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Surgical Bypass Summit — Session 5:
Open surgery versus endovascular revascularization; will cost play a role in the decision? — Michael Stoner, MD

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Michael Stoner, MD

Vascular care in the United States is largely supply-driven care that is not supported by robust science. This is because most randomized controlled trials fail to have external validity and are therefore not useful for science-based decision making. Thus, in the absence of quality science, advances in vascular care are driven by technological improvements and the lateral diffusion of technology. Patients, however, expect their surgeon to guide them to the safest and most effective procedure possible. Most patients do not care about the cost of the procedure because they are typically not the ones paying for it, so therefore their decision making is not driven by cost.

Figure 1.  Increased incidence of below-knee target and more severe TASC grade lesions in patients undergoing bypass after failed endovascular therapy.

Figure 1.  Increased incidence of below-knee target and more severe TASC grade lesions in patients undergoing bypass after failed endovascular therapy.

At first glance, an endovascular-first strategy appears to be a cost-saving approach to the treatment of peripheral artery disease (PAD). Moreover, many surgeons who use an endovascular-first strategy do so based upon the belief that a failed endovascular approach can be easily followed with surgical bypass. In actuality, a subset of patients who experience early failure with endovascular therapy develop more complex lesions (Figure 1). The patients then have a higher TASC grade and more distal targets. There are conflicting data about the outcomes for such patients, a group that is composed of more complex cases after failed endovascular therapy. Studies have attempted to determine if the more complicated cases reflect disease progression or are directly caused by endovascular therapy. A comparison of the subset of patients who received primary surgical revascularization versus those who received secondary surgical revascularization revealed that with regard to primary assisted patency, patients who underwent primary surgical revascularization had 75% primary assisted patency, whereas patients who underwent secondary surgery had 53% primary assisted patency. Limb salvage and tissue loss were also inferior in patients with critical limb ischemia who had a failed endovascular procedure and then went on to receive a surgical bypass.

The economic burden of reintervention may also provide a context for the creation of an endovascular treatment paradigm that reimburses based on patient value. An ideal organization for delivering such cost-efficient treatment would emphasize tighter collaboration between hospitals and providers and would create constant performance reporting and payment realignment for value. This has been proposed for the Centers for Medicare & Medicaid Services percutaneous coronary intervention pilot sites.


Patients’ lack of financial stake in the therapy is a weakness in current health care reform. Patients who have a financial stake in their therapy will place an increased value on durability, patency, and quality of life. Until the system has changed to incorporate patients as payors, surgeons must make pragmatic choices to use medication and technology, and to select patients for the appropriate therapy.

Michael Stoner, MD, is from University of Rochester in Rochester, New York. He has disclosed that he has received compensation from Gore for participating in the Summit and has received honoraria from Gore for writing this article. Dr. Stoner may be reached at