Southern Association For Vascular Surgery

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Contemporary Clinical and Financial Analysis of Open versus Percutaneous Mechanical Thrombectomy for Occluded Hemodialysis Access
Lynellen B. Gregory, Oscar H. Grandas, Isson T. Tayidi, Michael R. Buckley, Joshua A. Arnold, Alex W. Cantafio, Scott L. Stevens, Michael B. Freeman, Mitchell H. Goldman, Michael M. McNally

Systematic literature reviews remain inconclusive on defining optimal thrombectomy methods to treat occluded hemodialysis access. Recent changes in CMS bundling/reimbursement for endovascular thrombectomy procedures has led to renewed interest in delivering cost effective care. Percutaneous mechanical rotational thrombectomy devices(Cleaner XL=RT) have been developed to compete with traditional pharmacomechanical thrombectomy devices(Angiojet with TPA=PMT) for percutaneous thrombectomy procedures. The objective of this study was to evaluate clinical and economic factors of open surgical thrombectomy(OST) compared with contemporary percutaneous mechanical thrombectomy(PERC) devices for thrombosed hemodialysis vascular access.
Data analysis was performed from a tertiary care hospital prospectively maintained hemodialysis database between 2012-2016. All patients undergoing outpatient thrombectomy for occluded hemodialysis access were captured. Clinical endpoints included arteriovenous access type, thrombectomy method, operative time, estimated blood loss and intervention success rates. Financial endpoints included direct cost, total cost, operating margin and total margin. Additional subgroup analysis of the percutaneous thrombectomy group was performed to compare pharmacomechanical to rotational techniques. Analysis using univariate and multivariate measures was performed with significance assigned as p<0.05.
Between 2012-2016, 1072 hemodialysis arteriovenous accesses(88.3% AVF n=947, 11.7% AVG, n=125) were created. 391 patients required thrombectomy(OST n=64, PERC n=327). 670 thrombectomy procedures were performed(OST n=71, PERC n= 599). Arteriovenous graft was the predominant type of access requiring thrombectomy(77%AVG n=506 vs 23%AV F n=151;OST 97.2%, PERC 74.5%,ns). Most accesses were in the upper extremity(Upper Ext 90.7% n =592, Lower Ext 9.3% n= 60;OST 87.5%, PERC 91.2%,ns). Despite more diabetic patients treated with PERC, no other statistical difference between groups was observed in gender or comorbidities including HTN, CAD, CHF, tobacco abuse or hypercoagulable disorder. Concurrent intervention with outflow venous angioplasty was the most common single intervention(52.7%). Each thrombectomy method had high technical success rates(OST 95.8%, PERC 95.7%,ns). Subgroup analysis between percutaneous methods(42.7% RT n= 256, 53.1%PMT n= 318, 4.2% RT+PMT n=25) showed RT therapy had lower EBL(p<0.001) and shorter operative time(RT 48min, PMT 52 min,p<0.03). The highest successful thrombectomy rate was RT(97.7% RT vs 94.7%, p<0.07). Financially all economic endpoints, specifically direct supply cost(OST $3334, RT $3241, PMT $3529, RT+PMT $4414, p<0.001), total cost(OST $7220, RT $6291, PMT $7317, RT+PMT $9735 p=0.001), operating margin(OST $1331, RT $-360, PMT $-311, RT+PMT $-1154, p<0.001) and total margin(OST $-894, RT $-2200, PMT $-2902, RT+PMT $-4596, p<0.001) favored OST therapy.
With equal success rates between hemodialysis access thrombectomy methods, RT has the lowest operating and total cost, while open surgical thrombectomy has significantly better profit margins in a hospital based setting. All thrombectomy procedure types had a negative profit margin in an outpatient hospital based setting. Percutaneous mechanical thrombectomy utilizing RT decreases operative time, blood loss and cost compared to pharmacomechanical thrombectomy. Combination percutaneous thrombectomy leads to the greatest financial loss compared to any single therapy. With recent reimbursement/bundling changes for percutaneous hemodialysis thrombectomy, open surgical thrombectomy should be considered as first line treatment for occluded hemodialysis access in a hospital based setting, while RCT may be more cost efficient in office based settings as the cost profile is more favorable.

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