Decision analysis model of open repair versus endovascular treatment in patients with asymptomatic popliteal artery aneurysms Wouter Hogendoorn, MD,

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Presentation transcript:

Decision analysis model of open repair versus endovascular treatment in patients with asymptomatic popliteal artery aneurysms Wouter Hogendoorn, MD, Felix J.V. Schlösser, MD, PhD, Frans L. Moll, MD, PhD, Bart E. Muhs, MD, PhD, M.G. Myriam Hunink, MD, PhD, Bauer E. Sumpio, MD, PhD Journal of Vascular Surgery Volume 59, Issue 3, Pages 651-662.e2 (March 2014) DOI: 10.1016/j.jvs.2013.09.026 Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 1 Simplified bubble diagram shows a Markov state transition model for treatment of asymptomatic popliteal artery aneurysms (aPAAs). Each health state has a possible transition to itself, which is not shown in this figure for clarity. The “remain same” health state is only included in the optimal medical treatment (OMT) group. The “stent” health states are only included in the group undergoing endovascular repair with a covered stent (stenting). PTA, Percutaneous transluminal angioplasty. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 2 A, Total expected quality-adjusted life-years (QALYs) at 0 to 35 years after the initial intervention of an asymptomatic popliteal artery aneurysm (aPAA) with great saphenous vein bypass (GSVB), endovascular repair with a covered stent (Stenting), or optimal medical treatment (OMT). In black, the results for reference-case patients (65-year-old men with aPAAs) using peripheral arterial disease (PAD)-based data for analysis. In grey, the results for the reference-case patients (65-year-old men with an aPAA) using abdominal aortic aneurysm (AAA)-based data for analysis, with further details in the Results. B, Total expected QALYs for GSVB, stenting, and OMT at the age of initial intervention for the reference-case patients (65-year-old men with aPAAs with PAD analysis), with further details in the Results. For clarity, the data using AAA analysis are not depicted, due to the virtual exact overlap with the PAD analysis. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 3 Two-way sensitivity analysis depicts the relation between age at initial treatment (x-axis) and relative risk (RR) for perioperative death (y-axis). For example, great saphenous vein bypass (GSVB) is preferred for the reference case, a 65-year-old patient with an RR of 1 (*), and endovascular repair with a covered stent (Stenting) is preferred for an 85-year-old patient with an RR of 3 (**). OMT, Optimal medical treatment. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 4 Total expected quality-adjusted life-years (QALYs) for different 5-year primary patency rates of endovascular repair with a covered stent (Stenting) for reference-case patients (65-year-old men with an asymptomatic popliteal artery aneurysm [aPAA]). Threshold patency (defined as where stenting is preferred above great saphenous vein bypass [GSVB]) is 80%. Both interventions are preferred over optimal medical treatment (OMT) for the reference case, regardless of the 5-year primary stent patency. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 5 Total expected reinterventions per patient after initial treatment of an asymptomatic popliteal artery aneurysm (aPAA) for reference-case patients (65-year-old men with an aPAA). The x-axis shows the number of years after initial intervention, and the y-axis shows the total expected reinterventions per patient, with further details in the Results. Note that these are the first interventions for optimal medical treatment (OMT), because no initial intervention was performed in the OMT group. GSVB, Great saphenous vein bypass; Stenting, endovascular repair with covered stent. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 6 Cost-effectiveness scatterplot of great saphenous vein bypass (GSVB), endovascular repair with covered stent (Stenting), and optimal medical treatment (OMT) of asymptomatic popliteal aortic aneurysms (aPAAs) for the reference-case patients (65-year-old men with aPAAs). Each point represents a single patient value based on the analysis of 10,000 reference-case patients in the Monte Carlo simulation. Depicted is that GSVB is dominant over the other two treatment options, because the effectiveness is higher and costs are lower. QALYs, Quality-adjusted life-years. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 1 (online only) Total expected quality-adjusted life-years (QALYs) for treatment of asymptomatic popliteal artery aneurysms (aPAAs) in the reference-case patient (a 65-year-old man with an aPAA) with great saphenous vein bypass (GSVB), endovascular repair with covered stent (Stenting), and optimal medical treatment (OMT) per 30-day perioperative mortality. Expected QALYs for stenting are higher if 30-day perioperative mortality of GSVB increases to 6%. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 2 (online only) Total expected quality-adjusted life-years (QALYs) for treatment of asymptomatic popliteal artery aneurysms (aPAAs) in the reference-case patient (a 65-year-old man with an aPAA) with great saphenous vein bypass (GSVB), endovascular repair with covered stent (Stenting), and optimal medical treatment (OMT) per quality of life (QoL) for amputation. Expected QALYs for GSVB are always higher than for stenting and OMT, and the total QALYs for OMT are most affected by QoL for amputation. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 3 (online only) Total expected quality-adjusted life-years (QALYs) for treatment of asymptomatic popliteal artery aneurysms (aPAAs) in the reference-case patient (a 65-year-old man with an aPAA) with great saphenous vein bypass (GSVB), endovascular repair with covered stent (Stenting), and optimal medical treatment (OMT) if an unlimited number of percutaneous transluminal angioplasties (PTAs) were possible. The assumption in the reference case was that only two PTAs were possible after every intervention. The expected QALYs are almost equal to the reference case for GSVB (8.43; in reference case, 8.43), stenting (8.08; in reference case, 8.07), and OMT (5.76, in reference case 5.77), if an unlimited number of PTAs were possible. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 4 (online only) Total expected quality-adjusted life-years for treatment of asymptomatic popliteal artery aneurysms (aPAAs) in the reference-case patient (a 65-year-old man with an aPAA) with great saphenous vein bypass (GSVB), endovascular repair with covered stent (Stenting), and optimal medical treatment (OMT) per discount rate. Expected QALYs for all treatments decrease if the discount rate is increased, but GSVB remains the preferred treatment option. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 5 (online only) Total expected costs (in US$) for treatment of asymptomatic popliteal artery aneurysms (aPAAs) in the reference-case patient (a 65-year-old man with an aPAA) with great saphenous vein bypass (GSVB), endovascular repair with covered stent (Stenting), and optimal medical treatment (OMT) per discount rate. The expected costs for all treatments decrease if the discount rate is increased, but GSVB remains the least expensive treatment option. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 6 (online only) Total expected costs for treatment of asymptomatic popliteal artery aneurysm (aPAA) in the reference-case patient (a 65-year-old man with an aPAA) with great saphenous vein bypass (GSVB), endovascular repair with covered stent (Stenting), and optimal medical treatment (OMT) per length of hospitalization. The expected costs for stenting are always higher than for GSVB, regardless of the length of hospitalization for stenting. Journal of Vascular Surgery 2014 59, 651-662.e2DOI: (10.1016/j.jvs.2013.09.026) Copyright © 2014 Society for Vascular Surgery Terms and Conditions