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Outcomes and Cost Effectiveness Analysis of Autologous Alternative Veins Compared to Prosthetic Conduits for Infrainguinal Bypasses in the Absence of Great Saphenous Vein
Elizabeth A. Genovese, MD, Rabih A. Chaer, MD, MSc, Adham A. Ali, MD, Natalie A. Domenick, MD, Georges E. Al-Khoury, MD, Michel S. Makaroun, MD, Efthymios D. Avgerinos, MD.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Objectives: Infrainguinal bypass efficacy of autologous alternative vein(AAV) compared to prosthetic conduits(PC) in the absence of adequate great saphenous vein is highly variable. We sought to identify the optimal conduit through a meta-analysis and a cost-effectiveness analysis.
Methods: The meta-analysis included studies with a direct comparison of AAV to PC infrainguinal bypasses for critical limb ischemia(1995-2015). Data was pooled on baseline patient and bypass characteristics, complications, patency and limb salvage up to 5 years. The cost-effectiveness analysis utilized two Markov models simulating complications, patency, and limb salvage to estimate the additional cost for each quality adjusted life year(QALY) gained when using AAV compared to PC for a below-knee bypass;1st model annual mortality= 11.7%, 2nd model(shortened life expectancy) annual mortality=25%.
Results: Seven studies were included, resulting in 900 AAV and 623 PC bypasses. Baseline characteristics, including runoff score, were similar between groups, except PC had lower rates of diabetes(OR=0.58,p<0.001), tissue loss(OR=0.42,p<.001), and tibial targets (OR=0.18,p<.001). There were no significant differences in mortality, complications, primary patency or limb salvage rates through all 5 years. At 1&2 years, primary assisted and secondary patency were similar between the groups(Figure), however at 3 and 4 years, PC had an increased relative risk(RR) of loss of primary assisted and secondary patency(year 3: RR=1.45,p<.001 and RR=1.41,p<.001; year 4: RR=1.45,p<.001 and RR=1.59,p=.048, respectively). AAV was associated with an overall cost of ,263 and 3.97 QALYs and PC ,416 and 3.91 QALYs, for an incremental cost effectiveness ratio(ICER) of ,601/QALY when using AAV over PC. For a shortened life expectancy, the ICER=,011/QALY. By sensitivity analysis, the costs of AAV were driven by multiple reinterventions, while the decreased QALYs of PCs were driven by higher rates of bypass failure.
Conclusions: In the short term, AAV and PC have equivalent patencies and limb salvage. Beyond 2 years, AAV have superior primary assisted and secondary patency, nevertheless primary patency and limb salvage rates remain equivalent between conduit types. Overall costs of PC are less compared to AAV, however, despite multiple reinterventions to maintain graft patency, AAV is a cost effective strategy in clinically appropriate scenarios, such as in patients with longer life expectancies.


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