The economics of femorocrural reconstruction for critical leg ischemia with and without autologous vein

Abstract

It is well established that primary arterial reconstruction, even to crural vessels, is cheaper than amputation. Reintervention increases expenditure and may produce mean costs exceeding those of primary amputation. Furthermore, secondary amputation may eventually become necessary. Femorocrural grafts have the highest average "reconstruction policy" cost (i.e., primary procedure and all further operations necessary during follow-up). We must therefore seek support for this potentially expensive form of treatment. In conjunction with health economists we have compared the average policy cost of 130 reconstructions with grafts exceeding 70 cm in length (89 vein grafts, 41 polytetrafluoroethylene grafts with a distal vein collar) with 67 vascular amputations, at mean follow-up of 3 years. One-month mortality rate after reconstruction was less than 1% but was 10% after amputation. At 3 years, however, 20% of both groups were dead. Overall 3-year patency is 65% (72% for vein grafts, 48% for polytetrafluoroethylene grafts). Ninety-seven percent of irreversible graft occlusions resulted in amputation in these patients. After autologous vein grafting reintervention, our follow-up showed increased mean costs from $6898 to $15,024 per patient. After prosthetic grafting, the higher reintervention rate increased from $6898 to $20,416. These mean costs remained less than amputation, reintervention, and additional mobility costs, which amounted to a mean of $21,726 per patient. Important differences in outcome were observed: 70% of patients undergoing amputation were confined to the home compared with only 9% of patients undergoing reconstruction; 30% of patients undergoing amputation were confined to bed or had to use a wheelchair compared with 1% of patients undergoing reconstruction.