Cost-effectiveness of Endovascular Versus Open Arteriovenous Fistula Creation in the United States

In the United States, an estimated $1 billion annually is spent on vascular access and its complications. Endovascular arteriovenous fistula (endoAVF) creation is a novel, minimally invasive alternative to traditional surgical AVF (sAVF) creation in up to 60% of patients. Although cost effective in single-payer systems, the clinical and financial impact of endoAVF in the United States remains uncertain. We constructed a decision tree followed by a probabilistic cohort state-transition model to study the cost effectiveness of endoAVF versus sAVF creation. We conducted a systematic review to obtain input parameters including technical success, maturation, patency, and utility values. We derived costs from the Medicare 2022 fee schedule and from the literature. We used a 5-year time horizon, an annual discount rate of 3% for costs and utilities (measured in quality-adjusted life-years, QALYs), and the common willingness-to-pay threshold of $50,000. One-way sensitivity analyses varied technical success, patency, reintervention, cost, and utility parameters. In the base-case scenario, endoAVF ($24.9 million costs; 1177 QALYs; 74% patent at 5 years) was not cost effective compared with sAVF ($9.5 million costs; 1142 QALYs; 68% patent at 5 years), generating an incremental cost-effectiveness ratio (ICER) of $441,641 per QALY gained. EndoAVF only becomes cost effective when the initial cost of sAVF creation exceeds endoAVF by at least $950 (eg, if endoAVF creation costs ≤$2650 relative to the base-case sAVF cost of $3600), the additional QALYs gained from endoAVF exceeds 0.2 QALYs/year (eg, 0.89 QALYs gained/year from endoAVF compared with base-case sAVF 0.69 QALYs/year), the sAVF primary-assisted patency rate is less than 35% (base case 73%), or the sAVF maturation rate is less than 55% (base case 78%) (Fig). EndoAVF is not cost effective compared with sAVF when modeling 5-year outcomes. The main drivers of sAVF remaining cost effective are the four times higher up-front cost for endoAVF creation, as well as a relatively low initial maturation rate and low primary unassisted patency rate for endoAVF. It will be important to establish how the endoAVF learning curve contributes to up-front costs and given the annual cost attributed to vascular access, a randomized controlled trial is warranted.