Early exploration of the economic impact of transradial access (TRA) versus transfemoral access (TFA) for neurovascular procedures in Spain

Figures & data

Figure 1. Modelling approach for diagnostic and therapeutic procedures.

Table 1. Diagnostic procedure success rate, times and contrast volume, and complications.

a) Diagnostic procedure success rate
Literature data
Input	TRA	TFA	Source
Procedure success rate	96.8%	98.7%	Stone et al.^22 Proportion that required a crossover.
Data used
Input	TRA	TFA	Source
Procedure success rate	Average: 95.8% Min-Max: 95%-97%	Average: 99.2% Min-Max: 98.6%-100%	Data based on expert consensus.
b) Diagnostic procedure time and contrast volume
Literature data
Input	TRA	TFA	Source
Procedure time (minutes)	66	67	Stone et al.^22
Contrast volume (mls)	143	140	Stone et al.^22
c) Diagnostic procedure complication rates
Literature data
Input	TRA	TFA	Source
Access site haematoma	1.5%	22.8%	Catapano et al.^20
Vessel perforations	0.0%	2.9%	Catapano et al.^20
Intracranial haemorrhage	0.0%	1.0%	Catapano et al.^20
Occlusive femoral artery	0.0%	1.0%	Catapano et al.^20
Retroperitoneal bleed	0.0%	0.5%	Catapano et al.^20
Thromboembolic event	0.5%	1.0%	Catapano et al.^20
Nerve injury	0.0%	0.4%	Oneissi 2020^a^, ^32
Wound infection	0.0%	0.4%	Oneissi 2020^a^, ^32
Access site local pain	1.3%	1.9%	Stone et al.^22
Vasospasm	0.6%	0.0%	Stone et al.^22
Data used
Input	TRA	TFA	Source
Access site haematoma	Average: 1.79 Min–Max: 0.51%–5%	Average: 5.34% Min–Max: 4%–8.4%	Data based on expert consensus.
Vessel perforations	Average: 0.89% Min–Max: 0%–2.5%	Average: 0.2% Min–Max: 0%–0.71%
Occlusive artery	Average: 0.26% Min–Max: 0%–1.06%	Average: 0.46% Min–Max: 0%–0.5%
Retroperitoneal bleed	0%	Average: 0.11% Min–Max: 0%–2%
Thromboembolic event	Average: 0.43% Min–Max: 0%–2%	Average: 0.44% Min–Max: 0%–2%
Nerve injury	Average: 0.0025%	Average: 0.0022%
Access site local pain^a	1.3%	1.9%	Stone et al.^22
Vasospasm	Average: 2.2% Min–Max:0.7%–7.18%	0.0%	Data based on expert consensus.

^a Very subjective variable. Low-cost management.

Table 2. Therapeutic procedure success rate, times and contrast volume, and complications.

a) Diagnostic procedure success rate
Literature data
Input	TRA	TFA	Source
Procedure success rate	98.5%	98.7%	Catapano et al.^20 Proportion that required a crossover.
Data used
Input	TRA	TFA	Source
Procedure success rate	Average: 97.6% Min–Max: 90%–100%	Average: 98.6% Min–Max: 95%–100%	Data based on expert consensus.
b) Diagnostic procedure complication rates
Literature data
Input	TRA	TFA	Source
Access site haematoma	1.5%	22.8%	Catapano et al.^20
Vessel perforations	0.0%	2.9%	Catapano et al.^20
Intracranial haemorrhage	0.0%	1.0%	Catapano et al.^20
Occlusive femoral artery	0.0%	1.0%	Catapano et al.^20
Retroperitoneal bleed	0.0%	0.5%	Catapano et al.^20
Thromboembolic event	0.5%	1.0%	Catapano et al.^20
Nerve injury	0.0%	0.4%	Oneissi 2020^32
Access site local pain	1.3%	1.9%	Stone et al.^22
Vasospasm	0.6%	0.0%	Stone et al.^22
Data used
Input	TRA	TFA	Source
Access site haematoma	0.38% Min–Max: 0%–1.1%	6% Min–Max: 5%–7%	Data based on expert consensus.
Vessel perforations	0%	0.8% Min–Max: 0%–3%	Data based on expert consensus
Intracranial haemorrhage	0.1% Min–Max: 0%–0.5%	0.49% Min–Max: 0%–1.75%	Data based on expert consensus.
Occlusive artery	0.2%	0.43%	Catapano et al.^20
Retroperitoneal bleed	NA	0.4% Min–Max: 0%–1.75%	Data based on expert consensus.
Thromboembolic event	0.2%	0.43%	Data based on expert consensus.
Nerve injury^a	0.0025% Min–Max: 0%–1.75%	0.0022% Min–Max: 0%–1.75%	Data based on expert consensus.
Access site local pain^b	1.3%	1.9%	Stone et al.^22, Expert consensus.
Vasospasm^b	0.63%	0.0%	Stone et al.^22, Expert consensus.

^a Very low incidence. Same as diagnostic.

^b (Same as in the diagnostic part).

Table 3. Costs.

