A comparison of open and endovascular revascularization for chronic mesenteric ischemia in a clinical decision model Wouter Hogendoorn, MD, M.G. Myriam.

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A comparison of open and endovascular revascularization for chronic mesenteric ischemia in a clinical decision model Wouter Hogendoorn, MD, M.G. Myriam Hunink, MD, PhD, Felix J.V. Schlösser, MD, PhD, Frans L. Moll, MD, PhD, Bart E. Muhs, MD, PhD, Bauer E. Sumpio, MD, PhD Journal of Vascular Surgery Volume 60, Issue 3, Pages 715-725.e2 (September 2014) DOI: 10.1016/j.jvs.2014.03.009 Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 1 Simplified bubble diagram of the Markov state transition model for treatment of chronic mesenteric ischemia (CMI). Each health state has a possible transition to itself that is not shown in this figure for clarity of the figure. The dotted lines indicate the start of the intervention or reintervention. EV, Endovascular revascularization; OR, open revascularization. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 2 Cost-effectiveness scatterplot of open revascularization (OR) and endovascular revascularization (EV) for treatment of chronic mesenteric ischemia (CMI) for the reference-case patients (65-year-old women). Each point represents one sample value based on the analysis of 10,000 reference-case samples in the Monte Carlo simulation. The results indicate that EV is dominant over OR because effectiveness is higher and costs are lower. See Results section for further details. QALYs, Quality-adjusted life years. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 3 Total expected quality-adjusted life-years (QALYs) for open revascularization (OR) and endovascular revascularization (EV), depending on age at initial intervention of chronic mesenteric ischemia (CMI) for the reference-case patients (65-year-old women). See Results section for further details. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 4 a, Cumulative expected reinterventions per patient after initial treatment of chronic mesenteric ischemia (CMI) for the reference-case patients (65-year-old women). See Results section for further details. b, Number of expected reinterventions depending on the age at initial intervention for CMI for the reference-case patients (65-year-old women). See Results section for further details. EV, Endovascular revascularization; OR, open revascularization. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 5 Total expected costs for open revascularization (OR) and endovascular revascularization (EV) by age at initial intervention for the reference-case patients (65-year-old women with chronic mesenteric ischemia [CMI]). Shown is that EV is more expensive until the age of 60 years. After the age of 60 years, OR is more expensive. See Results section for further details. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 6 The 95% confidence ellipse for the cost-effectiveness of endovascular revascularization (EV) vs open revascularization (OR) for 10,000 samples of the reference-case patients (65-year-old women with chronic mesenteric ischemia [CMI]). On the x-axis, the incremental quality-adjusted life-years (QALYs) for EV compared with OR. On the y-axis, the incremental costs for EV compared with OR. For each of the 10,000 samples, the difference between the QALYs (incremental QALYs) and the difference between the costs (incremental costs) for EV and OR are calculated and depicted as a dot in the figure. The circle depicts 95% of the distribution. The willingness-to-pay (WTP) of $60,000/QALY is indicated. All dots southeast of the WTP line are considered cost-effective. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 7 Acceptability curve for different willingness-to-pay threshold points for the treatment of chronic mesenteric ischemia (CMI). On the x-axis, the willingness-to-pay; and on the y-axis, the percentage of samples that is cost-effective. Shown is that even if the willingness-to-pay decreases to $0, endovascular revascularization (EV) is cost-effective in the majority of the cases compared with open revascularization (OR). Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 1 (online only) Total quality-adjusted life-years (QALYs) for treatment of chronic mesenteric ischemia (CMI) in the reference-case patient with open revascularization (OR) and endovascular revascularization (EV) for different relative risks. Expected QALYs for EV are always higher, independent of the relative risk. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 2 (online only) Total quality-adjusted life-years (QALYs) for treatment of chronic mesenteric ischemia (CMI) in the reference-case patient with open revascularization (OR) and endovascular revascularization (EV) per perioperative mortality for OR. Expected QALYs for OR are higher if perioperative mortality of OR decreases to 3.1% (in reference-case: 7.1%), if we assume that perioperative mortality for EV is still 3.6%. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 3 (online only) Two-way sensitivity analysis for perioperative mortality for endovascular revascularization (EV) and open revascularization (OR). The colored areas indicate which treatment is preferred on the basis of quality-adjusted life-years (QALYs). The reference-case is indicated with an asterisk: perioperative mortality of 7.1% for OR and 3.6% for EV. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 4 (online only) Incremental cost-effectiveness ratio (ICER) for treatment of chronic mesenteric ischemia (CMI) in the reference-case patient per age at initial intervention. The ICER of endovascular revascularization (EV) vs open revascularization (OR) had a maximum at age 50 years: $4032 per quality-adjusted life-year (QALY). After the age of 60 years, costs for EV are lower and QALYs are higher, implying that EV dominates OR. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 5 (online only) Incremental cost-effectiveness ratio (ICER) for treatment of chronic mesenteric ischemia (CMI) in the reference-case patient per length of postoperative period for open revascularization (OR). The ICER of endovascular revascularization (EV) vs OR is always below the willingness-to-pay threshold of $60,000/QALY. A longer hospitalization period than 16 days for OR results in lower costs for EV and higher quality-adjusted life-years (QALYs), implying that EV dominates OR. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 6 (online only) Total quality-adjusted life-years (QALYs) for patients with and without bowel resection. For patients with immediate bowel resection (100% chance) for chronic mesenteric ischemia (CMI), the QALYs are lower compared with patients without (0%) bowel resection. EV, Endovascular revascularization; OR, open revascularization. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 7 (online only) Total quality-adjusted life-years (QALYs) per quality of life for major morbidities for treatment of chronic mesenteric ischemia (CMI) in the reference-case patient with open revascularization (OR) and endovascular revascularization (EV). Expected QALYs for EV are always higher than for stenting and OR, regardless of the value of the quality of life for major morbidities. Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 8 (online only) Total quality-adjusted life-years (QALYs) for the treatment of chronic mesenteric ischemia (CMI) in the reference-case patient if type of reintervention after initial open revascularization (OR) is endovascular revascularization (EV), tested over a wide range (0%-100%). Journal of Vascular Surgery 2014 60, 715-725.e2DOI: (10.1016/j.jvs.2014.03.009) Copyright © 2014 Society for Vascular Surgery Terms and Conditions