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

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.