Procedure Materials	Unitary cost	Source
Diagnostic-Catheter (TRA)	€248.00	Data based on expert consensus.
Diagnostic-Catheter (TFA)	€214.40
Therapeutic-Catheter (TRA)	€600
Therapeutic-Catheter (TFA)	€500
Additional cost of crossover TRA	€229
Additional cost of crossover TFA	€372
Closure device (TFA)	€181
Radial compression device	€35
Introducer TRA	€30
Introducer TFA	€15.73
Medication	€10
Ultrasound	€59
Recovery
Bed day (ambulatory)	€57	Calculated as a pro-rata of bed day.
Bed day (non-critical bed)	€680	Spanish Cost Database, e-salud. Oblikue consulting: http://www.oblikue.com/bddcostes/. Accessed Aug 2022
Complications
Access site haematoma^a	€2.5	Spanish Cost Database, botplus: https://botplusweb.farmaceuticos.com/. Accessed Aug 2022
Vessel perforations (femoral)	€9865	Spanish Cost Database, e-salud. Oblikue consulting: http://www.oblikue.com/bddcostes/. Accessed Aug 2022
Vessel perforations (radial)	€1973
Intracranial haemorrhage	€10,148
Occlusive artery (femoral)	€3369
Occlusive artery (radial)	€1
Retroperitoneal bleed (TFA)	€3476
Thromboembolic event	€5852
Nerve injury^b	€75
Access site local pain^a	€2.5	Spanish Cost Database, botplus: https://botplusweb.farmaceuticos.com/. Accessed Aug 2022
Vasospasm^c	€6	Spanish Cost Database, botplus: https://botplusweb.farmaceuticos.com/. Accessed Aug 2022

^a Paracetamol, pain relief only.

^b 4 physiotherapy sessions.

^c BNF 5 mg of verapamil and one 400 micrograms sublingual glyceryl trinitrate spray.

Table 4. Model results: Diagnostic procedures.

a) Differential costs for diagnostic procedures
Base case (120 min TRA vs 1-night TFA)	Radial access	Femoral access	Incremental
Cost per patient	€ 637	€ 1066	−€ 429
Total cost per cohort	€ 6,365,363	€ 10,655,885	−€ 4,290,522
Alternative analysis 1 (60 min TRA vs 1-night TFA)
Cost per patient	€ 580	€ 1066	−€ 486
Total cost per cohort	€ 5,795,390	€ 10,655,885	−€ 4,860,494
Alternative analysis 2 (60 min TRA vs 8 h TFA)
Cost per patient	€ 580	€ 793	−€ 214
Total cost per cohort	€ 5,795,390	€ 7,932,551	−€ 2,137,161
Alternative analysis 3 (60 min TRA vs 6 h TFA)
Cost per patient	€ 580	€ 737	−€ 157
Total cost per cohort	€ 5,795,390	€ 7,365,885	−€ 1,570,494
b) Diagnostic procedure base-case cost breakdown
Category	Radial access	Femoral access	Incremental
Procedure costs (Materials for access only)	€ 471	€ 321	€ 150
Recovery	€ 114	€ 680	−€ 566
Complications	€ 52	€ 65	−€ 13
Total cost	€ 637	€ 1,066	−€ 429
c) Clinical outcomes base-case for diagnostic procedures
Category	Radial access	Femoral access	Incremental
Number of catheterisations without crossover	9580	9920	−340
Recovery time (hours)	20,000	240,000	−220,000
Number of complications	687	845	−158

Figure 2. Results diagnostic deterministic sensitivity analysis (Tornado diagram, base case, ±15% variation).

Figure 3. Results diagnostic deterministic sensitivity analysis (Tornado diagram, base case, variation based on expert panel min/max values).

Table 5. Model results: Therapeutic procedures.

a) Differential costs for therapeutic procedures
Base case (without length of stay)	Radial access	Femoral access	Incremental
Cost per patient	€ 812.4	€ 790.8	€ 21.6
Total cost per cohort	€ 812,397.7	€ 790,836.7	€ 21,561.0
Alternative analysis 1 (1-night TRA vs 2-nightsTFA)
Cost per patient	€ 1492	€ 2151	−€ 658
Total cost per cohort	€ 1,492,396	€ 2,151,838	−€ 658,442
b) Therapeutic procedure base-case cost breakdown
Category	Radial access	Femoral access	Incremental
Procedure costs (Materials for access only)	€ 783.7	€ 608.4	€ 175.3
Recovery	–	–	–
Complications	€ 28.7	€ 182.4	−€ 153.7
Total cost	€ 812.4	€ 790.8	€ 21.6
c) Clinical outcomes base-case for therapeutic procedures
Category	Radial access	Femoral access	Incremental
Number of catheterisations without crossover	976	986	−10
Number of complications	28.13	104.52	−76.40

Figure 4. Results therapeutic deterministic sensitivity analysis (Tornado diagram, base case).

Stone JG, Zussman BM, Tonetti DA, et al. Transradial versus transfemoral approaches for diagnostic cerebral angiography: a prospective, single-center, non-inferiority comparative effectiveness study. J Neurointerv Surg. 2020;12(10):993–998. doi: 10.1136/neurintsurg-2019-015642.

 PubMed Web of Science ®Google Scholar

Catapano JS, Fredrickson VL, Fujii T, et al. Complications of femoral versus radial access in neuroendovascular procedures with propensity adjustment. J Neurointerv Surg. 2020;12(6):611–615. doi: 10.1136/neurintsurg-2019-015569.

 PubMed Web of Science ®Google Scholar

Oneissi M, Sweid A, Tjoumakaris S, et al. Access-site complications in transfemoral neuroendovascular procedures: a systematic review of incidence rates and management strategies. Oper Neurosurg. 2020;19(4):353–363. doi: 10.1093/ons/opaa096.

 Web of Science ®Google Scholar

Data availability statement

The manuscript and supplement included all relevant data.