AN OLD DOG VERSUS NEW TRICKS: A CRITICAL APPRAISAL OF COST AND LIMB SALVAGE IN OPEN AND ENDOVASCULAR THERAPY

OBJECTIVES- Advances in endoluminal therapy have led many authors to support its use as a first line therapy in critical limb ischemia. They site its low morbidity, lower initial cost and reasonable limb salvage rates. The aim of this study was to compare the amortized cost of open and endovascular therapy in the context of limb salvage and patency.
METHODS- A retrospective review of femoropopliteal therapy in the setting of critical limb ischemia was performed collecting clinical, demographic and anatomical variables. An amortized cost model was developed and utilized to calculate cost per day of limb salvage.
RESULTS- Over a three year period a total of 199 femoropopliteal segments were treated; 105 open and 95 endovascular. Primary assisted patency rate by Kaplan-Meyer lifetable analysis was significantly better in the open group versus the endovascular group at one year. (66% vs. 51%, P=0.03) One year limb salvage rates were 82% in the open group and 61% in the endovascular group (P=0.02) Endovascular therapy, diabetes mellitus, end stage renal disease and ≤ 1 patent tibial vessel were independent risk factors for limb loss (p<0.05). The initial cost of open therapy $13,277 ± 598 versus $7176 ± 309 in the endovascular limb (P=0.001) The amortized cost of limb salvage ($/day of limb salvage) was 127 ± 36 in the open group versus 191 ± 63 in the endovascular group. (P=NS)
CONCLUSION- Open revascularization of femoropopliteal lesions in critical limb ischemia has superior primary assisted patency and limb salvage. Open and endovascular therapy are cost equivalent in an amortized cost model. Open revascularization offers superior results to that of endovascular therapy and should remain the gold standard.