VESS18 - Cost of Open and Endovascular Infrainguinal Lower Extremity Revascularization for CLTI in the Medicare Population

Objectives: Infrainguinal bypass with single segment great saphenous vein (BYPASS) has been recently shown to have superior outcomes compared to endovascular peripheral vascular interventions (PVI) as initial treatment of patients with chronic limb-threatening ischemia (CLTI). However, the costs of these strategies have not been studied. This project compares the outcomes and costs of primary endovascular and open repair in Medicare beneficiaries.

Methods: Patients undergoing BYPASS with single segment saphenous vein and PVI for CLTI were identified in the Medicare-linked VISION database (2010-2019). Outcomes and Medicare payments during hospitalization for revascularization were compared between the 2 groups.

Results: A total of 4,385 patients were analyzed (80.7% PVI, N=3,538) and 44.2% (N=1,565) underwent index revascularization as outpatient in the PVI group. Patients undergoing BYPASS were more likely to be male (63.2% vs 54.9%, p< 0.001) and white (81% vs 76.1%, p=0.002). Patients undergoing PVI were more likely to be older and have multiple comorbidities. (Table I)

Patients undergoing PVI had significantly higher mortality compared to BYPASS (5-year mortality: 58.4% vs 72.2%, p< 0.001) without significant difference in major amputation or reintervention. (Figure 1) Cox regression analysis similarly showed that BYPASS was independently associated with lower mortality compared to PVI (HR=0.76 [0.66 – 0.88]). However, looking at frequency of reinterventions, those undergoing BYPASS were more likely to have 2 or more reinterventions (p < 0.001).

At initial procedure, Medicare payments were significantly higher for BYPASS compared to PVI ($21,397 vs $14,497, p< 0.001) but there was no difference in payments for reinterventions between the 2 groups. Thus, total payments were higher in the BYPASS group ($30,844 vs $22607, p< 0.001). However, subgroup analysis of inpatient initial revascularizations only showed no difference in payments for initial revascularization or reinterventions between the 2 groups. (Table I)

Conclusions: BYPASS for the treatment of CLTI is associated with improved outcomes compared to PVI in the Medicare population but is more expensive. The cost of revascularization could be reduced with selective use of endovascular procedures in the outpatient setting.