An economic appraisal of lower extremity bypass graft maintenance

Objective: Infrainguinal graft surveillance leads to intervention on the basis of duplex-identified stenoses. We have become increasingly concerned about the high frequency with which such revisions are required to maximize graft patency and limb salvage rates. The economic implications of these procedures have not been carefully analyzed or justified. Methods: We retrospectively reviewed 155 consecutive autogenous infrainguinal bypass grafts performed for chronic leg ischemia in 141 patients. All patients were enrolled in a prospective surveillance program using color flow duplex imaging. Full economic appraisal (cost analysis, cost-effect analysis, and cost-benefit analysis) was performed for all graft surveillance and limb salvage-related interventions through use of standard accounting and valuation techniques. Results: Mean follow-up was 27 months. Five-year assisted primary patency (72%) and limb salvage rates (91%) were calculated by means of life table analysis. A total of 61 grafts required 86 revisions. Within 1 year of implantation, 36% of the grafts required revision. During this first year, the mean cost per graft enrolled was $9417. Time intervals after the initial year demonstrated a reduced annual revision rate (6%) and cost ($1725 per graft). The mean S-year cost of graft maintenance ($16, 318) approached that of the initial bypass graft ($19, 331). The sum of the initial cost of bypass graft and 5-year graft maintenance cost ($35, 649) was similar to the cost of amputation ($36, 273). Grafts revised for duplex-detected stenoses (n = 46), in comparison with those revised after thrombosis (n = 15), had an improved 1-year patency (93% vs 57%; P < .01), required fewer amputations (2% vs 33%; P < .01), less frequently required multiple graft revisions (P = .06), and generated fewer expenses (at 12 months after revision, $17, 688 vs $45, 252, P < .01). Conclusion: The cost associated with graft maintenance is significant, particularly within the first year, and demands consideration. Revision of a duplex-identified stenosis was significantly less costly than revision after graft thrombosis. Compared with the cost of limb amputation, limb salvage-related expenses appear to be justified.