Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States.

OBJECTIVES: Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective. METHODS: Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years. RESULTS: Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention. CONCLUSION: Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.

Variations in utilization and clinical outcomes for endoscopic sphenopalatine artery ligation and endovascular arterial embolization in a single multi-hospital network.

PURPOSE: Endoscopic sphenopalatine artery ligation (ESPAL) and endovascular arterial embolization (EAE) are increasingly common treatment options for patients with refractory epistaxis. The objective of this study was to compare the utilization pattern and clinical outcomes between these interventions within our single multi-hospital network. MATERIALS AND METHODS: A retrospective study of all patients undergoing ESPAL and/or EAE within any of the hospitals in a single healthcare network between 2008 and 2017 was conducted. We compared differences in procedure utilization with various hospital characteristics. Secondarily, we evaluated clinical outcomes and costs associated with each procedure. RESULTS: Forty-three ESPAL and 33 EAE procedures were performed across 7 hospitals, with the majority of procedures being performed at teaching institutions (65% and 91%, p = .013). The majority of both interventions were performed in larger hospitals and EAE patients were more likely to undergo inter-hospital transfer compared to ESPAL patients (48.5% and 16.3%, p = .02). Success rates for ESPAL and EAE were comparable (95% and 93%); however, the median direct cost of treatment for EAE was significantly higher than the cost for ESPAL ($12984.89 and $5002.02, p < .0001). CONCLUSIONS: The majority of both ESPAL and EAE interventions were performed at teaching and larger hospitals. Transfers occurring prior to EAE may have been due to the limited availability of interventional radiology services, and likely contributed to the increased cost of treatment. ESPAL is a known cost-effective management strategy and should be considered early in treatment algorithms of refractory epistaxis.

Cost determinants in management of brain arteriovenous malformations.

INTRODUCTION: There is little data on the cost of treating brain arteriovenous malformations (AVMs). The goal of this study then is to identify cost determinants in multimodal management of brain AVMs. METHODS: One hundred forty patients with brain AVMs prospectively enrolled in the UCSF brain AVM registry and treated between 2012 and 2015 were included in the study. Patient and AVM characteristics, treatment type, and length of stay and radiographic evidence of obliteration were collected from the registry. We then calculated the cost of all inpatient and outpatient encounters, interventions, and imaging attributable to the AVM. We used generalized linear models to test whether there was an association between patient and AVM characteristics, treatment type, and cost and length of stay. We tested whether the proportion of patients with radiographic evidence of obliteration differed between treatment modalities using Fisher's exact test. RESULTS: The overall median cost of treatment and interquartile range was $77,865 (49,566-107,448). Surgery with preoperative embolization was the costliest treatment at $91,948 (79,914-140,600), while radiosurgery was the least at $20,917 (13,915-35,583). In multi-predictor analyses, hemorrhage, Spetzler-Martin grade, and treatment type were significant predictors of cost. Patients who had surgery had significantly higher rates of obliteration compared with radiosurgery patients. CONCLUSIONS: Hemorrhage, AVM grade, and treatment modality are significant cost determinants in AVM management. Surgery with preoperative embolization was the costliest treatment and radiosurgery the least; however, surgical cases had significantly higher rates of obliteration.

In-hospital cost analysis of prostatic artery embolization compared with transurethral resection of the prostate: post hoc analysis of a randomized controlled trial.

OBJECTIVES: To perform a post hoc analysis of in-hospital costs incurred in a randomized controlled trial comparing prostatic artery embolization (PAE) and transurethral resection of the prostate (TURP). PATIENTS AND METHODS: In-hospital costs arising from PAE and TURP were calculated using detailed expenditure reports provided by the hospital accounts department. Total costs, including those arising from surgical and interventional procedures, consumables, personnel and accommodation, were analysed for all of the study participants and compared between PAE and TURP using descriptive analysis and two-sided t-tests, adjusted for unequal variance within groups (Welch t-test). RESULTS: The mean total costs per patient (±sd) were higher for TURP, at €9137 ± 3301, than for PAE, at €8185 ± 1630. The mean difference of €952 was not statistically significant (P = 0.07). While the mean procedural costs were significantly higher for PAE (mean difference €623 [P = 0.009]), costs apart from the procedure were significantly lower for PAE, with a mean difference of €1627 (P < 0.001). Procedural costs of €1433 ± 552 for TURP were mainly incurred by anaesthesia, whereas €2590 ± 628 for medical supplies were the main cost factor for PAE. CONCLUSIONS: Since in-hospital costs are similar but PAE and TURP have different efficacy and safety profiles, the patient's clinical condition and expectations - rather than finances - should be taken into account when deciding between PAE and TURP.

