Revascularization for femoropopliteal disease. A decision and cost-effectiveness analysis

Abstract

Objective: To evaluate the relative benefits and cost-effectiveness of revascularization for femoropopliteal disease using percutaneous transluminal angioplasty or bypass surgery.

Design: Decision analysis using a multistate transition simulation model (Markov process) and cost-effectiveness analysis from the perspective of the health care system.

Setting: Based on mortality, morbidity, patency, and cost data from a literature review.

Patients: Hypothetical cohort of patients with chronic femoropopliteal disease who desire revascularization. Subgroup analysis for patients defined by age, sex, indication, lesion type, and graft type.

Interventions: Percutaneous transluminal angioplasty, bypass surgery, and a strategies combining the two treatments.

Main outcome measures: Five-year patency results, quality-adjusted life expectancy, lifetime costs, and incremental cost-effectiveness ratios.

Results: For 65-year-old men with disabling claudication and a femoropopliteal stenosis or occlusion and for 65-year-old men with chronic critical ischemia and a femoropopliteal stenosis, initial angioplasty increased quality-adjusted life expectancy by 2 to 13 months and resulted in decreased lifetime expenditures compared with bypass surgery. For patients with chronic critical ischemia and a femoropopliteal occlusion, initial bypass surgery increased quality-adjusted life expectancy by 1 to 4 months and resulted in decreased lifetime expenditures compared with angioplasty. Sensitivity analysis demonstrated that angioplasty would always be the preferred initial treatment if the angioplasty 5-year patency rate exceeds 30%.

Conclusion: Angioplasty is the preferred initial treatment in patients with disabling claudication and a femoropopliteal stenosis or occlusion and in those with chronic critical ischemia and a stenosis. Bypass surgery is the preferred initial treatment in patients with chronic critical ischemia and a femoropopliteal occlusion.