Cost Effectiveness of Endovascular Thrombectomy for Large Ischemic Strokes: A US Healthcare Payer Markov Model Informed by Randomized Trials

Endovascular thrombectomy is standard for acute large-vessel occlusion stroke, but the value of endovascular thrombectomy in patients with large ischemic regions remains uncertain from a US healthcare payer perspective. This study evaluated the cost effectiveness of endovascular thrombectomy plus medical management (MM) versus MM alone in patients with large ischemic regions, synthesizing data from a recent meta-analysis of all available randomized trials. We developed a decision tree linked to a Markov model to perform a cost-utility analysis of endovascular thrombectomy plus MM versus MM alone from a US healthcare payer perspective over 90-day, 1-year, 5-year, and 20-year horizons. The target population was adults with acute ischemic stroke from large-vessel occlusion and Alberta Stroke Program Early CT Score (ASPECTS) < 6 or infarct core volume ≥ 50 mL. Clinical inputs came from a systematic review of randomized trials. The primary outcome was the incremental cost-effectiveness ratio, expressed as cost per quality-adjusted life-year (QALY) gained. Scenario analyses (90-day, 1-year, 5-year, and 20-year horizons) and sensitivity analyses evaluated uncertainty. Over 20 years, endovascular thrombectomy plus MM yielded 0.44 additional QALYs and US dollars 19,611 higher costs versus MM alone, with an incremental cost-effectiveness ratio of US dollars 45,117 per QALY. Endovascular thrombectomy plus MM was cost effective in 59.4% and 94.3% of simulations at willingness-to-pay thresholds of US dollars 50,000 and 100,000 per QALY, respectively, whereas MM alone was dominant over a 90‑day horizon. From a US healthcare payer perspective, endovascular thrombectomy for large ischemic strokes is unlikely to be cost effective in the short term but becomes more likely to be cost effective over a 20-year time horizon at commonly used willingness-to-pay thresholds, highlighting the importance of adopting long‑term perspectives in coverage and reimbursement decisions.