RESUMEN
OBJECTIVE: The suggested high costs of endovascular aneurysm repair (EVAR) hamper the choice of insurance companies and financial regulators for EVAR as the primary option for elective abdominal aortic aneurysm (AAA) repair. However, arguments used in this debate are impeded by time related aspects such as effect modification and the introduction of confounding by indication, and by asymmetric evaluation of outcomes. Therefore, a re-evaluation minimising the impact of these interferences was considered. METHODS: A comparative analysis was performed evaluating a period of exclusive open repair (OR; 1998-2000) and a period of established EVAR (2010-2012). Data from four hospitals in The Netherlands were collected to estimate resource use. Actual costs were estimated by benchmark cost prices and a literature review. Costs are reported at 2019 prices. A break even approach, defining the costs for an endovascular device at which cost equivalence for EVAR and OR is achieved, was applied to cope with the large variation in endovascular device costs. RESULTS: One hundred and eighty-six patients who underwent elective AAA repair between 1998 and 2000 (OR period) and 195 patients between 2010 and 2012 (EVAR period) were compared. Cost equivalence for OR and EVAR was reached at a break even price for an endovascular device of 13 190. The main cost difference reflected the longer duration of hospital stay (ward and Intensive Care Unit) of OR (11 644). Re-intervention rates were similar for OR (24.2%) and EVAR (24.6%) (p = .92). CONCLUSION: Cost equivalence for EVAR and OR occurs at a device cost of 13 000 for EVAR. Hence, for most routine repairs, EVAR is not costlier than OR until at least the five year follow up.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/economía , Análisis Costo-Beneficio , Procedimientos Quirúrgicos Electivos/economía , Procedimientos Endovasculares/economía , Complicaciones Posoperatorias/economía , Cuidados Posteriores/economía , Cuidados Posteriores/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/economía , Aneurisma de la Aorta Abdominal/mortalidad , Prótesis Vascular/economía , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/métodos , Procedimientos Quirúrgicos Electivos/efectos adversos , Procedimientos Quirúrgicos Electivos/instrumentación , Procedimientos Quirúrgicos Electivos/métodos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Países Bajos/epidemiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Reoperación/economía , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Stents/economía , Factores de Tiempo , Resultado del TratamientoRESUMEN
External beam irradiation has a documented effect on intimal hyperplasia reduction. However, it did not result in less reinterventions or stenoses after radiation treatment of the venous anastomosis in polytetrafluoroethylene dialysis access.
Asunto(s)
Derivación Arteriovenosa Quirúrgica , Prótesis Vascular , Oclusión de Injerto Vascular/prevención & control , Diálisis Renal , Túnica Íntima/efectos de la radiación , Adulto , Anciano , Anciano de 80 o más Años , Velocidad del Flujo Sanguíneo , Arteria Braquial/efectos de la radiación , Arteria Braquial/cirugía , Venas Braquiocefálicas/efectos de la radiación , Venas Braquiocefálicas/cirugía , Constricción Patológica/prevención & control , Femenino , Antebrazo/irrigación sanguínea , Supervivencia de Injerto/efectos de la radiación , Humanos , Hiperplasia , Masculino , Persona de Mediana Edad , Politetrafluoroetileno , Estudios Prospectivos , Dosificación Radioterapéutica , Túnica Íntima/patología , Ultrasonografía Doppler DúplexRESUMEN
OBJECTIVE: The aim of this study was to describe perioperative morbidity and mortality of patients presenting with resectable lung cancer and to investigate the long-term survival. METHODS: We reviewed the records of 344 patients who underwent lung resection for bronchogenic carcinoma. Follow-up information was obtained from visits to the outpatient clinic. RESULTS: Between January 1991 and December 1995 there were 263 males and 81 females included with a mean age of 65.7 years. One hundred and eight (31%) patients underwent a pneumonectomy, 159 (46%) a lobectomy, 43 (13%) a bilobectomy, four (1%) a segmental resection and 30 (9%) an explorative thoracotomy. A total of 341 complications occurred. The 30 day mortality rate was 7.9% (27 patients). Patients with a low FEV1% and older patients have a higher risk of mortality within 30 days. Postoperative myocardial infarction and pneumonia were associated with an increase in 30 day mortality. The median survival was 3.6 years for stage I, 1.9 years for stage II, 1.0 years for stage IIIa, 0.9 years for stage IIIb and 0.9 years for stage IV. Prognostic factors for the long-term survival included stage, pneumonectomy, percentage FEV1 <70, and large cell carcinoma. CONCLUSIONS: Pulmonary resection can be performed at an acceptable risk. Critical reviewing of our results made it possible to make recommendations for improvements.
Asunto(s)
Carcinoma Broncogénico/cirugía , Neoplasias Pulmonares/cirugía , Complicaciones Posoperatorias , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Tumor Carcinoide/mortalidad , Tumor Carcinoide/patología , Tumor Carcinoide/cirugía , Carcinoma Broncogénico/mortalidad , Carcinoma Broncogénico/patología , Carcinoma de Células Grandes/mortalidad , Carcinoma de Células Grandes/patología , Carcinoma de Células Grandes/cirugía , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Comorbilidad , Femenino , Estudios de Seguimiento , Humanos , Modelos Logísticos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Estadificación de Neoplasias , Neumonectomía , Neumonía/mortalidad , Complicaciones Posoperatorias/mortalidad , Pronóstico , Tasa de SupervivenciaRESUMEN
Cell-based therapy has been proposed as a novel strategy for patients with severe peripheral arterial disease by stimulating vascular growth. In clinical studies of this therapy, the emphasis has been on demonstrating recovery of clinical parameters, rather than on evaluation of blood flow recovery. Angiography is still the gold standard for the assessment of lower leg arteries. Therefore, we studied the usefulness of angiography in the evaluation of cell-based therapy. Sixteen patients with critical leg ischemia (ischemic rest pain or ulcers), or persistent (>12 months) profound disabling claudication were unilaterally treated with autologous bone marrow-derived mononuclear cells. Pre- and 6 months post-treatment digital subtraction angiographies (DSA) were assessed and compared in a blinded fashion twice by a panel of seven vascular surgeons and interventional radiologists. Inter- and intraobserver variability on qualitative (poor/moderate/rich) and semi-quantitative (increase/no difference/decrease) assessment of collateral circulation were evaluated. Agreement was expressed inter- and intraclass correlation coefficients (CC). Inter- and intraobserver agreement was moderate for the qualitative grading of collateral extent (CC = 0.46 and 0.60, respectively). Agreement was moderate (inter-CC = 0.60) to good (intra-CC = 0.73) for comparing pre- and post-treatment DSA. Clinical response was based on limb salvage, pain-free walking distance, ankle-brachial pressure index and pain scores. No difference was observed in the extent of collateral circulation between pre- and post treatment DSA after separate analysis of clinical responding and non-responding patients (P = 0.92). DSA is not a suited modality for the evaluation of therapeutic angiogenesis.