Mechanical Venous Thrombectomy Is a Cost-effective Treatment for Iliofemoral Deep Vein Thrombosis

Abstract

Mechanical venous thrombectomy (MVT) has gained popularity as an alternative to catheter-directed thrombolysis (CDL) and medical management (MM) of iliofemoral deep vein thrombosis (DVT), potentially combining the benefits of a minimally invasive approach with a lower risk of bleeding and shorter hospital stay. Emerging evidence shows MVT to have excellent perioperative outcomes. However, the cost effectiveness of MVT is not well-understood. Incorporating data from ATTRACT Trial, retrospectively published data, and local cost data, we compared the cost-effectiveness of these three treatment modalities (MVT, CDL, and MM) for iliofemoral DVT using a Markov state transition model to quantify lifetime costs in 2022 US dollars and effectiveness in quality-adjusted life-years (QALYs). We accounted for perioperative bleeding, long-term risks of post-thrombotic syndrome (PTS) and reintervention. Based on ATTRACT, we assumed a start age of 51 and a cost-effectiveness acceptability threshold or willingness-to-pay of $100,000/QALY gained. Sensitivity analyses were performed. A treatment that was dominated when it was both less effective and more costly than other options. In the base case scenario, MVT cost $20,238/QALY gained compared with MM, well below the frequently cited $100,000/QALY gained threshold. CDL was dominated by being more expensive and less effective than other strategies, largely due to a greater periprocedural bleeding risk (Table). In one-way sensitivity analysis, if severe PTS risk after MVT was >9.0% (base case risk, 3.4%), then it would no longer be economically favorable compared with MM at its current procedural cost. In a probabilistic sensitivity analysis, varying all parameters simultaneously over distributions, MVT was favored in 33.6% of model iterations at $100,000/QALY (Figure). At current cost and outcomes, MVT appears to be a cost-effective intervention for iliofemoral DVT compared to anticoagulation alone. Despite marginal decreases in long-term PTS rates, CDL does not meet the traditional cost-effectiveness threshold. Patients with iliofemoral DVT should be considered for MVT from a cost-effectiveness perspective.TableCosts and utilities associated with different treatment optionsStrategyCost ($)Incremental cost increase ($)EffectivenessIncremental effectivenessICERMM83,6659.22MVT93,73910,0749.710.5020,237.94CDL130,563368,428.88−0.84−44,054.63DominatedCDL, catheter-directed lysis; ICER, incremental cost-effectiveness ratio; MM, medical management; MVT, mechanical venous thrombectomy. Open table in a new tab