Wixon C L, Mills J L, Westerband A, Hughes J D, Ihnat D M
University of Arizona Health Science Center, Tucson, AZ 85724-5072, USA.
J Vasc Surg. 2000 Jul;32(1):1-12. doi: 10.1067/mva.2000.107307.
Infrainguinal graft surveillance leads to intervention on the basis of duplex-identified stenoses. We have become increasingly concerned about the high frequency with which such revisions are required to maximize graft patency and limb salvage rates. The economic implications of these procedures have not been carefully analyzed or justified.
We retrospectively reviewed 155 consecutive autogenous infrainguinal bypass grafts performed for chronic leg ischemia in 141 patients. All patients were enrolled in a prospective surveillance program using color flow duplex imaging. Full economic appraisal (cost analysis, cost-effect analysis, and cost-benefit analysis) was performed for all graft surveillance and limb salvage-related interventions through use of standard accounting and valuation techniques.
Mean follow-up was 27 months. Five-year assisted primary patency (72%) and limb salvage rates (91%) were calculated by means of life table analysis. A total of 61 grafts required 86 revisions. Within 1 year of implantation, 36% of the grafts required revision. During this first year, the mean cost per graft enrolled was $9417. Time intervals after the initial year demonstrated a reduced annual revision rate (6%) and cost ($1725 per graft). The mean 5-year cost of graft maintenance ($16,318) approached that of the initial bypass graft ($19,331). The sum of the initial cost of bypass graft and 5-year graft maintenance cost ($35,649) was similar to the cost of amputation ($36,273). Grafts revised for duplex-detected stenoses (n = 46), in comparison with those revised after thrombosis (n = 15), had an improved 1-year patency (93% vs 57%; P <.01), required fewer amputations (2% vs 33%; P <.01), less frequently required multiple graft revisions (P =.06), and generated fewer expenses (at 12 months after revision, $17,688 vs $45,252, P <.01).
The cost associated with graft maintenance is significant, particularly within the first year, and demands consideration. Revision of a duplex-identified stenosis was significantly less costly than revision after graft thrombosis. Compared with the cost of limb amputation, limb salvage-related expenses appear to be justified.
腹股沟下移植血管监测可依据双功超声识别的狭窄情况进行干预。我们越来越关注为使移植血管通畅率和肢体挽救率最大化而进行此类修复的高频率。这些手术的经济影响尚未得到仔细分析或论证。
我们回顾性分析了141例患者为治疗慢性下肢缺血而进行的155例连续自体腹股沟下旁路移植术。所有患者均纳入了一项使用彩色血流双功成像的前瞻性监测项目。通过使用标准会计和估值技术，对所有移植血管监测及肢体挽救相关干预措施进行了全面的经济评估（成本分析、成本效果分析和成本效益分析）。
平均随访时间为27个月。通过生命表分析计算出5年辅助原发性通畅率（72%）和肢体挽救率（91%）。共有61条移植血管需要进行86次修复。在植入后的1年内，36%的移植血管需要修复。在这第一年中，每条纳入监测的移植血管的平均成本为9417美元。初始年份后的时间间隔显示年度修复率降低（6%），成本也降低（每条移植血管1725美元）。移植血管维护的平均5年成本（16318美元）接近初始旁路移植的成本（19331美元）。旁路移植的初始成本与5年移植血管维护成本之和（35649美元）与截肢成本（36273美元）相似。与因血栓形成后进行修复的移植血管（n = 15）相比，因双功超声检测到狭窄而进行修复的移植血管（n = 46）1年通畅率更高（93%对57%；P <.01），截肢需求更少（2%对33%；P <.01），多次移植血管修复的频率更低（P =.06），且产生的费用更少（修复后12个月时，17688美元对45252美元，P <.01）。
与移植血管维护相关的成本很高，尤其是在第一年，需要加以考虑。因双功超声识别的狭窄进行修复的成本明显低于移植血管血栓形成后进行修复的成本。与肢体截肢成本相比，与肢体挽救相关的费用似乎是合理的。
