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Long-term value in open and endovascular repair of chronic mesenteric ischemia
Daniel Lehane1, Joshua Geiger1, Baqir Kedwai1
1Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
Insights
Endovascular revascularization (ER) offers superior 5-year value for chronic mesenteric ischemia (CMI) compared to open revascularization (OR), despite higher reintervention rates. This suggests ER is a cost-effective first-choice treatment for CMI.
Area of Science:
- Vascular Surgery
- Health Economics
- Interventional Cardiology
Background:
- Current guidelines recommend open revascularization (OR) over endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) in younger, healthier patients.
- Long-term cost-effectiveness and value of these treatment modalities concerning patient life expectancy remain underexplored.
Purpose of the Study:
- To investigate the 5-year value, defined as life-years per $100,000 in charges, for ER versus OR in patients with CMI.
- To identify factors influencing the long-term value of CMI treatment.
Main Methods:
- Utilized data from the New York statewide all-payor database (2000-2014) for CMI patients, excluding acute cases.
- Performed propensity score matching on demographics and comorbidities for a cohort of 209 patients in each group (ER and OR).
- Employed multiple linear regression and Kaplan-Meier analysis to assess 5-year value, survival, and reintervention-free survival.
Main Results:
- Endovascular revascularization (ER) demonstrated significantly higher 5-year value ($8.04 ± 11.42$ life-years/$100k) compared to open revascularization (OR) ($4.89 ± 5.28$ life-years/$100k; P < .01).
- The ER group had more reinterventions (37 vs 17; P < .01) and lower reintervention-free survival (43.7% vs 58.1%; P = .04).
- Factors negatively associated with value included OR, advanced age, congestive heart failure, dysrhythmia, cancer, and ICU days; ER was positively associated.
Conclusions:
- Endovascular revascularization (ER) provides superior long-term value for chronic mesenteric ischemia (CMI) treatment compared to open revascularization (OR), despite a higher need for reinterventions.
- ER is validated as the preferred initial treatment for CMI in patients with suitable anatomy, based on superior procedural value.
- Age, comorbidities (CHF, dysrhythmia, cancer), and intensive care unit utilization negatively impact treatment value.
Objective:
Guidelines recommend open revascularization (OR) over endovascular revascularization (ER) for the treatment of chronic mesenteric ischemia (CMI) for younger, healthier patients. However, little is known about the long-term costs of these recommendations with respect to patients' overall life expectancy. This study investigated whether 5-year value differs between these treatment modalities.
Methods:
Patient data were extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payor database containing demographics, diagnoses, treatments, and charges. The database was queried for patients with an International Classification of Diseases, ninth revision, code for CMI, with the specific exclusion of acute ischemia cases. A propensity score match was performed using the Charlson Comorbidity Index, age, sex, race, renal status, and pulmonary disease for the final cohort of patients. Multiple linear regression and mixed effects linear regression were used to determine factors associated with 5-year value, calculated as life-years/$100k in charges. Charges were gathered from the index admission and subsequent admissions for acute or CMI, mesenteric angiography, or follow-up reintervention. Kaplan-Meier estimation was performed for survival and reintervention-free survival.
Results:
From 2000 to 2014, 875 patients underwent intervention for CMI. Of those meeting inclusion criteria, 209 (28.1%) underwent OR and 535 (71.9%) ER. After propensity score matching (n = 209 in each group), the ER group showed higher value at 5 years after the procedure (8.04 ± 11.42 life-years/$100k charges vs 4.89 ± 5.28 life-years/$100k charges; P < .01). More patients underwent reintervention in the ER group (37 patients vs 17 patients; P < .01), with 55 reinterventions in the ER group and 19 in the OR group (P < .01). Multiple linear regression analysis showed that age, congestive heart failure, dysrhythmia, cancer, and days spent in the intensive care unit were negatively associated with value at 5 years, whereas ER was positively associated. Survival was 59.6 ± 3.76% vs 62.3% ± 3.49% at 5 years (P = .91), and reintervention-free survival was 43.7 ± 3.86% vs 58.1 ± 3.53% (P = .04), for ER and OR respectively.
Conclusions:
Despite increased reinterventions and lower reintervention-free survival, the value for patients with CMI was higher in those who underwent ER in the largest propensity score-matched cohort to date looking at long-term value. Factors negatively associated with value were OR, age, days in intensive care, congestive heart failure, dysrhythmia, and cancer. In patients with amenable anatomy, ER is validated as the first-choice treatment for CMI based on the superior procedural value.
