Related Experiment Video
Updated: Sep 4, 2025
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Cost-Effectiveness of Percutaneous Coronary Intervention Versus Bypass Surgery for Patients With Left Main Disease:
Elizabeth A Magnuson1,2, Khaja Chinnakondepalli1, Katherine Vilain1
1Saint Luke's Mid America Heart Institute, Kansas City, MO (E.A.M., K.C., K.V.).
Insights
Coronary artery bypass graft surgery (CABG) is cost-effective long-term for left main coronary artery disease compared to percutaneous coronary intervention (PCI). However, this depends on mortality rates, with CABG becoming less cost-effective if PCI shows better long-term survival.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Interventional Cardiology
Background:
- The EXCEL trial compared coronary artery bypass graft surgery (CABG) with percutaneous coronary intervention (PCI) for left main coronary artery disease.
- At 5 years, no significant difference was found in death, stroke, or myocardial infarction between CABG and PCI.
- However, all-cause mortality was higher with PCI, prompting an evaluation of long-term cost-effectiveness.
Purpose of the Study:
- To evaluate the lifetime cost-effectiveness of CABG versus PCI in patients with left main coronary artery disease.
- To compare the economic outcomes of these two revascularization strategies.
Main Methods:
- A Markov model was developed using 5-year EXCEL trial data and US lifetables.
- Costs were assessed using resource-based costing and Medicare reimbursement rates.
- Health utilities were measured using the EuroQOL 5-dimension questionnaire.
Main Results:
- CABG incurred higher initial procedure and hospitalization costs compared to PCI.
- Over 5 years, CABG resulted in higher cumulative costs.
- CABG was projected to increase lifetime costs by $21,551 and improve quality-adjusted life expectancy by 0.49 QALYs, yielding an ICER of $44,235/QALY.
Conclusions:
- CABG appears to be an economically attractive long-term strategy for left main coronary artery disease.
- The cost-effectiveness of CABG is sensitive to long-term mortality differences between strategies.
- When using pooled data from other trials, CABG is no longer considered highly cost-effective.
Background:
The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) demonstrated in patients with left main coronary artery disease, no significant difference between coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) with everolimus-eluting stents for the composite end point of death, stroke, or myocardial infarction at 5 years. However, all-cause mortality at 5 years was higher with PCI. Long-term cost-effectiveness of these 2 strategies has heretofore not been evaluated.
Methods:
From 2010 to 2014, 1905 patients with left main coronary artery disease were randomized to CABG (n=957) or PCI (n=948). Costs ($2019) were assessed over 5 years using resource-based costing and Medicare reimbursement rates. Health utilities were assessed using the EuroQOL 5-dimension questionnaire. Five-year EXCEL data in combination with US lifetables were used to develop a Markov model to evaluate lifetime cost-effectiveness. An incremental cost-effectiveness ratio <$50 000 per quality-adjusted life year (QALY) gained was considered highly cost-effective.
Results:
Index revascularization procedure costs were $4,850/patient higher with CABG, and total costs for the index hospitalization were $17 610/patient higher with CABG ($32 297 versus $19 687, P<0.001). Cumulative 5-year costs were $20 449/patient higher with CABG. CABG was projected to increase lifetime costs by $21 551 while increasing quality-adjusted life expectancy by 0.49 QALYs, yielding an incremental cost-effectiveness ratio of $44 235/QALY. In a post hoc sensitivity analysis using mortality hazard ratios from a meta-analysis of all randomized CABG versus PCI in left main disease trials, the gain associated with CABG was 0.08 to 0.14 QALYs, resulting in an incremental cost-effectiveness ratio of $139 775 to $232 710/QALY gained.
Conclusions:
Based on data from the EXCEL trial, CABG is an economically attractive revascularization strategy compared with PCI over a lifetime horizon for patients with significant left main coronary artery disease. However, this conclusion is sensitive to the long-term mortality rates with the 2 strategies, and CABG is no longer highly cost-effective when substituting the pooled treatment effect from the 4 major PCI versus CABG trials for left main disease.
Registration:
URL: https://www.
Clinicaltrials:
gov; Unique identifier: NCT01205776.
More Related Videos
13:10Direct Re-implantation of Left Coronary Artery into the Aorta in Adults with Anomalous Origin of Left Coronary Artery from the Pulmonary Artery ALCAPA
Published on: April 24, 2017
12:00Evaluation of a Novel Laser-assisted Coronary Anastomotic Connector - the Trinity Clip - in a Porcine Off-pump Bypass Model
Published on: November 24, 2014
Related Concept Videos
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:24Cardiac Catheterization III: Left Heart Catheterization
01:27Coronary Artery Disease V: Interprofessional Care
01:27Peripheral Artery Disease III: Interprofessional Care