Abstract:
Objectives
Recent studies have shown a trend supporting endovascular revascularization (ER) in
the treatment of chronic mesenteric ischemia (CMI). However, few studies have compared
the cost effectiveness of ER and open revascularization (OR) for this indication.
The purpose of this study is to conduct a cost-effectiveness analysis comparing open
versus endovascular revascularization for CMI.
Methods
We built a Markov model with Monte Carlo microsimulation using transition probabilities
and utilities from existing literature for CMI patients undergoing OR versus ER. Costs
were derived from the hospital perspective using the 2020 Medicare Physician Fee Schedule.
The model randomized 20,000 patients to either OR or ER and allowed for one subsequent
reintervention with three other intervening health states: alive, alive with complications,
and dead. Quality adjusted life years (QALYs), costs, and incremental cost-effectiveness
ratio (ICER) were analyzed over a five-year period. One-way sensitivity and probabilistic
sensitivity analyses were conducted to study the impact of parameter variability on
cost effectiveness.
Results
OR cost $4532 for 1.03 QALYs while ER cost $5092 for 1.21 QALYs, leading to an ICER
of $3037 per QALY gained in the ER arm. This ICER was less than our willingness to
pay threshold of $100,000. Sensitivity analysis demonstrated that our model was most
sensitive to costs, mortality, and patency rates after OR and ER. Probabilistic sensitivity
analysis demonstrated ER would be considered cost effective 99% of iterations.
Conclusions
This study found that while five-year costs for ER were greater than OR, ER afforded
greater QALYs than OR. Although ER is associated with lower long-term patency and
higher rates of reintervention, it appears to be more cost effective than OR for the
treatment of CMI.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Annals of Vascular SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References:
- Atherosclerosis of the visceral arteries.VASA Z Gefasskrankheiten. 1995; 24: 9-14
- The Incidence of Chronic Mesenteric Ischemia in the Well-Defined Region of a Dutch Mesenteric Ischemia Expert Center.Clin Transl Gastroenterol. 2020; 11e00200
- Chronic atherosclerotic mesenteric ischemia (CMI).Vasc Med Lond Engl. 2010; 15: 333-338
- For The Dutch Mesenteric Ischemia Study Group. The Impact of Revascularisation on Quality of Life in Chronic Mesenteric Ischemia.Can J Gastroenterol Hepatol. 2019 Nov 12; 20197346013
- Acute and chronic thrombosis of the mesenteric arteries associated with malabsorption; a report of two cases successfully treated by thromboendarterectomy.N Engl J Med. 1958; 258: 874-878
- Mesenteric revascularization: management and outcomes in the United States, 1988-2006.J Vasc Surg. 2009; 50: 341-348.e1
- Open surgical treatment for chronic mesenteric ischemia in the endovascular era: when it is necessary and what is the preferred technique?.Semin Vasc Surg. 2010; 23: 36-46
- Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery.J Vasc Surg. 2021 Jan; 73: 87S-115S
- The Society for Vascular Surgery clinical practice guidelines define the optimal care of patients with chronic mesenteric ischemia.J Vasc Surg. 2021; 73: 84S-86S
- Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes.J Vasc Surg. 2009; 49: 1472-1479.e3
- Comparison of clinical outcomes of endovascular versus open revascularization for chronic mesenteric ischemia: a meta-analysis.Ann Vasc Surg. 2015 Jul; 29: 934-940
- Risk factors and outcomes for bowel ischemia after open and endovascular abdominal aortic aneurysm repair.J Vasc Surg. 2019 Sep; 70: 869-881
- Patient survival after open and endovascular mesenteric revascularization for chronic mesenteric ischemia.J Vasc Surg. 2013 Mar; 57: 747-755
- A systematic review and meta-analysis of endovascular versus open surgical revascularization for chronic mesenteric ischemia.J Vasc Surg. 2018 May; 67: 1598-1605
- Endovascular Versus Surgical Revascularization for Chronic Mesenteric Ischemia: Insights From the National Inpatient Sample Database.JACC Cardiovasc Interv. 2017 Dec; 10: 2440-2447
- Improved mortality in treatment of patients with endovascular interventions for chronic mesenteric ischemia.J Vasc Surg. 2018 Jun; 67: 1805-1812
- Cost-effectiveness analysis in surgery.Surgery. 1998; 123: 151-156
