Procedural and 12-month in-hospital costs of primary infrapopliteal bypass surgery, infrapopliteal best endovascular treatment, and major lower limb amputation for chronic limb threatening ischemia

Objective: Chronic limb-threatening ischemia (CLTI) is a growing global problem due to the widespread use of tobacco and increasing prevalence of diabetes. Although the financial consequences are considerable, few studies have compared the relative cost-effectiveness of different CLTI management strategies. The Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL)-2 trial is randomizing patients with CLTI to primary infrapopliteal (IP) vein bypass surgery (BS) or best endovascular treatment (BET) and includes a comprehensive within-trial cost-utility analysis. The aim of this study is to compare over a 12-month time horizon, the costs of primary IP BS, IP best endovascular treatment (BET), and major limb major amputation (MLLA) to inform the BASIL-2 cost-utility analysis. Methods: We compared procedural human resource (HR) costs and total in-hospital costs for the index admission, and over the following 12-months, in 60 consecutive patients undergoing primary IP BS (n = 20), IP BET (n = 20), or MLLA (10 transfemoral and 10 transtibial) for CLTI within the BASIL prospective cohort study. Results: Procedural HR costs were greatest for BS (BS 2551; pound 95% confidence interval [CI], 1934- pound 2807 pound vs MLLA 1130; pound 95% CI, 1046- pound 1297 pound vs BET 329; pound 95% CI, 242- pound 390; pound P <.001, Kruskal-Wallis) due to longer procedure duration and greater staff requirement. With regard to the index admission, MLLA was the most expensive due to longer hospital stay (MLLA 13,320; pound 95% CI, 8986- pound 18,616 pound vs BS 8714; pound 95% CI, 6097- pound 11,973 pound vs BET 4813; pound 95% CI, 3529- pound 6097; pound P <.001, Kruskal-Wallis). The total cost of the index admission and in-hospital care over the following 12 months remained least for BET (MLLA 26,327; pound 95% CI, 17,653- pound 30,458 pound vs BS 20,401; pound 95% CI, 12,071- pound 23,926 pound vs BET 12,298; pound 95% CI, 6961- pound 15,439; pound P <.001, Kruskal-Wallis). Conclusions: Over a 12-month time horizon, MLLA and IP BS are more expensive than IP BET in terms of procedural HR costs and total in-hospital costs. These economic data, together with quality of life data from BASIL-2, will inform the calculation of incremental cost-effectiveness ratios for different CLTI management strategies within the BASIL-2 cost-utility analysis.