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

Abstract

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.

Keywords

angioplasty bypass surgery cost-effectiveness analysis endovascular treatment femoropopliteal segment occlusion peripheral artery disease popliteal artery stenosis stent superficial femoral artery

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References

Hirsch

Hartman

Town

et al . National health care costs of peripheral arterial disease in the Medicare population. Vasc Med. 2008;13:209–215.

Jaff

Cahill

et al . Clinical outcomes and medical care costs among Medicare beneficiaries receiving therapy for peripheral arterial disease. Ann Vasc Surg. 2010;24:577–587.

Norgren

Hiatt

Dormandy

et al . Inter-society Consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45(suppl S):S5-S67.

Mazari

Khan

Carradice

et al . Randomized clinical trial of percutaneous transluminal angioplasty, supervised exercise and combined treatment for intermittent claudication due to femoropopliteal arterial disease. Br J Surg. 2012;99:39–48.

Spronk

Bosch

den Hoed

et al . Cost-effectiveness of endovascular revascularization compared to supervised hospital-based exercise training in patients with intermittent claudication: a randomized controlled trial. J Vasc Surg. 2008;48:1472–1480.

Lindgren

Gottsäter

Qvarfordt

et al . Invasive treatment for infrainguinal claudication has satisfactory 1 year outcome in three out of four patients: a population-based analysis from Swedvasc. Eur J Vasc Endovasc Surg. 2014;47:615–620.

Aboyans

Ricco

Bartelink

MEL

et al . 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55:305–368.

Surowiec

Davies

Eberly

et al . Percutaneous angioplasty and stenting of the superficial femoral artery. J Vasc Surg. 2015;41:269–278.

AbuRahma

Robinson

Holt

. Prospective controlled study of polytetrafluoroethylene versus saphenous vein in claudicant patients with bilateral above knee femoropopliteal bypasses. Surgery. 1999;126:594–601.

10.

Malas

Enwerem

Qazi

et al . Comparison of surgical bypass with angioplasty and stenting of superficial femoral artery disease. J Vasc Surg. 2014;59:129–135.

11.

Bradbury

Adam

Bell

et al . Multicentre randomised controlled trial of the clinical and cost-effectiveness of a bypass-surgery-first versus a balloon-angioplasty-first revascularisation strategy for severe limb ischaemia due to infrainguinal disease. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial. Health Technol Assess. 2010;14:1–210.

12.

Tang

Paravastu

SCV

Thomas

et al . Cost analysis of initial treatment with endovascular revascularization, open surgery, or primary major amputation in patients with peripheral artery disease. J Endovasc Ther. 2018;25:504–511.

13.

Vossen

Vahl

Leijdekkers

et al . Long-term clinical outcomes of percutaneous transluminal angioplasty with optional stenting in patients with superficial femoral artery disease: a retrospective, observational analysis. Eur J Vasc Endovasc Surg. 2018;56:690–698.

14.

Von Elm

Altman

Egger

et al . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg. 2014;12:1495–1499.

15.

Husereau

Drummond

Petrou

et al . Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Value Health. 2013;6:e1–e5.

16.

Von Allmen

Weiss

Tevaearai

et al . Completeness of follow-up determines validity of study findings: results of a prospective repeated measures cohort study. PLoS One. 2015;10:e0140817.

17.

Statistics Netherlands. Consumer Prices. Den Haag, the Netherlands: Centraal Plan Bureau voor de statistiek. 2016. http://statline.cbs.nl/Statweb/publication/?DM=SLNL&PA=83131ned&D1=0-6&D2=191&D3=(l-39)-l&VW=T . Accessed February 17, 2016.

18.

Azur

Stuart

Frangakis

et al . Multiple imputation by chained equations: what is it and how does it work? Int J Methods Psychiatr Res. 2011;20:40–49.

19.

Van Buuren

. Multiple imputation of discrete and continuous data by fully conditional specification. Stat Methods Med Res. 2007;16:219–242.

20.

Rubin

. Multiple Imputation for Nonresponse in Surveys. New York, NY: Wiley; 1987.

21.

Moriarty

Murad

Shah

et al . A systematic review of lower extremity arterial revascularization economic analyses. J Vasc Surg. 2011;54:1131–1144.

22.

Janne d’Othee

Morris

Powell

et al . Cost determinants of percutaneous and surgical interventions for treatment of intermittent claudication from the perspective of the hospital. Cardiovasc Intervent Radiol. 2008;31:56–65.

23.

Stoner

Defreitas

Manwaring

et al . Cost per day of patency: understanding the impact of patency and reintervention in a sustainable model of healthcare. J Vasc Surg. 2008;48:1489–1496.

24.

Laurila

Brommels

Standertskjöld-nordenstam

et al . Cost-effectiveness of percutaneous transluminal angioplasty (PTA) versus vascular surgery in limb-threatening ischaemia. Int J Angiol. 2000;9:214–219.

25.

De Vries

Visser

de Vries

et al . Intermittent claudication: cost-effectiveness of revascularization versus exercise therapy. Radiology. 2002;222:25–36.

26.

Torsello

Bisdas

Debus

et al . Cost and cost-effectiveness in the treatment of peripheral arterial occlusion disease—what is proven? [in German] Zentralbl Chir. 2015;140:18–26.

27.

Eneroth

Apelqvist

Troeng

et al . Operations, total hospital stay and costs of critical leg ischemia. A population-based longitudinal outcome study of 321 patients. Acta Orthop Scand. 1996;67:459–465.

28.

Jansen

de Vries

Cullen

et al . Cost-identification analysis of revascularization procedures on patients with peripheral arterial occlusive disease. J Vasc Surg. 1998;28:617–623.

29.

Sachs

Pomposelli

Hamdan

et al . Trends in the national outcomes and costs for claudication and limb threatening ischemia: angioplasty vs bypass graft. J Vasc Surg. 2011;54:1021–1031.

30.

Mays

Casserly

Kohrt

et al . Assessment of functional status and quality of life in claudication. J Vasc Surg. 2011;53:1410–1421.

31.

Landry

. Functional outcome of critical limb ischemia. J Vasc Surg. 2007;45(suppl A):A141–A148.

32.

Marshall

Billingham

Bryan

. Can we afford to ignore missing data in cost-effectiveness analyses? Eur J Health Econ. 2009;10:1–3.

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