.

1. Is endovascular revascularisation of lower
limb a cost-effective treatment ?
Frank Vermassen
Ghent University Hospital
Ghent - Belgium

2. Cost-effectiveness analysis: why?
 In a restricted health care budget choices have to be made
on what the money can best be spent.
 Comparison
 Different procedures for the same pathology
 Treatment for different pathologies
 Small improvement for large numbers of patients vs.
very expensive treatment for small numbers of patients
 Therapeutic interventions vs screening programs or care for
the elderly
 In the absence of cost-consideration, it is inevitable that
health care resources will be inefficiently allocated, which
results in reduced health benefits for the total population

3.  Cost
 Cost of procedure
 Indirect costs
 Costs of complications
 Effectiveness
 Prevented costs
 Life years gained
 Quality adjustment
= QALY (Cost-utility)
Cost-effectiveness studies
Cost ofCost of
procedureprocedure
Indirect costsIndirect costs
Cost ofCost of
complicationscomplications
CE-Ratio: Cost per QALY gained

4. CE parameters in CLI
 Direct costs
Intervention
Complications
Follow-up
Reinterventions or
amputations
 Indirect costs
Nursing care
Institutional care
 Life years
Mortality of procedure
Survival
 Quality adjustment
QOL with CLI
QOL after CLI
QOL after amputation
Comorbidity

5. Is revascularisation cost-effective in CLI ?
 Critical limb ischemia
• QOL with active ulcer: 0,42
QOL with amputation: 0,54
• Cost of amputation : 2x cost of surgical revascularisation
Cost of prosthetic and institutional care (only 52%
ambulatory after amputation)
->Loss of utility: 0,3

6. CE of revascularisation for CLI
 Finnish vascular registry (Laurilla, Int J Angiol 2000)
118 patients with CLI: PTA or bypass
Surgery was better for
 Hemodynamic result
 Reoperation free years
 Limb-salvage
PTA was less expensive: 8855 $ vs 16470 $
Cost per year of leg saved
 PTA: 3877 $
 Surgery: 6055 $

7. • 452 patients in 27 UK
hospitals
• Severe limb ischemia
• Suitable for randomisation
between PTA and bypass
• Conclusion:
 SLI patients that are likely to
survive > 2 yrs are probably
better served by bypass
surgery first
 SLI patients that are unlikely to
live > 2 yrs are probably better
served by angioplasty
BASIL-trial
Amputation-free survival
Bradbury JVS 2010

8. CE analysis of Basil results
• Costs  Survival
AFS: + 12 d. for PTA
OS: +32 d for PTA
 QOL
 QALY: + 11 d for Surgery
0
10000
20000
30000
40000
50000
1 yr 3 yr
Bypass Angioplasty
Difference at 3 yr: 5521 $
ICER at 3 yrs: 184492 $/QALY
Angioplasty is cost-effective
over surgery in CLI at 3 yrs
Angioplasty is cost-effective
over surgery in CLI at 3 yrs
Forbes JVS 2010

9. Is treatment cost-effective in claudicants ?
Intermittent claudication
 Moriarty (JVS 2011)
Systematic review of 19 studies of different design, including
economical analysis
Conclusions:
All approaches (exercise, endovascular, bypass) are cost-effective
with the baseline comparator approach of no treatment
Existing lower extremity arterial revascularisation literature is
inadequate for drawing cost-efficacy conclusions and cannot
inform guidelines for open vs endovascular treatment

10. Nordanstig (Circulation 2014)
RCT
158 patients
Non-invasive treatment
Invasive treatment
HRQOL evaluation after 1 year
Results
Invasive treatment improves ICD
Invasive treatment improves quality
of life @ 1 year
Invasive treatment vs exercise treatment

11. Murphy et al. (Circulation 2012)
111 patients
Optimal Medical Control (OMC)
OMC + Supervised exercise
OMC + Stenting
Results
Greatest improvement in walking
distance with supervised exercise
Best improvement of quality of life
with stenting
Endovascular vs Exercise

12. Greenhalgh (EJVES 2008)
RCT: Mimic trial
144 patients (out of 1401)
Supervised exercise
Supervised exercise + angioplasty
Separate femoro-popliteal and
aorto-iliac analysis
Results
Angioplasty adds to walking
distance in patients under exercise
treatment
Non-significant improvement in
QOL
PTA on top of exercise treatment

13. Invasive treatment vs exercise treatment
 Meta-analysis 9 trials (873 participants).
• Endovascular (EVT) superior to medical therapy
for ABI, MWD and ICD
• No significant difference in MWD between
endovascular and supervised exercise (SVE)
• EVT + SVE significant better than SVE alone for
ABI, MWD and ICD

14. Which endovascular technique?
BJS 2013

15. Conclusions
 Revascularisation in CLI patients is cost-effective,
regardless of the technique that is used
 In claudicants invasive treatment can best be added to a
background of optimal medical treatment including
exercise
 Endovascular techniques seem in general more cost-
effective than surgical techniques but efforts should be
made to further decrease the number of reinterventions
 Prevention is probably most cost-effective of all