LAUSR

Objective: Percutaneous access for endovascular aneurysm repair (PEVAR) is less invasive compared with surgical access (S-EVAR) and is associated with faster recovery and fewer wound complications. However, vascular closure devices (VCDs) are costly, and better understanding of the precise economic impact of P-EVAR has important implications for resource allocation. The objective was to determine the differences in cost between P-EVAR and S-EVAR. Methods: We used a decision tree to analyze costs from a payer’s perspective during the course of the index hospitalization. Probabilities, relative risks, and mean difference summary measures were obtained from a systematic review and meta-analysis. We modeled differences in surgical site infection, lymphocele, and length of hospitalization. Cost parameters were derived from the 2014 U.S. National Inpatient Sample using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Attributable costs were estimated using generalized linear models adjusted by age, sex, and comorbidities. Results: A total of 6876 abdominal and thoracic EVARs were identified. P-EVAR resulted in a cost saving of $751 per procedure. The costs were $1287 (95% confidence interval [CI], $884-$1835) for P-EVAR and $2038 (95% CI, $757-$4280) for S-EVAR. P-EVARs were converted to open repair in 4.3% of cases. P-EVAR patients had a difference of 1.4 days (95% CI, 0.12 to 2.68) in length of hospitalization at a cost of $1190/day (standard error, $298). The cost saving of P-EVAR was primarily driven by the cost difference in length of hospitalization. In the base case, four VCDs were used per P-EVAR at $200/device. In the two-way sensitivity analysis, P-EVAR was cost saving even when 1.5 times more VCDs were used per procedure and the cost of each VCD was 1.5 times greater (Fig). In our probabilistic sensitivity analysis, P-EVAR was the cost-saving strategy in 82.6% of 10,000 Monte Carlo simulations when simultaneously varying parameters across their uncertainty ranges. Conclusions: P-EVAR had lower costs compared with S-EVAR and is economically feasible.