Impact of collateral flow on cost-effectiveness of endovascular thrombectomy

Abstract

OBJECTIVE Acute ischemic stroke patients with large-vessel occlusion and good collateral blood flow have significantly better outcomes than patients with poor collateral circulation. The purpose of this study was to evaluate the cost-effectiveness of endovascular thrombectomy (EVT) based on collateral status and, in particular, to analyze its effectiveness in ischemic stroke patients with poor collaterals. METHODS A decision analysis study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT based on collateral status. The study was performed over a lifetime horizon with a societal perspective in the US setting. Base-case analysis was done for good, intermediate, and poor collateral status. One-way, two-way, and probabilistic sensitivity analyses were performed. RESULTS EVT resulted in greater effectiveness of treatment compared to no EVT/medical therapy (2.56 QALYs in patients with good collaterals, 1.88 QALYs in those with intermediate collaterals, and 1.79 QALYs in patients with poor collaterals), which was equivalent to 1050, 771, and 734 days, respectively, in a health state characterized by a modified Rankin Scale (mRS) score of 0–2. EVT also resulted in lower costs in patients with good and intermediate collaterals. For patients with poor collateral status, the EVT strategy had higher effectiveness and higher costs, with an incremental cost-effectiveness ratio (ICER) of $44,326/QALY. EVT was more cost-effective as long as it had better outcomes in absolute numbers in at least 4%–8% more patients than medical management. CONCLUSIONS EVT treatment in the early time window for good outcome after ischemic stroke is cost-effective irrespective of the quality of collateral circulation, and patients should not be excluded from thrombectomy solely on the basis of collateral status. Despite relatively lower benefits of EVT in patients with poor collaterals, even smaller differences in better outcomes have significant long-term financial implications that make EVT cost-effective.

The Compensation Index Is Better Associated with DSA ASITN Collateral Score Compared to the Cerebral Blood Volume Index and Hypoperfusion Intensity Ratio

“…Good CS is associated with higher chances of successful recanalization following MT, better penumbra salvage and favorable functional outcomes [16,[25][26][27][28][29][30][31][32][33]. Hence, assessing CS before treatment can aid in prognostication for AIS-LVO patients.…”

Cost-effectiveness of endovascular thrombectomy in acute stroke patients with large ischemic core

“…To date, a smaller body of literature has conducted a long-term assessment of expected health benefits and costs associated with AIS patients with large core infarctions 10–12. Using data from the HERMES meta-analysis, Wu et al found that EVT is more cost-effective than medical care alone, and Khunte et al stated that EVT yields higher quality-adjusted life years (QALYs) regardless of the quality of collateral circulation 11 12. However, previous cost-effectiveness analyses used data from trials that were not designed to select low ASPECTS patients.…”