Background Transradial artery (TRA) access for neuroendovascular procedures is associated with fewer complications than transfemoral artery (TFA) access. This study compares hospital costs associated with TRA access to those associated with TFA access for neurointerventions.
Methods Elective neuroendovascular procedures at a single center were retrospectively analyzed from October 1, 2018 to May 31, 2019. Hospital costs for each procedure were obtained from the hospital financial department. The primary outcome was the difference in the mean hospital costs after propensity adjustment between patients who underwent TRA compared with TFA access.
Results Of the 338 elective procedures included, 63 (19%) were performed through TRA versus 275 (81%) through TFA access. Diagnostic procedures were more common in the TRA cohort (51 of 63, 81%) compared with the TFA cohort (197 of 275, 72%), but the difference was not significant (p=0.48). The TRA cohort had a shorter length of hospital stay (mean (SD) 0.3 (0.5) days) compared with the TFA cohort (mean 0.7 (1.3) days; p=0.02) and lower hospital costs (mean $12 968 ($6518) compared with the TFA cohort (mean $17 150 ($10 946); p=0.004). After propensity adjustment for age, sex, symptoms, angiographic findings, procedure type, sheath size, and catheter size, TRA access was associated with a mean hospital cost of $2514 less than that for TFA access (95% CI −$4931 to −$97; p=0.04).
Conclusion Neuroendovascular procedures performed through TRA access are associated with lower hospital costs than TFA procedures. The lower cost is likely due to a decreased length of hospital stay for TRA.
Data availability statement
There are no additional data to share.
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Transradial artery (TRA) access for neuroendovascular procedures is associated with a decreased rate of complications compared with the standard transfemoral artery (TFA) catheterization.1 In addition, several studies have shown that TRA access can be performed effectively for a variety of neurointerventions.1–6 Preferentially accessing the radial artery has been adopted by interventional cardiologists as standard practice for acute coronary syndromes, largely due to improved outcomes and improved patient satisfaction compared with TFA access.7–16 Coronary angiography and interventions accessed through the radial artery, compared with those accessed through the femoral artery, are associated with significantly decreased hospital costs.11 Cost analysis in cardiac literature included total hospital cost initially, with a large systematic review performing a cost-benefit analysis years later that included procedure details and complications.11 17 18 However, a cost analysis of neurointerventions accessed through the TRA versus the TFA has not yet been reported.
In this study, we used propensity-adjusted analysis to compare the hospital costs of all elective neuroendovascular procedures performed through TRA access versus TFA access at a single large tertiary center. The authors hypothesize that, similar to interventional cardiology, neuroendovascular procedures performed through TRA access are associated with reduced hospital costs compared with those performed through TFA access.
A retrospective review was performed of all patients who underwent a neuroendovascular procedure at a single institution from October 1, 2018 to May 31, 2019. The study protocol was approved by the institutional review board of St Joseph’s Hospital and Medical Center in Phoenix, Arizona. The need for patient consent was waived due to the low risk to patients. Exclusion criteria were all non-elective procedures, patients with access site crossover, and patients with multiple neuroendovascular procedures or subsequent surgical intervention not from a complication during their hospitalization. Types of elective neurointerventions included in the study were diagnostic cerebral angiography, embolization of aneurysms, embolization of dural arteriovenous fistulas, embolization for other causes, stent placement or angioplasty, and other procedures (eg, Wada tests, balloon test occlusions). Other data collected via chart review included age, sex, presenting symptoms, pathologic findings, sheath size, catheter size, hospital length of stay (LOS), and complications. Hospital costs were obtained from the Strategic Support Services department of Dignity Health Arizona. Hospital costs were defined as the cost the hospital estimated for the patient’s procedure and hospital services, which included all services, such as costs for medical equipment, the patient’s room, nursing personnel and other staff, imaging studies, and laboratory work.
Patients were separated into two cohorts for comparison: those who underwent procedures through TRA access, and those who underwent procedures through TFA access. The primary outcome measured was hospital costs between the two cohorts. Secondary outcomes included complications and LOS. Access site was determined by the neuroendovascular surgeons (AFD and FCA), with the majority of cases early in the study performed via TFA access; however, toward the end of the study, as the surgeons became more comfortable with TRA access, the majority of cases were performed radially.
Statistical analysis was performed using SPSS Statistics, version 26 (IBM Corp, Armonk, NY). Means, standard deviations, and percentages were calculated for patient demographics and characteristics. Comparisons between the cohorts were performed using the independent-samples t test or χ2 analysis. A propensity adjustment was conducted for age, sex, symptoms, angiographic findings, procedure type, sheath size, and catheter size, with subsequent linear regression analysis for a comparison of hospital costs. A value of p<0.05 was considered significant.
Of the 338 patients who met the inclusion criteria during the 8 month study period, 63 (19%) patients underwent procedures through TRA access, and 275 patients (81%) underwent procedures through TFA access. No significant differences were found between patients undergoing procedures through TRA versus TFA access in sex, age, presenting symptoms, pathologic findings, type of procedure, inpatient status, sheath size, or catheter size (table 1). In both cohorts, most procedures were performed for diagnostic angiography, including 51 of 63 patients (81%) in the TRA cohort and 197 of 275 (72%) in the TFA cohort.
