Axelrod David A, Fendrick A Mark, Carlos Ruth C, Lederman Robert J, Froehlich James B, Weder Alan B, Abrahamse Paul H, Stanley James C
Departments of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan 498109-0604, USA.
J Endovasc Ther. 2003 Jun;10(3):546-56. doi: 10.1177/152660280301000321.
To determine the incremental cost-effectiveness of prophylactic percutaneous transluminal angioplasty with stent placement (PTA-S) in patients with incidentally discovered, asymptomatic renal artery stenosis (RAS) compared to delaying PTA-S until patients develop refractory hypertension or renal insufficiency (therapeutic PTA-S).
The Markov decision analysis model was used to determine the incremental cost per quality adjusted life year (QALY) saved for prophylactic PTA-S as compared to therapeutic PTA-S in a hypothetical cohort of patients with 50% unilateral atherosclerotic RAS followed from age 61 to death.
Prophylactic PTA-S compared to therapeutic PTA-S results in more QALYs/patient (10.9 versus 10.3) at higher lifetime costs ($23,664 versus $16,558). The incremental cost effectiveness of prophylactic PTA-S was estimated to be $12,466/QALY. Prophylactic stenting was not cost effective (>$50,000/QALY) if the modeled incidence of stent restenosis exceeded 15%/year and the incidence of progression in the contralateral renal artery was <2% of arteries/year.
PTA-S of incidental, asymptomatic unilateral RAS may improve patients' quality of life at an acceptable incremental cost. However, this technology should be used hesitantly until a randomized comparison confirms its effectiveness.
确定与将经皮腔内血管成形术加支架置入术（PTA-S）推迟至患者出现难治性高血压或肾功能不全时进行（治疗性PTA-S）相比，对偶然发现的无症状肾动脉狭窄（RAS）患者进行预防性PTA-S的增量成本效益。
采用马尔可夫决策分析模型，在一个假设队列中，对50%单侧动脉粥样硬化性RAS且年龄从61岁开始随访直至死亡的患者，确定预防性PTA-S相对于治疗性PTA-S每挽救一个质量调整生命年（QALY）的增量成本。
与治疗性PTA-S相比，预防性PTA-S导致每位患者的QALY更多（10.9对10.3），但终生成本更高（23,664美元对16,558美元）。预防性PTA-S的增量成本效益估计为12,466美元/QALY。如果模型中支架再狭窄的发生率超过每年15%，且对侧肾动脉进展的发生率低于每年动脉的2%，则预防性支架置入术不具有成本效益（>50,000美元/QALY）。
对偶然发现的无症状单侧RAS进行PTA-S可能以可接受的增量成本改善患者的生活质量。然而，在随机对照研究证实其有效性之前，应谨慎使用该技术。