- Practical Guide to Cost-effectiveness Analysis.JAMA Surg. 2020; 155: 250-251
- A comparison of open and endovascular revascularization for chronic mesenteric ischemia in a clinical decision model.J Vasc Surg. 2014; 60: 715-725
- Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group. Cost-effectiveness of open versus endovascular repair of abdominal aortic aneurysm in the OVER trial.J Vasc Surg. 2012 Oct; 56: 901-909.e2
- The impact of psychiatric comorbidities on patient-reported surgical outcomes in adults treated for the median arcuate ligament syndrome.J Vasc Surg. 2018 Nov; 68: 1414-1421
- Chronic Mesenteric Ischemia: Patient Outcomes Using Open Surgical Revascularization.Dig Surg. 2017; 34: 340-349
- Meta-analysis of prospective trials determining the short- and mid-term effect of elective open and endovascular repair of abdominal aortic aneurysms on quality of life.Br J Surg. 2013 Mar; 100: 448-455
- Health-related quality-of-life outcomes after open versus endovascular abdominal aortic aneurysm repair.J Vasc Surg. 2015 Aug; 62: 491-498
- Fixed and variable cost of carotid endarterectomy and stenting in the United States: A comparative study.J Vasc Surg. 2017 May; 65: 1398-1406.e1
- Complication-Specific In-Hospital Costs After Carotid Endarterectomy vs Carotid Artery Stenting.J Endovasc Ther. 2018 Aug; 25: 514-521
- Real-world cost analysis of endovascular repair versus open repair in patients with nonruptured abdominal aortic aneurysms.J Vasc Surg. 2020 Feb; 71: 432-443.e4
- Health related quality of life utility weights for economic evaluation through different stages of chronic kidney disease: a systematic literature review.Health Qual Life Outcomes. 2020 Sep 21; 18: 310
- Health-Related Quality of Life Impacts Mortality but Not Progression to End-Stage Renal Disease in Pre-Dialysis Chronic Kidney Disease: A Prospective Observational Study.PLoS One. 2016 Nov 10; 11e0165675
- Recommendations for Conduct, Methodological Practices, and Reporting of Cost-effectiveness Analyses: Second Panel on Cost-Effectiveness in Health and Medicine.JAMA. 2016 Sep 13; 316: 1093-1103
- Cost-Effectiveness of TransCarotid Artery Revascularization versus Carotid Endarterectomy.J Vasc Surg. 2021 Jun 25; S0741-5214 (1)01004
- Dutch Randomized Endovascular Aneurysm Management (DREAM)Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.N Engl J Med. 2004 Oct 14; 351: 1607-1618
Malas M, Freischlag J. Interpretation of the Results of OVER in the context of EVAR, DREAM and the EUROSTAR Registry. Semin Vasc Surg. 23(3):165–169.
- One thousand health-related quality-of-life estimates.Med Care. 2000 Jun; 38: 583-637
- Chronic mesenteric ischemia: critical review and guidelines for management.Ann Vasc Surg. 2013 Jan; 27: 113-122
- Outcomes of reoperative open or endovascular interventions to treat patients with failing open mesenteric reconstructions for mesenteric ischemia.J Vasc Surg. 2014 Dec; 60 (e1-2): 1612-1619
- Endovascular therapy for chronic mesenteric ischemia.J Am Coll Cardiol. 2006 Mar 7; 47: 944-950
- Endovascular treatment for chronic atherosclerotic occlusive mesenteric disease: is stenting superior to balloon angioplasty?.Vasa. 2010 Nov; 39: 319-324
- Chronic mesenteric ischaemia: 28-year experience of endovascular treatment.Eur Radiol. 2012 Jun; 22: 1372-1384
- Dutch Mesenteric Ischemia Study group (DMIS). Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI): study protocol for a randomized controlled trial.Trials. 2019 Aug 20; 20: 519
- Low Frequency Vascular Disease Research Consortium Investigators. Multicenter study of retrograde open mesenteric artery stenting through laparotomy for treatment of acute and chronic mesenteric ischemia.J Vasc Surg. 2018 Aug; 68: 470-480.e1
- Retrograde open mesenteric stenting should be considered as the initial approach to acute mesenteric ischemia.J Vasc Surg. 2020 Oct; 72: 1260-1268
- Partners’ experiences of living with men who have screening-detected abdominal aortic aneurysms: A qualitative descriptive study.J Clin Nurs. 2020 Oct; 29: 3711-3720
Article info
Publication history
Accepted:
February 5,
2023
Received in revised form:
December 26,
2022
Received:
September 25,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Presented at Southern California Surgical Vascular Surgical Society 39th Annual Meeting 2021
Identification
Copyright
© 2023 Elsevier Inc. All rights reserved.