Mean hospital LOS was shorter for patients in the TRA access cohort (mean (SD) LOS 0.3 (0.5) days) compared with the TFA cohort (mean LOS 0.7 (1.3) days; p=0.02). LOS was also shorter when analyzing only patients admitted to the hospital. In 14 of 63 patients in the TRA cohort who were admitted, the mean LOS was 1.1 (0.3) days compared with 1.9 (1.5) days for the 85 of 275 patients admitted in the TFA cohort (p=0.04) (table 2). Hospital costs were significantly lower in the TRA cohort (mean $12 968 ($6518)) compared with the TFA cohort (mean $17 150 ($10 946); p=0.004). Hospital costs were also lower when comparing only patients admitted to the hospital. In the 14 patients admitted in the TRA cohort, mean hospital costs were $18 593 ($9020) compared with $28 216 ($11 220) for the 85 patients admitted in the TFA (p=0.002).
Only one of 63 patients (2%) in the TRA cohort had complications compared with 17 of 275 patients (6%) in the TFA cohort (p=0.18) (table 2). No patients (0%) had major complications in the TRA cohort compared with four of 275 patients (2%) in the TFA cohort (p=0.12); major complications included one occlusive femoral artery, one femoral artery pseudoaneurysm, one retroperitoneal bleed, and one intracranial hemorrhage. No patient had more than one complication. The mean LOS in the 18 of 338 patients with a complication was 2.5 (2.7) days compared with 0.4 (0.8) days in 320 of 338 patients with no complications (p<0.001); the mean costs for patients with complications was $23 287 ($15 707) compared with $15 818 ($9665) for patients with no complications (p<0.001) (table 2).
On propensity-adjusted linear regression analysis (adjusted for age, sex, symptoms, angiographic findings, procedure, sheath size, and catheter size), TRA access was found to be associated with a mean cost of $2514 less than TFA procedures (95% CI −$4931 to −$97; p=0.04) (table 3). Subsequently, separate propensity-adjusted analyses were performed for treatments and diagnostics. For treatments, TRA access was found to be associated with a mean cost of $8889 less than TFA procedures (95% CI −$15 269 to −$2510; p=0.007), but no significant difference was found in diagnostics.
TRA access for neuroendovascular procedures, compared with TFA access, is associated with fewer complications and has been shown to be preferred by patients.1 19 For these reasons, and because of the similar effectiveness of TRA compared with TFA access, the use of TRA catheterization by neurointerventionalists is gradually becoming more widespread.20 In addition, TRA access has been found to be more cost-effective than TFA procedures.11
At our institution, we have begun to adopt a radial-artery-first approach for neuroendovascular procedures. Therefore, many of the procedures were still performed through TFA during this transition period. We found TRA access to be associated with a relative decrease of $2514 in hospital costs per patient after propensity adjustment. Because our institution performs >500 elective neurointerventions per year, the switch to a radial artery approach has decreased the estimated total hospital costs for these procedures by more than $1.2 million per year. The cost difference is likely due to an increased LOS in patients with TFA compared with TRA access procedures. The increased length of hospitalization seems to be largely driven by an increased complication rate in patients who underwent procedures performed through TFA access. Although our study was not powered to analyze complications, we have previously found TFA access to be a greater risk factor for complications than TRA access.1 In addition, in the current analysis, patients with complications were found to have increased LOS and hospital costs compared with patients with no complications. Even when an outpatient procedure is planned, a complication may cause the patient to be admitted overnight or longer for observation. In our patient cohort, four patients in the TFA access group developed major complications, whereas no patients in the TRA access group developed complications. The mean LOS for patients with major complications was more than a week compared with less than a day for patients with no complications. Moreover, patients with complications often required additional procedures and imaging studies that likely further increased the cost.
Other factors in addition to complications may have driven the increased LOS and subsequent increase in the associated hospital costs. Although not analyzed in this study, TFA access has been associated with more postprocedure discomfort than TRA access.9 Furthermore, at our institution, vascular access closure devices are used after femoral artery puncture for TFA access, and after the procedure the patient must remain flat with the inability to ambulate or sit up for several hours. Both of these factors may lead to an increased LOS after TFA procedures, because an outpatient may need to be observed overnight or a scheduled inpatient may need to stay longer in the hospital.
In addition to possibly increasing the LOS, femoral artery closure devices are also associated with an increased instrument cost. Although this study did not analyze instrument cost between access sites, the cost for a femoral artery closure device has been previously estimated to be approximately $200 in the USA as of 2007.21 In contrast, for TRA procedures, compression with inexpensive dressings or bands is commonly used. This option is not used in TFA procedures because the lack of a closure device has been shown to be associated with a higher rate of major complications, a risk that is not seen with TRA procedures.21
Recently, our institution has adopted a radial-artery-first approach for neuroendovascular procedures. Previous studies have shown a lower rate of complications associated with TRA access compared with TFA access. The present study found that TRA is associated with lower hospital costs than TFA procedures, likely due to a shorter hospital stay for TRA procedures.
Data availability statement
There are no additional data to share.
The authors thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.
Contributors All authors made substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work; drafted the work or revised it critically for important intellectual content; provided final approval of the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests AFD is a consultant for Penumbra, Stryker, Medtronic, Cerenovus, and Koswire, and has ownership interest in Aneuvas, Inc.
Provenance and peer review Not commissioned; externally peer reviewed.