Health Economic Impact of Incomplete Reperfusion Patterns After Endovascular Thrombectomy in Acute Ischemic Stroke

Background and Purpose: Incomplete reperfusion in endovascular thrombectomy (EVT) impacts patients’ outcomes. Different incomplete reperfusion patterns may benefit from targeted therapeutic strategies, e.g. EVT-accessible incomplete reperfusion patterns could improve by performing additional EVT attempts, while EVT-non-accessible incomplete patterns might benefit from pharmacological therapies. The health-economic implications of these therapies are uncertain. This study aims to assess the potential economic benefits of improving incomplete reperfusion patterns after EVT. Materials and Methods: Retrospective Data analysis from the ESCAPE-NA1 trial, which included patients with large vessel occlusion strokes undergoing EVT. Reperfusion patterns were classified as near-/complete (eTICI 2c3), EVT-accessible incomplete (eTICI 2b), or EVT-non-accessible incomplete (eTICI 2b) and we compared multiple attempts to achieve eTICI 2c3 vs. first-pass eTICI 2c3. A Markov-Model was built to compare lifetime costs and quality adjusted life-years (QALY) for each reperfusion pattern over a lifetime horizon, considering both healthcare and societal perspectives. Results: A total of 1105 of patients were enrolled in the ESCAPE-NA1 trial of which 949 with eTICI 2b, 2c and 3 were further analyized (mean age 70.7 ± 13.6 [SD]; 463 female). Near-Complete reperfusion (eTICI 2c3) was achieved in 506/1105 patients (45.8%). Incomplete reperfusion patterns (eTICI 2b) were found in 450/1105 (40.7%) patients. Angiography imaging could be further investigated in 443/450 (98.4%) cases with 147/443(33.2%) EVT-accessible and 296/443(66.8%) EVT-non-accessible incomplete reperfusion patterns. Compared to EVT-accessible and EVT-non-accssible incomplete reperfusion, achieving complete (eTICI 2c3) reperfusion resulted in lower costs and an additional 1.14/0.45 QALYs, making it the dominant strategy from a health-economic perspective. In the complete reperfusion (eTICI 2c3) group, cumulative lifetime QALYs were similar with 5.25 for single-pass eTICI 2c3 and 5.19 for multi-pass eTICI 2c3. Conclusions: Improving incomplete reperfusion patterns after EVT has considerable potential health economic benefits, both in the presence and absence of a target occlusion that is amenable to EVT.