Venous Stents Drive Most Costs of Iliocaval Stent Reconstruction, Analysis Finds

A new cost analysis of iliocaval venous stent reconstruction turns that assumption on its head. Using a time-driven activity-based costing approach, researchers calculated that a single reconstruction for chronic lower extremity venous occlusive disease carries a base cost of $26,201.01, and that disposable materials account for 83.2 percent of that figure, while personnel costs contribute just 16.8 percent. Venous stents themselves emerged as the single largest and most variable expense, with sensitivity analyses showing total costs swinging from $17,801.01 to $34,811.01 depending on stent price alone.

The study, published as an open access original article in CVIR Endovascular, reviewed thirty-one iliocaval venous stent reconstruction procedures performed for chronic iliocaval occlusive disease, defined as symptomatic venous occlusive disease lasting more than four weeks. The work was approved by an Institutional Review Board and conducted in compliance with the Health Insurance Portability and Accountability Act.

Time-driven activity-based costing, or TDABC, is a process-based expense estimation method borrowed from industrial engineering that has become a standard in many industries. Rather than relying on charge-to-cost ratios or relative value unit tabulation, TDABC maps every step of a care cycle, identifies the resources consumed at each step, and multiplies the duration of each step by a capacity cost rate, defined as the monetary cost of a resource per unit of time in dollars per hour. That rate is calculated by dividing the total cost of a resource by the approximate time it is utilized, and it can be applied to human resources, calculated as wages plus benefits divided by hours worked, to equipment, calculated as purchase cost divided by lifetime use, and to occupancy, calculated as rental costs divided by total annual productive occupancy time.

To build the model, the team created process maps for every party involved in iliocaval stent reconstruction after interviewing representatives from each group. The maps captured all steps, decision points, and the individuals present or responsible at each stage of the care episode, which in this analysis ran from institutional overhead through preoperative holding, the procedure itself, and post-anesthesia care unit recovery. Time estimates came from electronic medical record event logs that recorded when each team member entered and exited the room and how long each resource was in use, supplemented by structured staff interviews; when the two sources disagreed, electronic record timestamps took priority. Costs related to outpatient follow-up, medications, imaging, and complication management were explicitly excluded.

Practical capacity, the actual time a resource was available, was estimated at 85 percent of full capacity in consultation with the institution’s Director of Clinical Operations, an assumption applied uniformly to personnel and room resources because precise utilization rates for individual in-room equipment were unavailable. Capacity cost rates were derived by dividing annual salary estimates, drawn from payroll records, the United States Bureau of Labor Statistics Occupational Employment Statistics database, and other public institutional data, by practical capacity time in hours per year. Capital equipment, defined as non-disposable materials purchased for long-term use, included anesthesia machines, fluoroscopy tables, and other fixed components of the interventional suite. The total equipment cost of a suite without computed tomography capability was $4.5 million, depreciated over seven years within a ten-year replacement horizon, and budgeted suite capacity of roughly 79 hours per week per room across 12 rooms yielded a cost rate of $129 per room per hour. Institution-specific capital equipment costs added 3.1 percent to total costs.

Disposable material prices were obtained from the institution’s charge master and cross-checked against market analysis and published data. Because individual inputs such as salaries and materials costs are proprietary, the researchers ran extensive sensitivity analyses. Univariate analyses varied salaries between the 10th and 90th percentiles of national data, task times between 50 and 200 percent of the mean procedure duration, and device prices based on published online market values, vendor discussions, and the institutional central supply department. Multivariate analyses then varied all minimum and maximum values simultaneously, producing a striking total cost range of $7,842.95 to $66,066.05 per case. Using local salary information and negotiated material prices, the authors estimated the true institutional cost per case at $25,750.33.

