A Study Comparing the Cost of Transjugular Intrahepatic Portosystemic Shunt (TIPS) and Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) as Secondary Prophylaxis to Prevent Recurrent Gastric Variceal Bleeding

To generate and compare costing data on Transjugular Intrahepatic Portosystemic Shunt (TIPS) and Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) at a tertiary university hospital and calculate the cost of secondary prevention for gastric variceal bleeding {1}.

Materials and Methods:

We included costs from all patients treated between 1 January 2017 and 1 January 2024 who received either TIPS or BRTO. Data on procedure, non-procedure, and ward costs were collected. Ward costs were only calculated for elective admissions.

There were 38 patients in the cohort, mean age 56.8 years (SD 12.0) and 25 patients (66%) were male sex. Most patients had Childs-Pugh (CP) B cirrhosis (19, 50%) and the most common cause of cirrhosis was alcohol overuse (23, 61%). TIPS was performed in 27 patients (71%). The TIPS and BRTO groups had similar mean age, proportion of male sex, CP grading, and proportion of elective admissions.

All costs were measured from a healthcare system perspective using a combination of bottom-up and top-down approaches, and included direct and indirect costs where relevant {2}. A 5% indexation for inflation was applied to non-fixed costs.

Results:

The TIPS group had a longer median procedure time (185 vs 120 minutes, p=0.004), longer median length of hospital stay (2 vs 0 days, p=0.001), and higher use of anesthesiology (100% vs 18%, p< 0.001). The TIPS group also had a non-significantly higher proportion of periprocedural complications (22% vs 0%, p=0.088) and all-cause 30-day mortality (19% vs 0%, p=0.126).

TIPS was associated with higher median procedure costs (6482 vs 1949, p< 0.001), median non-procedure costs (1013 vs 256, p< 0.001) and ward costs (1380 vs 277, p< 0.001). The combined median total cost for TIPS was $8065 (range 4196-35550) while the median total cost for BRTO was $2457 (range 1285-3442), p< 0.001. A sub analysis was also performed on a group of 10 age, sex, and CP-matched patients, and cost differences were similar to the unmatched cohort (TIPS 11726 vs BRTO 2652, p=0.009).

The cost to prevent future gastric re-bleed was calculated based on this costing data adjusted for outcome data from the meta-analysis of Wang et al. {3}. The cost to prevent 1 re-bleed using TIPS was median $9843 while the cost to prevent 1 re-bleed using BRTO was $2590.

Conclusion:

BRTO offers a significantly lower-cost alternative to TIPS when used for secondary prevention of gastric variceal bleeding but requires favorable anatomy. More costing studies should be performed and costs should form a key component of the value of IR to modern healthcare.