although limited to 48 occluded bypasses, demonstrates that endovascular treatment with pMTH is less invasive, less time consuming and less expensive, and produces greater health benefits than traditional OS.

WITHDRAWN: One-Year Freedom from Amputation, Survival, and Cost of Care following Tibial and Pedal Endovascular Interventions for Critical Limb Ischemia: The Role of Atherectomy and Drug-Eluting Stents

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Mortality After Paclitaxel-Coated Device Use in Patients With Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose:

To report the risk of all-cause mortality after treatment with paclitaxel-coated devices vs uncoated controls in patients with chronic limb-threatening ischemia (CLTI).

Materials and Methods:

A search of the PubMed, Embase, Cochrane, CINAHL, DARE, and PROSPERO databases was made on 5 November 2019 to identify randomized controlled trials (RCT) using intention-to-treat analysis to compare a paclitaxel-coated device to an uncoated device in PAD patients having clinical follow-up of at least 6 months. Half of the study population had to have CLTI or extractable data on the CLTI subgroup if <50%. The search identified 11 trials having 1450 patients randomized to a paclitaxel-coated device (n=866) or an uncoated control (n=584). There were 1367 (94.3%) patients with CLTI (range 10–429). The single endpoint was all-cause mortality, which was analyzed by pooling the mortality data in a DerSimonian and Laird random effects model. Summary statistics are expressed as relative risk ratios (RR) with a 95% confidence interval (CI).

Results:

The mean follow-up was 25.6 months (range 6–60); 10 of 11 studies reported a minimum 12-month follow-up. There were 161 (18.6%) deaths among 866 subjects in the paclitaxel device group and 116 deaths among 584 (19.9%) subjects in the non-coated control group (RR 0.93, 95% CI 0.78 to 1.12, p=0.45).

Conclusion:

There was no observed difference in short- to midterm mortality among a pooled patient population of predominately CLTI patients treated with paclitaxel-coated balloons or stents compared with uncoated controls.

Temporal trends and hospital costs associated with an endovascular-first approach for acute limb ischemia

OBJECTIVE

Recent studies suggest similar perioperative outcomes for endovascular and open surgical management of acute limb ischemia (ALI). We sought to describe temporal trends, patient factors, and hospital costs associated with contemporary ALI management.

METHODS

We used the weighted National Inpatient Sample to estimate primary ALI cases requiring open or endovascular intervention (2005-2014). We used multivariable regression models to examine temporal trends, patient factors, and hospital costs associated with endovascular-first vs open-first management.

RESULTS

Of 116,451 admissions for ALI during the study period, 35.2% were treated by an endovascular-first approach. The percentage of admissions managed with an endovascular-first approach increased over time (P < .001). Independent predictors of endovascular-first management included younger age, male sex, renal insufficiency, and more recent calendar year of admission (P ≤ .02), whereas patients who underwent fasciotomy, those with Medicaid, and those admitted on a weekend were more likely to undergo open-first management (P ≤ .02). Endovascular-first management had higher mean hospital costs than open-first management ($29,719 vs $26,193; P < .001). After adjustment for patient, hospital, and admission characteristics, there was an increase of $981 in treatment costs per year in the endovascular-first group (95% confidence interval [CI], $571-$1392; P < .001), whereas the costs associated with an open-first approach remained relatively stable over time ($10 per year; 95% CI, -$295 to $315; P = .95; P < .001 for interaction). The risk-adjusted odds of in-hospital major amputation was similar in both groups (adjusted odds ratio, 0.99; 95% CI, 0.85-1.15; P = .88).

CONCLUSIONS

Use of an endovascular-first approach for the treatment of ALI has significantly increased over time. Although major amputation rates are similar for both approaches, the costs associated with an endovascular-first approach are increasing over time, whereas the costs of open surgery have remained stable. The cost-effectiveness of modern ALI management warrants further investigation.

A Comparative Cost-Effectiveness Analysis of Percutaneous Transluminal Angioplasty With Optional Stenting and Femoropopliteal Bypass Surgery for Medium-Length TASC II B and C Femoropopliteal Lesions

Purpose: To evaluate the total midterm costs and cost-effectiveness of percutaneous transluminal angioplasty with optional stenting (PTA/S) as initial treatment compared with femoropopliteal bypass (FPB) surgery in patients with medium-length TransAtlantic Inter-Society Consensus II (TASC) B and C femoropopliteal lesions. Materials and Methods: Over a period of 3 years, all hospital health care costs for 226 consecutive patients were calculated: 170 patients with a TASC B lesion and 56 patients with a TASC C lesion. In the 135-patient PTA/S group (mean age 69.9±10.9 years; 83 men), 108 (63.5%) patients had TASC B lesions and 27 (48.2%) patients had TASC C lesions. Ninety-one patients (mean age 68.4±10.9 years; 60 men) were treated with FPB for 62 TASC B and 29 TASC C femoropopliteal lesions. The main outcome measure was the primary patency rate at 3-year follow-up. Multiple imputation and bootstrapping techniques were used to analyze the data. The adjusted incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in total costs by the difference in 3-year primary patency rate. Costs were expressed in euros (€), and cost differences are presented with the 95% confidence interval (CI). Results: Mean total costs per patient were €29,058 in the PTA/S treatment group vs €42,437 in the FPB group (mean adjusted difference –€14,820, 95% CI –€29,044 to −€5976). Differences in 3-year primary patency between PTA/S and FPB were small and nonsignificant (68.9% and 70.3%, respectively). An ICER of 563,716 was found, indicating that FPB costs €563,716 more per one extra patient reaching 3-year primary patency in comparison with PTA/S treatment. Conclusion: FPB in medium-length femoropopliteal lesions involved higher total costs when evaluated over a 3-year follow-up period. An endovascular-first approach is recommended, as this will result in cost minimization for patients with medium-length femoropopliteal disease.