Economic and outcomes-based analysis of the care of symptomatic varicose veins.

OBJECTIVE: Endoluminal treatment of symptomatic varicose veins (VV) reduces or eliminates inpatient hospital stays, lowers complication rates, and increases revenue for vein care centers adopting the technique. This study compares the outcomes and economics of two treatments for VV. METHODS: Since May 2007, endovenous radiofrequency ablation (RFA) of symptomatic VV has been performed at our institution. For outcome measurements, a cohort of 100 RFA procedures (26% CEAP class C5 and C6) was compared with 100 open greater or lesser saphenous stripping and ligation procedures (SL, 18% C5 and C6). Procedures were performed between August 2002 and October 2007. The time frame was chosen to allow for a 6-mo follow-up. Patients who had adjunctive removal of secondary varicosities were included in both cohorts. Cost estimates are based on the actual total direct costs derived from the hospital's charge sheets for 20 of the 100 patients in each of the cohorts (n = 40). The actual direct costs are based on 2009-dollar values and do not include the surgeons' professional fees. RESULTS: Seventy-nine percent of the RFA therapies were performed in an outpatient clinic treatment room with the remaining 21% performed in an operating room (OR). For the SL group, all procedures were performed in the OR with 68% of patients requiring at least one night of hospital stay (average length of stay 1.2 d). The estimated direct cost of performing RFA in the treatment room was $906. This was considerably less than the estimated $4241 total direct cost for open SL followed by in-hospital observation. Outpatient open SL cost $2622, which is only slightly more than the $2533 cost for outpatient RFA performed in the OR. The use of RFA was associated with an earlier return to normal leisure activities (3.3 d versus 26 d, P < 0.05), fewer total hospital nights (3 d versus 82 d, P < 0.05), and less use of general anesthesia (16% versus 95%, P < 0.05). There were no major complications in the RFA group compared with three major complications in the SL group. CONCLUSIONS: With the introduction of endovenous techniques at our institution, there has been a significant increase in the volume of patients seeking this less invasive treatment modality. This is due largely to the ease and comfort with which patients can now be treated as well as the reduced length of stay, reduction of general anesthetic use, and the speed at which they can return to normal activities. We recommend endovenous ablation techniques as both cost-saving and patient-preferred.

Endovenous ablation for the treatment of chronic venous insufficiency and venous ulcerations.

OBJECTIVE: Conventional treatment of chronic venous disease with ulceration is layered compression dressings. Saphenous vein stripping is reserved for recurrent or nonhealing ulcers. This study examines outcomes of aggressive endovenous therapy in promoting ulcer healing and/or preventing ulcer recurrence. The role of additional perforator vein ablation also is analyzed. METHODS: This retrospective chart review occurred during a 2.5-year time frame during which 356 patients with venous insufficiency were seen in our vein center and underwent 412 venous operations (56 with bilateral disease treated on separate dates). A cohort of 75 (21.1%) patients with severe chronic venous disease underwent 83 (20.1%) procedures (C5: n = 52, 63%; C6: n = 31, 37%); 8 patients had bilateral procedures. Data analysis included body-mass index (BMI), history of deep vein thrombosis (DVT) or previous vein surgery, and type of procedure (radiofrequency ablation (RFA) of greater saphenous vein (GSV) alone or GSV and perforator ablation (GSVP)). Complications, ulcer healing rates, and recurrent ulcerations were examined. Descriptive statistics are reported and contingency tables used when appropriate. RESULTS: Overall, the patients were 63.5 +/- 13.4 years of age (men: n = 36, women: n = 39) with a BMI of 32.4 (range, 20.8-53.4). All of the patients had GSV insufficiency and 30 (44%) patients had deep vein incompetence. Only 19 (28%) patients had a history of a DVT and 13 (19%) had previous vein procedures. The 31 extremities with C6 disease had been treated conservatively with compression for an average of 7.6 +/- 4.2 (range, 1-156) months before undergoing ablation. Ablation site was GSV in 49 (72%) and GSVP in 19 (28%). Only two (2.9%) complications occurred: excessive hemosiderin staining and paresthesias each occurred in one patient. Of the C5 patients treated, two (4.7%) developed recurrent ulcerations and five (20%) C6 patients did not heal completely or developed a recurrent ulcer. There was no statistically significant difference in ulcer healing or recurrence rates between C5 and C6 patients treated with and without the addition of perforator interruption. CONCLUSIONS: Chronic venous insufficiency with active or healed ulceration is commonly seen in our academic vein center. In this series, endovenous ablation allowed for excellent healing rates and acceptable recurrent ulcer rates. It is unclear from this small cohort whether the addition of perforator ablation was of benefit in improving venous hemodynamics.

Stent-graft repair for blunt traumatic aortic injury as the new standard of care: is there evidence?

Designed to treat degenerative aneurysms of the thoracic and abdominal aorta, endovascular stent-grafts have been increasingly employed as an off-label emergency treatment for blunt traumatic aortic injury (BTAI). In this review we explore the controversies associated with thoracic endovascular aortic repair (TEVAR) for BTAI. Early versus delayed treatment of aortic injuries is controversial, and stent-graft repair has further confused the issue of timing the repair. The diagnosis and management of minimal aortic injuries remains elusive. We analyze the available literature pertaining to BTAI, including the recent multicenter prospective trial from the American Association for the Surgery of Trauma. The strengths and weaknesses of the stent-grafts currently available for use in the US are examined to provide insight into which graft may be best suited for BTAI at the present time. Also of importance, we offer recommendations regarding clinical situations in which TEVAR should not be the first line therapy for BTAI. We conclude with a discussion of upcoming trials and new devices that will shape the future of endovascular treatment of BTAI.

Intravascular ultrasound.

Intravascular ultrasound (IVUS) has an interesting history that parallels that of many of the advancements that have led to the endovascular era. The use of IVUS in conjunction with standard cross-sectional imaging and three-dimensional reconstructions offers a powerful tool in both the diagnosis and treatment of complex vascular pathology. The use of IVUS has increased over the years and is currently in the process of being incorporated into several modalities that will offer more in the way of real-time information in both the aortic arena and the treatment of increasingly complex peripheral vascular disease. Currently, we use IVUS as a powerful adjunct in combination with other modalities to increase our understanding of vessel architecture and assist in the management of complex vascular pathology.