Cost-effectiveness in the contemporary management of critical limb ischemia with tissue loss

J Vasc Surg. 2012 Oct;56(4):1015-24.e1. doi: 10.1016/j.jvs.2012.02.069. Epub 2012 Jul 31.


Background: The care of patients with critical limb ischemia (CLI) and tissue loss is notoriously challenging and expensive. We evaluated the cost-effectiveness of various management strategies to identify those that would optimize value to patients.

Methods: A probabilistic Markov model was used to create a detailed simulation of patient-oriented outcomes, including clinical events, wound healing, functional outcomes, and quality-adjusted life-years (QALYs) after various management strategies in a CLI patient cohort during a 10-year period. Direct and indirect cost estimates for these strategies were obtained using transition cost-accounting methodology. Incremental cost-effectiveness ratios (ICERs), in 2009 U.S. dollars per QALYs, were calculated compared with the most conservative management strategy of local wound care with amputation as needed.

Results: With an ICER of $47,735/QALY, an initial surgical bypass with subsequent endovascular revision(s) as needed was the most cost-effective alternative to local wound care alone. Endovascular-first management strategies achieved comparable clinical outcomes but at higher cost (ICERs ≥$101,702/QALY); however, endovascular management did become cost-effective when the initial foot wound closure rate was >37% or when procedural costs were decreased by >42%. Primary amputation was dominated (less effectiveness and more costly than wound care alone).

Conclusions: Contemporary clinical effectiveness and cost estimates show an initial surgical bypass is the most cost-effective alternative to local wound care alone for CLI with tissue loss and can be supported even in a cost-averse health care environment.

MeSH terms

  • Amputation, Surgical / economics
  • Cohort Studies
  • Cost-Benefit Analysis
  • Endovascular Procedures / economics
  • Health Care Costs*
  • Humans
  • Ischemia / economics
  • Ischemia / pathology*
  • Ischemia / therapy*
  • Lower Extremity / blood supply*
  • Markov Chains
  • Quality-Adjusted Life Years
  • Recovery of Function
  • Treatment Outcome
  • Vascular Grafting / economics
  • Wound Healing