Yttrium-90 Radioembolization Is Cost Effective in Intrahepatic Cholangiocarcinoma: A SEER Medicare Population Study.

PURPOSE: To analyze the cost-effectiveness of radioembolization in the treatment of intrahepatic cholangiocarcinoma (ICC) using the Surveillance, Epidemiology, and End Results (SEER) Medicare cancer database. MATERIALS AND METHODS: Cost as measured by total treatment-related reimbursement in patients diagnosed with ICC who received chemotherapy alone or chemotherapy and yttrium-90 radioembolization was assessed in the SEER Medicare cancer database (1999-2012). Survival analysis was performed, and incremental cost-effectiveness ratios were generated. RESULTS: The study included 585 patients. Average age at diagnosis was 71 years (standard deviation: 9.9), and 52% of patients were male. Twelve percent of patients received chemotherapy with radioembolization (n = 72), and 88% of patients (n = 513) received only chemotherapy. Median survival was 1043 days (95% confidence interval [CI]: 894-1244) for chemotherapy plus radioembolization and 811 days (95% CI: 705-925) for chemotherapy alone (P = .02). Patients who received combination therapy were slightly younger (71 vs 69 years, P = .03). No significant differences were observed between treatment groups in age at treatment, sex, race, or city size. Multivariable analysis showed a hazard ratio for progression for combination therapy versus chemotherapy alone of 0.76 (95% CI: 0.59-0.97, P = .029). The incremental cost-effectiveness ratio, a measure of cost of each added year of life, was $50,058.65 per year (quartiles: $11,454.63, $52,763.28). CONCLUSIONS: Combination therapy of ICC with chemotherapy and radioembolization is associated with higher median survival and can be a cost-effective treatment, with a median cost of $50,058.65 per additional year of survival.

Preoperative Inferior Mesenteric Artery Embolization is a Cost-effective Technique that May Reduce the Rate of Aneurysm Sac Diameter Enlargement and Reintervention After EVAR.

BACKGROUND: Type II endoleaks are the most common complications after endovascular repair of abdominal aortic aneurysms (EVARs). Some studies have shown the benefit of preventive inferior mesenteric artery (IMA) embolization, but its efficacy and cost-effectiveness continue to be controversial. The aim of this study was to evaluate the efficacy of this procedure on the increase in aneurysmal sac diameter during follow-up. MATERIALS AND METHODS: All consecutive patients who underwent the embolization of the IMA before EVAR in our center, between January 2014 and July 2016, were included. We retrospectively compared the diameter of the aortic aneurysm sac, the rate of endoleak and reinterventions, and the theoretical cost of management between these patients (group 2) and a historical cohort of patients treated for EVAR before January 2014 who did not undergo prior IMA embolization (group 1). RESULTS: Two hundred twenty-four patients were retrospectively analyzed. After exclusion, we compared a group of 37 embolized patients with a control group of 46 patients. The rate of enlargement in the aneurysmal sac diameter was significantly higher in the control group at 2 years (27.9% vs. 4.3%, P = 0.025). The type II endoleak rate at 2 years was significantly higher in the control group (53.1% vs. 18.2%, P = 0.012), as was the aneurysm-related reintervention rate (31.1% vs. 8.1%, P = 0.013). Multivariate analysis confirmed these results. At 2 years of follow-up, there was no difference in the overall cost of patient management between the 2 groups. CONCLUSIONS: Preventive IMA embolization is an effective, reliable, and cost-effective technique that seems to reduce the rate of the aneurysmal sac diameter enlargement, type II endoleak, and reinterventions after EVAR.

Cost-effectiveness of trans-nasal endoscopic sphenopalatine artery ligation vs arterial embolisation for intractable epistaxis: Long-term analyses.

