A cost-effectiveness analysis of infrainguinal bypass in the absence of great saphenous vein conduit

Background: Good-quality great saphenous vein (GSV) is the preferred conduit for infrainguinal surgical revascularizations, but it is not available in all patients. We sought to identify the alternative conduit that would maximize cost-effectiveness in the context of infrapopliteal bypass for critical limb ischemia and nonhealing foot wounds. Methods: A Markov model was used to create a detailed simulation of 10-year outcomes in a hypothetical Edifoligide for the Prevention of Infrainguinal Vein Graft Failure (PREVENT) III-type patient cohort undergoing infrainguinal bypass for nonhealing foot wounds. The following management options were evaluated: (1) conservative therapy (local wound care, amputation as needed); (2) primary amputation; (3) bypass with autologous alternative vein (AAV), including arm or lesser saphenous vein; (4) bypass with GSV <3 mm in diameter; (5) bypass with polytetrafluoroethylene (PTFE); (6) cryopreserved venous allograft; and (7) cryopreserved arterial allograft. Estimates of 10-year total costs were incorporated into the model. Cost-effectiveness was measured in terms of incremental United States dollars per additional year of ambulation. Results: Bypass with AAV had the highest effectiveness as measured in median years of ambulation. After primary amputation, bypass with PTFE had the lowest total costs. With incremental cost-effectiveness ratios of $5325 and $21,228, bypass with PTFE or AAV appeared to be cost-effective alternatives to conservative therapy for nonhealing ischemic wounds. Primary amputation, GSV <3 mm, and allograft options were dominated (ie, more costly and less effective). Primary amputation was weakly dominated. Conclusions: Bypass with PTFE or AAV appears to be a cost-effective option for the management of critical limb ischemia and nonhealing foot wounds when good-quality GSV is not available.