Endovascular thrombectomy in patients with large core ischemic stroke: a cost-effectiveness analysis from the SELECT study. Journal of neurointerventional surgery Sarraj, A., Pizzo, E., Lobotesis, K., Grotta, J. C., Hassan, A. E., Abraham, M. G., Blackburn, S., Day, A. L., Dannenbaum, M. J., Hicks, W., Vora, N. A., Budzik, R. F., Sharrief, A. Z., Martin-Schild, S., Sitton, C. W., Pujara, D. K., Lansberg, M. G., Gupta, R., Albers, G. W., Kunz, W. G., SELECT Investigators 2020


BACKGROUND: It is unknown whether endovascular thrombectomy (EVT) is cost effective in large ischemic core infarcts.METHODS: In the prospective, multicenter, cohort study of imaging selection study (SELECT), large core was defined as computed tomography (CT) ASPECTS<6or computed tomography perfusion (CTP) ischemic core volume (rCBF<30%) =50cc. A Markov model estimated costs, quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER) of EVT compared with medical management (MM) over lifetime. The willingness to pay (WTP) per QALY was set at $50000 and $100000 and the net monetary benefits (NMB) were calculated. Probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEAC) for EVT were assessed in SELECT and other pivotal trials.RESULTS: From 361 patients enrolled in SELECT, 105 had large core on CT or CTP (EVT 62, MM 43). 19 (31%) EVT vs 6 (14%) MM patients achieved modified Rankin Scale (mRS) score 0-2 (OR 3.27, 95%CI 1.11 to 9.62, P=0.03) with a shift towards better mRS (cOR 2.12, 95%CI 1.05 to 4.31, P=0.04). Over the projected lifetime of patients presenting with large core, EVT led to incremental costs of $33094 and a gain of 1.34 QALYs per patient, resulting in ICER of $24665 per QALY. EVT has a higher NMB compared with MM at lower (EVT -$42 747, MM -$76 740) and upper (EVT $155 041, MM $57 134) WTP thresholds. PSA confirmed the results and CEAC showed 77% and 92% acceptability of EVT at the WTP of $50000 and $100 000, respectively. EVT was associated with an increment of $29225 in societal costs. The pivotal EVT trials (HERMES, DAWN, DEFUSE 3) were dominant in a sensitivity analysis at the same inputs, with societal cost-savings of $37 901, $86164 and $22501 and a gain of 1.62, 2.36 and 2.21 QALYs, respectively.CONCLUSIONS: In a non-randomized prospective cohort study, EVT resulted in better outcomes in large core patients with higher QALYs, NMB and high cost-effectiveness acceptability rates at current WTP thresholds. Randomized trials are needed to confirm these results.CLINICAL TRIAL REGISTRATION: NCT02446587.

View details for DOI 10.1136/neurintsurg-2020-016766

View details for PubMedID 33188155