Intended for healthcare professionals


Cost effectiveness analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery

BMJ 2007; 334 doi: (Published 22 March 2007) Cite this as: BMJ 2007;334:621
  1. Christopher Rao, research fellow1,
  2. Omer Aziz, clinical research fellow1,
  3. Sukhmeet Singh Panesar, research fellow1,
  4. Catherine Jones, research fellow1,
  5. Stephen Morris, senior lecturer2,
  6. Ara Darzi, professor of surgery1,
  7. Thanos Athanasiou, consultant cardiac surgeon1
  1. 1Department of Biosurgery and Surgical Technology, Imperial College London, St Mary's Hospital, London W2 1NY
  2. 2Tanaka Business School, Imperial College London
  1. Correspondence to: T Athanasiou tathan5253{at}
  • Accepted 5 January 2007


Objective To compare the cost effectiveness of percutaneous transluminal coronary artery stenting with minimally invasive internal thoracic artery bypass for isolated lesions of the left anterior descending artery.

Design Cost effectiveness analysis.

Data sources Embase, Medline, Cochrane, Google Scholar, and Health Technology Assessment databases (1966-2005), and reference sources for utility values and economical variables.

Methods Decision analytical modelling and Markov simulation were used to model medium and long term costs, quality of life, and cost effectiveness after either intervention using data from referenced sources. Probabilistic sensitivity and alternative analyses were used to investigate the effect of uncertainty about the value of model variables and model structure.

Results Stenting was the dominant strategy in the first two years, being both more effective and less costly than bypass surgery. In the third year bypass surgery still remained more expensive but became marginally more effective. As the incremental cost effectiveness was £1 108 130.40 (€1 682 146.00; $2 179 194) per quality adjusted life year (QALY), the additional effectiveness could not be said to justify the additional cost at this stage. By five years, however, the incremental cost effectiveness ratio of £28 042.95 per QALY began to compare favourably with other interventions. At 10 years the additional effectiveness of 0.132 QALYs (range −0.166 to 0.430) probably justified the additional cost of £829.02 (range £205.56 to £1452.48), with an incremental cost effectiveness of £6274.02 per QALY. Sensitivity and alternative analysis showed the results were sensitive to the time horizon and stent type.

Conclusions Minimally invasive left internal thoracic artery bypass may be a more cost effective medium and long term alternative to percutaneous transluminal coronary artery stenting.


  • Contributors: CR was responsible for the study design, statistical analysis, data interpretation, and drafting of the manuscript. OA was responsible for drafting the manuscript, critical editing and manuscript direction, and revision for important intellectual content. SSP and CJ were responsible for data collection, data extraction analysis, and interpretation. SM was responsible for data extraction analysis, critical statistical analysis, and the study design. AD provided important intellectual content. TA is guarantor. His involvement was critical to every phase of this work and he had access to the data and controlled the decision to publish.

  • Funding: This study was undertaken as part of ongoing research at the Department of Biosurgery and Surgical Technology, Imperial College London, and did not receive separate funding.

  • Competing interests: None declared.

  • Ethical approval: Not required.

  • Accepted 5 January 2007
View Full Text