Cost-effectiveness analysis of the covered endovascular reconstruction of the aortic bifurcation versus kissing stents and open surgical repair for the treatment of aorto-iliac occlusive disease.

Abstract

Objective: To assess the cost effectiveness of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) versus kissing stents (KS) and open surgical repair (OSR) for treating extensive aorto-iliac occlusive disease (AIOD).

Methods: A decision tree followed by a health state transition model was developed to simulate changes in Rutherford status and the occurrence of reinterventions, amputation, and death. A Dutch health care perspective and a five-year time horizon were used. Model inputs were estimated using non-randomised data of individuals who underwent a CERAB or a KS procedure and literature. The total number of reinterventions, life years, quality-adjusted life years (QALYs) and health care costs per strategy were calculated as well as the incremental costs and QALYs between strategies, and corresponding incremental cost-effectiveness ratios (ICERs).

Results: OSR resulted in the lowest survival due to a higher peri-operative probability of death. OSR resulted in a lower probability of reinterventions (6%, 95% Confidence Interval (CI): 1-15%) than CERAB (17%, 95%CI: 11-27%) and KS (29%, 95%CI: 17-46%). CERAB dominated OSR since it led to 0.032 (95%CI: -0.038-0.082) incremental QALYs and €-11,466 (95%CI: €-18,934-€-3,415) incremental costs versus OSR. CERAB led to 0.048 (95%CI: 0.011-0.109) incremental QALYs, €5,324 (95%CI: €2,938-€10,397) incremental costs, and an ICER of €110,201 per QALY versus KS.

Conclusions: CERAB dominated OSR and resulted in the highest health benefits and costs but does not seem to be cost effective versus KS for treating AIOD. Performing a randomised comparison of these treatment modalities is essential to confirm these findings.