Periprocedural Cost-Effectiveness Analysis of Mechanical Thrombectomy for Acute Ischemic Stroke in the Stent Retriever Era

Abstract

Background: Early reperfusion is critical for favorable outcomes in acute ischemic stroke (AIS). Stent retrievers lead to faster and more complete reperfusion than previous technologies. Our aim is to compare the cost-effectiveness of stent retrievers to the previous mechanical thrombectomy devices. Methods: Retrospective review of endovascularly treated large-vessel AIS. Data from all consecutive patients who underwent thrombectomy from January 2012 through November 2012 were collected. Baseline characteristics, the total procedural cost, the rates of successful recanalization [modified thrombolysis in cerebral ischemia (mTICI) scores of 2b or 3], and the length of stay at the hospital were compared between the stent retriever (SR) and the non-stent retriever (NSR) groups. Results: After excluding the patients who underwent concomitant extracranial stenting (n = 22) or received intra-arterial tissue plasminogen activator only (n = 6), the entire cohort included 150 patients. The cost of the reperfusion procedure was significantly higher in the SR compared to the NSR group (USD 13,419 vs. 9,308, p <0.001). We were unable to demonstrate a statistically significant difference in the rates of mTICI 2b/3 reperfusion (81 vs. 74%, p = 0.337) or the length of stay (11.1 ± 9.1 vs. 12.8 ± 9.6 days, p = 0.260) amongst the SR and the NSR patients. Conclusion: The procedural costs of thrombectomy for AIS are increasing and account for the bulk of hospitalization reimbursement. The impact of these expenditures in the long-term sustainability of stroke centers deserves greater consideration. While it is likely that the SR technology results in higher rates of optimal reperfusion, better clinical outcomes, and shorter lengths of stay, larger studies are needed to prove its cost-effectiveness.

Total time of operation is a risk factor of stroke-associated pneumonia in acute ischemic stroke patients with intra-arterial treatment

“…[1,7] Identifying patients with the highest risk of developing SAP may be helpful for treatment and prevention.…”

Clinical, angiographic and radiographic outcome differences among mechanical thrombectomy devices: initial experience of a large-volume center

“…Thus, the clinical implication of higher rates of complete reperfusion with SR remains unclear, and future analyses with larger sample sizes are required to determine if such an impact on clinical outcomes exists. This is particularly important when taking into account the added cost of SR to stroke therapy, which we reported previously to be approximately $4000 more expensive than the older mechanical thrombectomy devices 26. Nevertheless, we have demonstrated in a multivariate analysis that the use of SR could potentially be an independent predictor of good functional outcome at 90 days (table 4).…”

Logistical and financial obstacles for endovascular therapy of acute stroke implementation

“…While the industry investments in research and development, healthcare personnel education, and clinical studies have been substantial and essential to the development of the field, the consumption of such high proportion of the reimbursement by devices alone represent a major threat to the long-term sustainability of endovascular stroke centers. 43…”