REVASCULARIZATION FOR FEMOROPOPLITEAL DISEASE - A DECISION AND COST-EFFECTIVENESS ANALYSIS

Objective.-To evaluate the relative benefits and cost-effectiveness of revascularization for femoropopliteal disease using percutaneous tran sluminal angioplasty or bypass surgery. Design.-Decision analysis usin g a multistate transition simulation model (Markov process) and cost-e ffectiveness analysis from the perspective of the health care system. Setting.-Based on mortality, morbidity, patency, and cost data from a literature review. Patients.-Hypothetical cohort of patients with chro nic femoropopliteal disease who desire revascularization. Subgroup ana lysis for patients defined by age, sex, indication, lesion type, and g raft type. Interventions.-Percutaneous transluminal angioplasty, bypas s surgery, and a strategies combining the two treatments. Main Outcome Measures.-Five-year patency results, quality-adjusted life expectancy , lifetime costs, and incremental cost-effectiveness ratios. Results.- For 65-year-old men with disabling claudication and a femoropoptiteal stenosis or occlusion and for 65-year-old men with chronic critical is chemia and a femoropopliteal stenosis, initial angioplasty increased q uality-adjusted life expectancy by 2 to 13 months and resulted in decr eased lifetime expenditures compared with bypass surgery. For patients with chronic critical ischemia and a femoropopliteal occlusion, initi al bypass surgery increased quality-adjusted life expectancy by 1 to 4 months and resulted in decreased lifetime expenditures compared with angioplasty. Sensitivity analysis demonstrated that angioplasty would always be the preferred initial treatment if the angioplasty 5-year pa tency rate exceeds 30%. Conclusion.-Angioplasty is the preferred initi al treatment in patients with disabling claudication and a femoropopli teal stenosis or occlusion and in those with chronic critical ischemia and a stenosis. Bypass surgery is the preferred initial treatment in patients with chronic critical ischemia and a femoropopliteal occlusio n.