1Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut.
2Department of Radiology and Biomedical Imaging, University of California, San Francisco, California.
J Neurosurg. 2022 Apr 29;137(6):1801-1810. doi: 10.3171/2022.2.JNS212887. Print 2022 Dec 1.
Acute ischemic stroke patients with large-vessel occlusion and good collateral blood flow have significantly better outcomes than patients with poor collateral circulation. The purpose of this study was to evaluate the cost-effectiveness of endovascular thrombectomy (EVT) based on collateral status and, in particular, to analyze its effectiveness in ischemic stroke patients with poor collaterals.
A decision analysis study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT based on collateral status. The study was performed over a lifetime horizon with a societal perspective in the US setting. Base-case analysis was done for good, intermediate, and poor collateral status. One-way, two-way, and probabilistic sensitivity analyses were performed.
EVT resulted in greater effectiveness of treatment compared to no EVT/medical therapy (2.56 QALYs in patients with good collaterals, 1.88 QALYs in those with intermediate collaterals, and 1.79 QALYs in patients with poor collaterals), which was equivalent to 1050, 771, and 734 days, respectively, in a health state characterized by a modified Rankin Scale (mRS) score of 0-2. EVT also resulted in lower costs in patients with good and intermediate collaterals. For patients with poor collateral status, the EVT strategy had higher effectiveness and higher costs, with an incremental cost-effectiveness ratio (ICER) of $44,326/QALY. EVT was more cost-effective as long as it had better outcomes in absolute numbers in at least 4%-8% more patients than medical management.
EVT treatment in the early time window for good outcome after ischemic stroke is cost-effective irrespective of the quality of collateral circulation, and patients should not be excluded from thrombectomy solely on the basis of collateral status. Despite relatively lower benefits of EVT in patients with poor collaterals, even smaller differences in better outcomes have significant long-term financial implications that make EVT cost-effective.
急性缺血性脑卒中患者大血管闭塞且侧支循环良好的患者预后明显优于侧支循环不良的患者。本研究旨在评估基于侧支循环状态的血管内血栓切除术（EVT）的成本效益，特别是分析其在侧支循环不良的缺血性脑卒中患者中的有效性。
采用Markov 模型进行决策分析研究，根据侧支循环状态估计 EVT 的终生质量调整生命年（QALY）和相关成本。本研究在美国的社会视角下进行了终生时间范围的研究。进行了良好、中等和较差侧支循环状态的基础案例分析。进行了单向、双向和概率敏感性分析。
与不进行 EVT/药物治疗相比，EVT 具有更高的治疗效果（在侧支循环良好的患者中为 2.56 QALY，在侧支循环中等的患者中为 1.88 QALY，在侧支循环不良的患者中为 1.79 QALY），这相当于改良Rankin 量表（mRS）评分在 0-2 之间的健康状态下的 1050、771 和 734 天。EVT 还降低了侧支循环良好和中等的患者的成本。对于侧支循环不良的患者，EVT 策略的效果更好，成本更高，增量成本效益比（ICER）为每 QALY 44326 美元。只要 EVT 在绝对数量上比药物治疗有更好的结果，在至少 4%-8%的患者中，EVT 就更具成本效益。
对于有良好预后的缺血性脑卒中患者，在早期时间窗内进行 EVT 治疗是具有成本效益的，无论侧支循环质量如何，都不应仅仅基于侧支循环状态将患者排除在血栓切除术之外。尽管 EVT 在侧支循环不良的患者中获益相对较低，但更好的结果的微小差异具有重大的长期经济意义，使 EVT 具有成本效益。