OBJECTIVES: Trans-nasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular arterial embolisation both provide excellent success rates for intractable epistaxis. Recent economic models suggest that TESPAL could be a cost-saving strategy. Our main aim was to perform cost-effectiveness analyses on TESPAL compared with embolisation to treat patients with epistaxis. DESIGN: We performed retrospective, monocentric, comparative analyses on patients referred to our centre and treated with embolisation or TESPAL. SETTING: This economic evaluation was carried out from a payer's perspective (ie French National Health Insurance) within a time horizon of 12 months. PARTICIPANTS: Thirty-seven TESPAL procedures and thirty-nine embolisation procedures to treat intractable epistaxis were used in the analyses. MAIN OUTCOME MEASURES: The primary outcome is presented as the cost per 1% of non-recurrence. Effectiveness was defined as avoiding recurrence of epistaxis during the 1-year follow-up. Cost estimates were performed from the payer's perspective. RESULTS: Hospitalisation costs were higher for embolisation compared with TESPAL (5972 vs 3769 euros). On average, hospitalisation costs decreased by 41% when a patient was treated by TESPAL compared with an embolisation strategy (P = 0.06). The presence of comorbidities increased hospitalisation costs by 79% (P = 0.04). TESPAL enabled 1867€ to be gained in intractable epistaxis. CONCLUSIONS: The outcomes from our decision model confirm that TESPAL is more cost-effective for patients with intractable epistaxis.

Overstenting the hypogastric artery during endovascular aneurysm repair with and without prior coil embolization: A comparative analysis from the ENGAGE Registry.

BACKGROUND: Endovascular aneurysm repair of aortoiliac or iliac aneurysms is often performed with stent graft coverage of the origin of the hypogastric artery (HA) to ensure adequate distal seal. It is considered common practice to perform adjunctive coiling of the HA to prevent a type II endoleak. Our objective was to question the necessity of pre-emptive coiling by comparing the outcomes of HA coverage with and without prior coil embolization. METHODS: Data from the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE), which prospectively enrolled 1263 endovascular aneurysm repair patients between March 2009 and April 2011 from multiple centers worldwide, were used for this study. We identified patients in whom the Endurant stent graft (Medtronic Vascular, Santa Rosa, Calif) covered one or both HAs and grouped them into cases in which prior HA embolization-coils or plugs-was performed (CE) and cases in which HA embolization was not performed (NE). The occurrence of covered HA-related endoleak and secondary interventions were compared between groups. RESULTS: In 197 patients, 225 HAs were covered. Ninety-one HAs were covered after coil embolization (CE group), and 134 HAs were covered without prior coil embolization (NE group). Both groups were similar at baseline and had comparable length of follow-up to last image (665.2 ± 321.7 days for CE patients; 641.6 ± 327.6 days for NE patients; P = .464). Importantly, both groups showed equivalent iliac morphology concerning common iliac artery proximal, mid, and distal dimensions and tortuosity, making them suitable for comparative analysis. During follow-up, HA-related endoleaks were sparse and occurred equally often in both groups (CE 5.5% vs NE 3.0%; P = .346). Secondary intervention to resolve an HA-related endoleak was performed twice in the CE group and three times in the NE group. Late non-HA-related endoleaks occurred more often in the CE group compared with the NE group, (25.0% vs 15.0%; P = .080). Secondary interventions for other reasons than HA-related endoleaks occurred in 7.5% of NE cases and 15.4% of CE cases (P = .057), mostly for occlusions in the ipsilateral iliac limb. During follow-up, 19 NE patients and 9 CE patients died, which is not significantly different (P = .225), and no deaths were related directly or indirectly to HA coverage. Also, no reports of gluteal necrosis and bowel ischemia were made. CONCLUSIONS: This study shows that HA coverage with the Endurant endograft without prior coil embolization does not increase the incidence of endoleak or related secondary interventions. These findings together with the already available evidence suggest that omission of coil embolization may be a more resource-effective strategy whenever HA coverage is required.

Trans-arterial radioembolization for intermediate-advanced hepatocellular carcinoma: a budget impact analysis.

