1. Tomov, E. MD Department of Vascular Surgery, Tokuda Hospital Sofia

2. Epidemiology

3. Treatment options

4. Goals of treatment Relief of significant lifestyle-limiting symptoms Limb salvage Prevention of disease progression

5. NEVER ENDING National Health Insurance Fund’s POT OF MONEY Money

6. In present days

7. Goals of treatment Relief of significant lifestyle-limiting symptoms Limb salvage Prevention of disease progression Cost of treatment

8. Difference of costs Geographic/economic difference between the countries:  Price of hospital stay  Doctor’s fee  Public medical system Marketing strategies of companies:  Different marketing strategies  Different prices of “toys”

9. Treatment options Surgery Autovenous bypass Prosthetic bypass Hybrid Endarterectomy Endarterectomy plus stenting Angioplasty Balloon angioplasty Stenting

10. We observe 110 patients All patients are treated for SFA occlusion in Department of Vascular Surgery at Tokuda Hospital Sofia, from January 2013 to December 2013 All patients are Rutherford stage 3,4 and 5 TASC II A, B, C, D First intervention for all patients Cost includes room and board, procedure-related medications and implants, ancillary departments. Does not include physician's fee.

11. Population M 61,8% (68), F 38,2% (42) Age 65,9 ± 11,2 (range: 51-87 years) Diabetes: 45,5% (50) Smokers 54,5% (60) Contralateral stenosis/occlusions of SFA 71,9% (78)

12. Treatment Surgery 47,3% (52) treated with open surgery: 34,6% (38) PTFE prosthetic graft bypass surgery 9,1% (10) Dacron UT Heparin prosthetic graft bypass surgery 3,6% (4) autograft (GSV) Hybrid 22,7% (25) treated via close TEA and implantation of stent Angioplasty 30% (33) treated with PTA: 27,3 (30) recanalisation and placing stent 2,7% (3) recanalisation and angioplasty with DEB

13. Outcomes Complications:  Cardiac 9,1% (10)  Respiratory 13,6% (15)  Wound inf./lymph. 3,6% (4)  Prosthetic inf. 1,8% (2)  Revisions:  Thrombosis 1,8% (2)  Hematoma/bleeding 4,5% (5) (Including puncture site hematoma 2) Amputations 0% Mortality0% Discharged home96,4% (106) ( 3 patients were transferred to Department of Cardiology and 1 to Department of Physiotherapy)

14. Cost analysis – hospital stay Surgery 5,8 days (range from 4,85 to 15) ~650€ (112€/day) ICU: 1 - 2 days Hybrid 4,7 days (range from 3,87 to 5,1) ~526€ (112€/day) ICU: 1 - 2 days Angioplasty 2,3 days (range from 1,85 to 4,1) ~258€ (112€/day) ICU: 0 – 1 days

15. Cost analysis – consumable Surgery ~ 765€ (317*-910€) Hybrid ~ 791€ (562-867€) Angioplasty ~ 1181€ (1063-1607€) Includes the cost of the implant – prosthesis graft (PTFE or Dacron UTH), bare-metal SE stents and DEB. * autovenous by-pass.

16. Cost analysis – total cost Surgery ~ 1482€ (1327-2704€) Hybrid ~ 1378€ (1276-1564€) Angioplasty ~ 1275€ (965-2018€) Includes the cost of the implant – prosthesis graft (PTFE or Dacron UTH), bare-metal SE stents and DEB. Does not include physician's fee.

17. Conclusions Open surgery with autovenous graft is “Gold standard” not only for patency, but also for economy Open surgery with prosthetic graft, with longer hospital stay and higher frequency of the complications is a worse economic option Endovascular treatment even with high cost implants but shortest hospital stay is an optimal economic treatment option

18. Conclusions Initial cost of treatment in hospital is not enough to make a conclusion. It is important to notice that cost of initial treatment in some cases is a small part of the final bill. For major conclusions it is necessary to add the cost of readmissions and reoperations and their frequency.