Peripheral Artery Disease procedures and trends in Asia Pacific 2010 - 2011

Clearstate (Singapore) Pte Ltd th 15 November 2011

Overview
Lower limb peripheral artery disease landscape Lower limb peripheral artery disease (PAD) or peripheral vascular disease (PVD) is a cardiovascular disease that leads to narrowing and hardening of arteries found outside the coronary, aortic arch and brain. With an estimated 10 million people in these markets who are diagnosed with lower limb PAD annually, another 76% (Taiwan) to 98% (India) of cases remain to undiagnosed due to low awareness or asymptomatic patients. Current methods for treating lower limb PAD generally commence with the prescription of medication and lifestyle changes for milder cases. However, lower limb PAD is often diagnosed in the later stages and treatment options include angioplasty (with or without stenting) and bypass grafting. Fig 1. Disease risk factors for PAD and statistics
China Estimate PAD prevalence (% of population) Estimate annual PAD incidence (cases) % Undiagnosed 1.1% 3,000,000

88%

South Korea Estimate PAD prevalence (% of population) Estimate annual PAD incidence (cases) India Estimate PAD prevalence (% of population) Estimate annual PAD incidence (cases) % Undiagnosed % Undiagnosed 8-10% 6,500,000 Taiwan Estimate PAD prevalence (% of population) Estimate annual PAD incidence (cases) % Undiagnosed 5% 180,000

2% 188,750

80%

98%

76%

Source: Clearstate

5 Magazine Road, #03-01 Singapore 059571 | t (65) 6303 5030 f (65) 6438 482

BRIDGING INTELLIGENCE GAPS IN HEALTHCARE

Key customer segments for peripheral vascular intervention devices As peripheral vascular intervention (PVI) is relatively less developed and specialized in China, the exact patient pathway still varies between hospitals depending largely on the hospital class. According to Clearstates estimates, vascular surgeons typically perform a higher volume of PVI procedures. In India, S. Korea and Taiwan, competition for patients exist between departments. While PVI procedures are traditionally performed by the interventional radiologists, there is a recent trend of interventional cardiologists performing more PVI procedures without referring patients to the radiology department. In addition, more vascular surgeons have generally shown keen interest in performing more interventional procedures and hold an advantage in having hybrid skills, combining interventional procedures with bypass surgery. Fig 2. Procedure caseload by department / specialist type
China India S. Korea Taiwan 25% Interventional Cardiologists Source: Clearstate 20% 45% 15% Interventional Radiologists 30% 30% 35% 60% Vascular surgeons 70% 50% 20%

While bypass surgeries were the original treatment method of choice amongst surgeons for cases of chronic total occlusion (CTO), newer technologies, e.g. Cordis FRONTRUNNER and ev3s SilverHawk systems, hold the possibility of treating CTO cases without the need for surgery. However, actual adoption in Asia remains slow due to low awareness, high costs, complexity and reluctance to switch from tested technology. Interventional procedural volumes and Device market size Stents are gaining popularity for iliac and SFA sites for all four markets, especially in India where majority of PVI procedures involve stent insertion. Even in Korea, where stenting is generally not as common, there is a growing trend towards the acceptance of stent usage especially amongst the interventional cardiologists and vascular surgeons. In line with international practices, BTK stenting is not commonly done. However on the whole, BTK procedures are seen to be the fastest growing segment in terms of procedural volumes.

5 Magazine Road, #03-01 Singapore 059571 | t (65) 6303 5030 f (65) 6438 482

BRIDGING INTELLIGENCE GAPS IN HEALTHCARE

Fig 3. Procedural volumes for peripheral artery disease (2010)

40,000 35,000 Procedure Volume (2010) 30,000 25,000 20,000 15,000 10,000 5,000
6,000 6,000 7,500 5,000 1,500 5,500 1000 700 1,000 1,500 2,000 1000 800 500 7,000 1,400 1,500 9,000 800

7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

7,500

0 China Iliac without stent Iliac with stent Source: Clearstate

India

S. Korea

Taiwan Below-the-knee (no stents)

SFA without stent SFA with stent

The 2010 market size for peripheral dilation catheters and stents for China was valued at approximately USD66 mil, and USD18 mil for India. South Korea and Taiwan each had a market size of about USD5 mil. The key brands in the region include Cordis, Medtronic Invatec, Cook Medical, Boston Scientific, Bard and ev3. Key issues and challenges in appropriate treatment for PAD
Peripheral Intervention Growth forecast China High India Moderate South Korea Moderate-High Taiwan Moderate

While diet and lifestyle changes and an aging population will lead to a general growth in PVI procedures, the key growth driver is increased efforts by the medical specialists and industry in educating and creating awareness of peripheral artery disease amongst the public and the general medical community. In India, the persistence of high device costs and growth of the more lucrative peripheral coronary intervention devices market are expected to be detrimental in the short term. While patient affordability is not as large an issue in the other markets due to national healthcare plans, tight pricing controls and reimbursement regulations is expected to dampen the growth in market value.

5 Magazine Road, #03-01 Singapore 059571 | t (65) 6303 5030 f (65) 6438 482

BRIDGING INTELLIGENCE GAPS IN HEALTHCARE