The Cost of SFA Interventions
How do factors such as in-stent restenosis impact the cost-effectiveness of angioplasty and stenting?
Lower-extremity occlusive disease can be severely debilitating. Traditionally, open bypass has been the gold standard for restoring circulation, but endovascular techniques have recently offered additional options (eg, angioplasty, laser atherectomy, and stenting). Results from angioplasty alone in superficial femoral artery (SFA) disease have been less than satisfactory.1-3 Angioplasty has been particularly limited for long-segment lesions and occlusions, and stenting has been seen as an answer to the high restenosis rates after suboptimal angioplasty. However, the best means by which to achieve favorable results in the SFA remains uncertain. Some studies report primary patency rates at 1 year to be as low as 29%.4 Better patency rates have been reported with the increased availability of long, self-expanding stents with significant radial strength. In 2001, Cheng et al reported primary patency rates at 1 year after SFA stenting to be 62.6%.5 Additionally, nitinol stents offer a constant radial force on the artery wall and plaque; they are also flexible and crush recoverable. Primary patency rates for nitinol stents are reported in the 80% range.6-8
One of the drawbacks of stenting is in-stent restenosis, which is believed to be caused by neointimal hyperplasia. PTFE-covered stents offer a potential way to decrease neointimal hyperplasia.9 Follow-up results at 6 months show primary patency rates of close to 80%.9 Drug-eluting stents are also a possible solution for neointimal hyperplasia.
THE RELATIVITY OF COST-EFFECTIVENESS
Endovascular techniques offer the potential for decreased operative mortality, shorter hospital stays, and fewer wound complications. These advantages can translate into increased cost-effectiveness if patency rates equal those of a vein bypass. The need for repeat procedures, however, regardless of their duration, can be the albatross of endovascular techniques. The initial benefits of lower cost as compared to open bypass can be offset by repeat procedures needed to maintain patency. One study estimates an open bypass to be twice the expense of an endovascular repair, but at 15 month follow-up, the cost per patient or cost per patent vessel is five times higher for an endovascular approach.10
SINGLE-CENTER AVERAGE COSTS
At our institution, the average physician charge for angioplasty is $2,304, for atherectomy, the charge is $3,028, and that for stent placement is $3,113. The average cost for an overnight hospital stay if there are no complications averages $8,245.66. The average physician charge for an open bypass is $4,508, with a hospital stay costing $26,117.80. Indeed, stenting and angioplasty offer decreased lengths of stay in the hospital with initial hospital stays that cost three times less. However, in cases of therapeutic failure, continuing to perform angioplasties diminishes the cost advantage. Not including the cost of the initial angioplasty and stent placement, an occlusion that recurs three times costs approximately $44,658.98. An in situ bypass would cost $30,625.80. Additionally, some believe there is a 22% absolute risk reduction of occlusion for performing bypass instead of PTA.11
The figures mentioned in this article are limited in that they only provide a glance at the fiscal aspects of endovascular versus open repair. Bypass surgery may also require reintervention, and that cost is not well documented here. A thorough study of patients that have undergone these different types of repairs is needed for an in-depth cost-benefit analysis. Factors such as complication rates or risk stratification were not explored for the sake of simplicity. The cost of subsequent surveillance studies was also not included. We feel that further evaluation of the cost of interventions will be crucial as to determine when an endovascular approach is no longer cost-effective in the current health care economic environment.
Virginia Oliva, MD, is a second-year resident in the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia. She has disclosed that she holds no financial interests in any of the products mentioned herein. She may be reached at (404) 727-8407; firstname.lastname@example.org.
Ross Milner, MD, is an Assistant Professor of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, Georgia. He has disclosed that he holds no financial interests in any of the products mentioned herein. Dr. Milner may be reached at (404) 727-8407; email@example.com.
1. Gray BH, Sullivan TM, Childs MB, et al. High incidence of restenosis/reocclusion of stents in the percutaneous treatment of long-segment superficial femoral artery disease after suboptimal angioplasty. J Vasc Surg. 1997;25:74-83.
2. Strecker EP, Boos IB, Gottmann D. Femoropopliteal artery stent placement: evaluation of long-term success. Radiology. 1997;205:375-383.
3. O'Donohoe MK, Sultan S, Colgan MP, et al. Outcome of the first 100 femoropopliteal angioplasties performed in the operating theatre. Eur J Vasc Endovasc Surg. 1999;17:66-71.
4. Kessel DO, Wijesinghe LD, Robertson I, et al. Endovascular stent-grafts for superficial femoral artery disease: results of 1-year follow-up. J Vasc Intervent Radiol. 1999;10:289-296.
5. Cheng SW, Ting AC, Wong J. Endovascular stenting of superficial femoral artery stenosis and occlusions: results and risk factor analysis. Cardiovasc Surg. 2001;9:133-140.
6. Vogel TR, Shindelman LE, Nackman GB, et al. Efficacious use of nitinol stents in the femoral and popliteal arteries. J Vasc Surg. 2003;38:1178-1184.
7. Henry M, Amor M, Beyar R, et al. Clinical experience with a new nitinol self-expanding stent in peripheral arteries. J Endovasc Surg. 1996;3:369-379.
8. Jahnke T, Voshage G, Muller-Hulsbeck S, et al. Endovascular placement of self-expanding nitinol coil stents for the treatment of femoropopliteal obstructive disease. J Vasc Intervent Radiol. 2002r;13:257-266.
9. Duda SH, Bosiers M, Pusich B, et al. Endovascular treatment of peripheral artery disease with expanded PTFE-covered nitinol stents: interim analysis from a prospective controlled study. Cardiovasc Intervent Radiol. 2002;25:413-418.
10. Galland RB, Whiteley MS, Gibson M, et al. Maintenance of patency following remote superficial femoral artery endarterectomy. Cardiovasc Surg. 2000;8:533-537.
11. van der Zaag ES, Legemate DA, Prins MH, et al. Angioplasty or bypass for superficial femoral artery disease? A randomised controlled trial. Eur J Vasc Endovasc Surg. 2004;28:132-137.