The sensitivity analyses pinpointed exactly where that money goes. On the labor side, the largest contributor was the time an anesthesiologist was required to be present, which moved total costs between $25,533.71 and $26,551.89, followed by nurse anesthetist wages, interventional radiology technologist wages, and technologist-hours per case, each shifting totals by only a few hundred dollars. Disposable materials dwarfed these effects. Beyond stent price, the number of stents used changed total costs from $19,326.01 to $29,363.01, and balloon catheter costs moved totals from $23,384.09 to $32,322.46. The authors note that complex cases using multiple items can produce wide cost variance, and that materials had a substantially greater impact on costs than wages, an inversion of the pattern seen in many previously studied medical settings where staffing dominates.

The authors suggest several avenues for cost reduction rooted in these findings. Because general anesthesia is generally appropriate for recanalization of chronic iliocaval thrombosis, since angioplasty of stenosed and occluded venous segments can be painful, anesthesiologist presence is hard to eliminate entirely, but opportunities for conscious sedation in select patients may reduce anesthesiologist utilization and cost. On the materials side, the relative lack of stents designed specifically for the iliocaval venous anatomy likely increases the number of stents needed to build modular constructs of varying caliber and branching, so meticulous anatomic mapping before stent selection can reduce unintentional waste. Intraprocedural intravascular ultrasound, currently used in 73 percent of iliocaval stent reconstructions, may facilitate proper stent number and sizing despite its upfront costs. The authors also point out that healthcare organizations have used TDABC to cut staffing full-time equivalents by 17 percent and cost per patient by 46 percent, and that reducing idle time during procedures, streamlining preoperative processes, and expanding post-anesthesia capacity are additional levers.

Context from other interventional radiology procedures supports the pattern. Retrospective TDABC calculations found disposable materials accounted for 62 percent of costs in conventional transarterial chemoembolization, with personnel and patient recovery contributing 25 and 13 percent respectively, and consumables contributed 58, 90, and 65 percent of costs in transarterial chemoembolization, transarterial radioembolization, and ablation respectively. A TDABC study of uterine artery embolization found consumables made up 51 percent of total cost, while analyses of arteriovenous malformation and venous malformation treatment found material shares of 45 and 75 percent. The authors suggest that as interventional radiology’s devices grow more sophisticated and improve procedural success, they generally increase costs, making structured cost accounting increasingly valuable for preserving access.

The study’s limitations deserve emphasis. The analysis was retrospective and limited to a single institution, and costs may vary with geographic location, inflation, internal cost accounting methodology, and local treatment preferences. Cost inputs were derived primarily from 2017 to 2018 data and reported in nominal dollars without inflation adjustment. Post-procedural management, including clinical follow-up, medical management, and imaging, was not assessed, and many time estimates came from chart review of procedure logs with timeline discrepancies. The authors also caution that costs were evaluated as independent variables but are likely confounded, since complex reconstructions probably involved both greater disposable material costs and prolonged procedure times that raise personnel costs, and the analysis did not study the effects of operator experience on procedural costs. Within those bounds, the conclusion is clear: anesthesia staffing and stent and catheter selection are large, potentially modifiable cost drivers, and future studies must define a reconstruction protocol that delivers savings without compromising the clinical outcomes that have made these procedures worthwhile, including the substantial symptom relief reported in prior systematic reviews of venous outflow interventions.

Subject of Research: Time-driven activity-based costing of iliocaval venous stent reconstruction for chronic lower extremity venous occlusive disease

Article Title: Cost analysis of venous stent reconstruction in the treatment of chronic lower extremity venous occlusive disease

Article References: Jambhekar, S. S., Bundy, J. J., Lewis, S. B., Srinivasa, R. N., Hage, A. N., Monroe, E. J., Chick, J. F. B., Shin, D. S., Abad-Santos, M., & Makary, M. S. (2026). Cost analysis of venous stent reconstruction in the treatment of chronic lower extremity venous occlusive disease. CVIR Endovascular, 9(1), Article 124. https://doi.org/10.1186/s42155-026-00648-0

Image Credits: AI Generated

DOI: 10.1186/s42155-026-00648-0

Keywords: iliocaval stent reconstruction, chronic venous occlusive disease, time-driven activity-based costing, interventional radiology, healthcare costs, venous stents, disposable materials, sensitivity analysis, anesthesia staffing, cost drivers, endovascular procedures, PACU