Percutaneous mechanical atherothrombectomy versus arterial bypass surgery for femoropopliteal in-stent restenosis: a budget impact analysis

Abstract

Background: There is a growing body of evidence attesting to the safety and efficacy of percutaneous mechanical atherothrombectomy (PMA) for patients with femoropopliteal (FP) in-stent restenosis (ISR) and occlusion. This study aimed to compare the costs of PMA with those of arterial bypass surgery and analyze the potential impact the introduction of PMA could have on the budget of a typical vascular service.

Methods: A budget impact model with a 5-year time horizon was developed assuming an annual caseload of 12 patients with FP-ISR for whom arterial bypass surgery was the only intervention available for treating FP-ISR before the introduction of a PMA device (Rotarex; BD) and that, after its introduction, 50% of patients would be treated by this endovascular approach. Interviews with local clinical experts were used to map these 2 treatment pathways in detail, and all other inputs were sourced from national registries and published literature. All costs were based on 2022 pound sterling. Uncertainty in the model was explored through one-way sensitivity analysis and through 2 alternative scenarios that investigated the impact of different FP-ISR incidence rates, intervention mixes, and postsurgery lengths of stay.

Results: The analysis estimated that the introduction of PMA into future practice at a typical vascular service could achieve a cost saving of £4750 for each patient with FP-ISR undergoing an endovascular procedure instead of bypass surgery. This became a total budget impact of £142,497 over the model's 5-year time horizon. Reductions in postsurgery lengths of stay, delayed discharges, and operating theater utilization were the major drivers of cost savings.

Conclusions: The introduction of PMA as a treatment option for FP-ISR can deliver significant cost savings for vascular services due to substantial reductions in inpatient bed and operating theater use that are maintained across sensitivity and scenario analysis. It has a valuable role to play in improving day surgery rates and reducing the intensity of vascular surgery workloads.

Keywords: Rotarex; femoropopliteal; in-stent restenosis; percutaneous mechanical atherothrombectomy.

Central Illustration

High-level process map of FP-ISR treatment pathways at UHS. CT, computed tomography; FP-ISR, femoropopliteal in-stent restenosis and occlusion; MDT, multidisciplinary team; UHS, University Hospital Southampton NHS Foundation Trust.

Figure 1

One-way sensitivity analysis of base case results. DES, drug-eluting stent, tPA, tissue plasminogen activator.