Technology assessment in the development of guidelines for vascularising the ischaemic leg

Critical leg ischaemia can be treated by amputation of the affected leg or by reconstruction of the arteries. Arterial reconstruction is perceived to be an expensive procedure, often requiring more than one operation, which does not always prevent amputation. However, amputation is associated with long term costs of rehabilitation and social support. A retrospective analysis was undertaken of 337 patients receiving initially arterial reconstruction or amputation between 1985 and 1989, a minimum of one year follow-up being obtained. Data were collected on the success of grafts, reoperation rates, type and rate of complications, hospital inpatient resource use and costs, subsequent rehabilitation and social support, and patient outcomes in terms of mobility and survival. A decision theoretic approach was used to assess the relative cost-effectiveness of distal reconstruction versus amputation, proximal reconstruction versus amputation and all reconstruction versus amputation. Overall, arterial reconstruction showed an expected net saving of £2730 per patient over amputation. Proximal grafts showed a saving of £3800 per patient and distal grafts a small net cost of £525. This net cost needs to be considered alongside any gains in social mobility and quality of life. This approach can be used to develop guidelines for arterial construction and data on outcomes and cost from other units could be used to assess cost-effectiveness in different locations.