Health Economic Impact of Incomplete Reperfusion Patterns After Endovascular Thrombectomy in Acute Ischemic Stroke

Incomplete reperfusion in endovascular thrombectomy (EVT) impacts patients' outcomes. Different incomplete reperfusion patterns may benefit from targeted therapeutic strategies, e.g. EVT-accessible incomplete reperfusion patterns could improve by performing additional EVT attempts, while EVT-non-accessible incomplete patterns might benefit from pharmacological therapies. The health-economic implications of these therapies are uncertain. This study aims to assess the potential economic benefits of improving incomplete reperfusion patterns after EVT.

Retrospective Data analysis from the ESCAPE-NA1 trial, which included patients with large vessel occlusion strokes undergoing EVT. Reperfusion patterns were classified as near-/complete (eTICI 2c3), EVT-accessible incomplete (eTICI 2b), or EVT-non-accessible incomplete (eTICI 2b) and we compared multiple attempts to achieve eTICI 2c3 vs. first-pass eTICI 2c3. A Markov-Model was built to compare lifetime costs and quality adjusted life-years (QALY) for each reperfusion pattern over a lifetime horizon, considering both healthcare and societal perspectives.

A total of 1105 of patients were enrolled in the ESCAPE-NA1 trial of which 949 with eTICI 2b, 2c and 3 were further analyized (mean age 70.7 ± 13.6 [SD]; 463 female). Near-Complete reperfusion (eTICI 2c3) was achieved in 506/1105 patients (45.8%). Incomplete reperfusion patterns (eTICI 2b) were found in 450/1105 (40.7%) patients. Angiography imaging could be further investigated in 443/450 (98.4%) cases with 147/443(33.2%) EVT-accessible and 296/443(66.8%) EVT-non-accessible incomplete reperfusion patterns. Compared to EVT-accessible and EVT-non-accssible incomplete reperfusion, achieving complete (eTICI 2c3) reperfusion resulted in lower costs and an additional 1.14/0.45 QALYs, making it the dominant strategy from a health-economic perspective. In the complete reperfusion (eTICI 2c3) group, cumulative lifetime QALYs were similar with 5.25 for single-pass eTICI 2c3 and 5.19 for multi-pass eTICI 2c3.

Improving incomplete reperfusion patterns after EVT has considerable potential health economic benefits, both in the presence and absence of a target occlusion that is amenable to EVT.