BACKGROUND: Trans-arterial radio-embolization (TARE) is an emerging treatment for the management of hepatocellular carcinoma (HCC). TARE may compete with systemic chemotherapy, sorafenib, in intermediate stage patients with prior chemoembolization failure or advanced patients with tumoral macrovascular invasion with no extra-hepatic spread and good liver function. We performed a budget impact analysis (BIA) evaluating the expected changes in the expenditure for the Italian Healthcare Service within scenarios of increased utilization of TARE in place of sorafenib over the next five years. METHODS: Starting from patient level data from three oncology centres in Italy, a Markov model was developed to project on a lifetime horizon survivals and costs associated to matched cohorts of intermediate-advanced HCC patients treated with TARE or sorafenib. The initial model has been integrated with epidemiological data to perform a BIA comparing the current scenario with 20 and 80% utilization rates for TARE and sorafenib, respectively, with increasing utilization rates of TARE of 30, 40 and 50% over the next 1, 3 and 5 years. RESULTS: Compared to the current scenario, progressively increasing utilization rates of TARE over sorafenib in the next 5 years is expected to save globally about 7 million Euros. CONCLUSIONS: Radioembolization can be considered a valuable treatment option for patients with intermediate-advanced HCC. These findings enrich the evidence about the economic sustainability of TARE in comparison to standard systemic chemotherapy within the context of a national healthcare service.

Comparison of polyvinyl alcohol copolymer with detachable balloons for the embolisation of direct carotid cavernous fistula: a single-centre experience.

OBJECTIVES: To characterise the safety, efficacy and cost of direct carotid-cavernous fistula (CCF) treatment using polyvinyl alcohol copolymer or detachable balloons. METHODS: We reviewed retrospectively patients with direct CCFs treated with either a detachable balloon or polyvinyl alcohol copolymer at our hospital from 2005 to 2015 and identified 94 patients with 105 CCFs. All patients had follow-up angiograms. The CCF occlusion rate, procedure complication rate, treatment expense and operation time were recorded. RESULTS: With a mean of 5.4 months of angiographic follow-up, the complete occlusion rate and recanalisation rate of the polyvinyl alcohol copolymer group was not significantly different from that of the detachable balloon group. The treatment expense was much higher and the operation time was much longer in the polyvinyl alcohol copolymer group than the detachable balloon group (P < 0.001). CONCLUSIONS: Embolisation of CCF with polyvinyl alcohol copolymer is as safe and effective as detachable balloon but has a much higher cost and longer operation time. KEY POINTS: • Carotid-cavernous fistula results from a damaged carotid artery. • Detachable balloons have been used with success for many years. • Some reported excellent outcomes after embolisation with polyvinyl alcohol copolymer. • Treatment expense is much higher in the polyvinyl alcohol copolymer group.

Real-World Data for the Evaluation of Transarterial Radioembolization versus Sorafenib in Hepatocellular Carcinoma: A Cost-Effectiveness Analysis.

OBJECTIVES: To perform a cost-effectiveness analysis comparing the use of transarterial radioembolization (TARE) with that of sorafenib in the treatment of patients with intermediate or advanced hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer staging system. METHODS: Patient-level data were consecutively recorded and collected at three oncology centers in Italy. A propensity score matching was performed to compare patients with similar clinical characteristics who underwent TARE or sorafenib treatment. Clinical data from the matched cohorts were used to populate a Markov model to project, on a lifetime horizon, life years, quality-adjusted life years, and economic outcomes associated with TARE and sorafenib for both intermediate and advanced HCC stages. RESULTS: Starting from data covering 389 and 241 patients who underwent TARE and sorafenib treatment, respectively, the propensity score matching yielded a total of 308 matched patients. For intermediate-stage patients, the model estimated for TARE versus sorafenib an incremental cost-utility ratio of €3,302/QALY (incremental cost-effectiveness ratio of €1,865 per life year gained), whereas for patients in advanced stage TARE dominated (lower costs and greater health improvements) compared with sorafenib. CONCLUSIONS: From an Italian health care service perspective, TARE could be a cost-effective strategy in comparison with sorafenib for patients with intermediate or advanced HCC. The results from forthcoming randomized controlled trials comparing TARE with sorafenib will be able to confirm or reject the validity of this preliminary evaluation. In the meantime, decision makers can use these results to control and coordinate the diffusion of the technology.

