Cost-effectiveness of intra-arterial thrombolytic therapy
L. J. Dacey, R. W. Dow, M. D. McDaniel, D. B. Walsh, R. M. Zwolak and J. L. Cronenwett
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Hanover, NH 03756.
We reviewed the clinical course of 23 patients who received 24
intra-arterial infusions of either streptokinase or urokinase to treat 14
arteries and ten arterial grafts that were occluded due to primary
thrombosis (22) or artery-artery embolism (two). Time from symptom onset to
treatment was one to 28 days (mean, 11 days). Five infusions (21%) were
completely successful since symptoms were eliminated without subsequent
operation. Seven infusions (29%) were partially successful since
thrombolysis aided, limited, or postponed subsequent surgery. Six infusions
(25%) were failures since thrombolysis or clinical improvement did not
occur and surgery was required. Six infusions (25%) were associated with
thrombolytic complications that required urgent operation (less severe
complications occurred in an additional 17% of cases [4/24]). Of the 19
patients without complete success after thrombolytic therapy, 16 underwent
surgery during the same admission, two were not operable due to distal
disease, and one declined operation. Of the 16 operations, 15 (94%) were
successful in restoring graft or artery patency and achieving limb salvage,
whereas one failed. In the 12 patients with failure or major complications
of thrombolytic treatment, all had successful surgical outcome without
morbidity. The actual mean cost of thrombolytic treatment was $8200 per
patient and was comparable with the actual mean cost of subsequent surgical
treatment in the 16 patients who required operation ($8900 per patient).
The effective cost of thrombolytic and surgical treatment was calculated by
dividing the actual costs by the proportion of successful cases. The
effective cost of thrombolytic therapy per complete success was $39,200 and
per complete or partial success was $16,500. This was significantly more
than the effective cost of $9400 per complete success of surgical therapy.
