Introduction:
Treatment of acute limb ischemia (ALI) has a high morbidity and mortality given patients’ multiple comorbidities, poor physiologic reserve, and the need for emergent intervention. Traditionally ALI of embolic origin has been treated with open revascularization (OR), however with increasing experience with thrombolytic therapy and adjuvant techniques, endovascular revascularization (ER) for ALI has become a more common treatment due to the lower associated morbidity and mortality.
Hypothesis:
Although associated with higher initial costs and lower technical success rates, ER will be cost effective given the decreased adverse event rate and mortality in a frail patient population.
Methods:
A Markov state-transition model was created to simulate patient oriented outcomes, including technical success, adverse events, limb salvage, discharge facility and quality adjusted life years (QALY) for patients presenting with Rutherford Classification I/IIa/IIb ALI secondary to cardiac embolism. A societal perspective was assumed with a 10-year time horizon. Parameter estimates were derived from published literature and primary data of cardioembolic ALI patients treated at our institution from 2005-2011 with either ER or OR. Costs were adjusted to 2013 U.S. dollars.
Results:
In the model, OR was technically successful in 87% patients, with a $23,881 cost for the initial hospitalization and a 11.5% perioperative mortality rate; ER was technically successful in 71% of patients, with a $39,619 initial cost, and a 4% mortality rate. At 10 years, the ER strategy cost $92,659/QALY gained compared to OR. Sensitivity analyses demonstrated that ER was favorable at a willingness to pay (WTP) threshold of $100,000/QALY when ER technical success was >70%, initial ER hospitalization cost was <$41,052 or if OR mortality was >10%. At a WTP of $50,000/QALY, ER was cost effective if technical success reached 79%, if ER cost was <$31,287 or if OR mortality was >23%.
Conclusions:
Contemporary endovascular treatment of cardioembolic ALI carries a greater cost compared to open revascularization, however it is associated with a decreased mortality rate. ER is potentially cost-effective in patients who are at high risk of post-operative mortality following OR.
SEX BASED DIFFERENCES IN OUTCOMES OF PATIENTS WITH ACUTE LIMB ISCHEMIA UNDERGOING ENDOVASCULAR TREATMENT