Embo-EVAR: A Technique to Prevent Type II Endoleak? A Single-Center Experience.

BACKGROUND: Intraprocedural aneurysm sac embolization (embo-EVAR) during endovascular abdominal aneurysm repair (EVAR) using coils and fibrin glue is a technique for preventing type II endoleak (EII). Our aim is to evaluate feasibility, safety and clinical outcome of this promising approach. MATERIALS AND METHODS: A retrospective clinical case analysis of 72 patients who underwent EVAR during the period 2011-2014. Two groups were compared at 6 and 12 months follow-up with contrast media computed tomography scan and contrast-enhanced ultrasound (CEUS) imaging: consecutively, 36 patients (group A) treated with classic EVAR and 36 patients (group B) treated with embo-EVAR. Coils were released filling better as possible the aneurysm sac; the embolization was completed by injecting fibrin glue. Device and materials used, differential systemic and sac pressures, presence of any endoleak, and complication were registered. RESULTS: In our experience, we had 100% technical success without surgical conversion. Embo-EVAR was performed, after endograft deployment, in group B patients, all with ratio of Δ-pressures (obtained from Δ-sac pressure/Δ-differential pressure) > 0.16. No early or late complications occurred and mortality was nil. Follow-up was performed with computed tomography-angiography and CEUS at 6 and 12 months. We observed 9 type II and 1 type Ia endoleak in group A and 2 type II and 1 type Ib endoleaks in group B. Mean radiation exposure time was 30.3 min in group A and 43.3 min in group B. EVAR procedure average cost was 9,000 €. The average cost of sac embolization was 1,500€. CONCLUSIONS: Although a randomized study is necessary, embo-EVAR may be a valid approach to prevent type II endoleaks and further complications. Mild costs and exposure-dose increase could be accepted to avoid reinterventions, and in our experience, it could be routinely performed with excellent results.

Pipeline embolization device versus coiling for the treatment of large and giant unruptured intracranial aneurysms: a cost-effectiveness analysis.

OBJECTIVE Rupture of large or giant intracranial aneurysms leads to significant morbidity, mortality, and health care costs. Both coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for the treatment of unruptured large and giant intracranial aneurysms; however, the relative cost-to-outcome ratio is unknown. The authors present the first cost-effectiveness analysis to compare the economic impact of the PED compared with coiling or no treatment for the endovascular management of large or giant intracranial aneurysms. METHODS A Markov model was constructed to simulate a 60-year-old woman with a large or giant intracranial aneurysm considering a PED, endovascular coiling, or no treatment in terms of neurological outcome, angiographic outcome, retreatment rates, procedural and rehabilitation costs, and rupture rates. Transition probabilities were derived from prior literature reporting outcomes and costs of PED, coiling, and no treatment for the management of aneurysms. Cost-effectiveness was defined, with the incremental cost-effectiveness ratios (ICERs) defined as difference in costs divided by the difference in quality-adjusted life years (QALYs). The ICERs < $50,000/QALY gained were considered cost-effective. To study parameter uncertainty, 1-way, 2-way, and probabilistic sensitivity analyses were performed. RESULTS The base-case model demonstrated lifetime QALYs of 12.72 for patients in the PED cohort, 12.89 for the endovascular coiling cohort, and 9.7 for patients in the no-treatment cohort. Lifetime rehabilitation and treatment costs were $59,837.52 for PED; $79,025.42 for endovascular coiling; and $193,531.29 in the no-treatment cohort. Patients who did not undergo elective treatment were subject to increased rates of aneurysm rupture and high treatment and rehabilitation costs. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about the costs and mortality risks for PED and coiling. Probabilistic sampling demonstrated that PED was the cost-effective strategy in 58.4% of iterations, coiling was the cost-effective strategy in 41.4% of iterations, and the no-treatment option was the cost-effective strategy in only 0.2% of iterations. CONCLUSIONS The authors' cost-effective model demonstrated that elective endovascular techniques such as PED and endovascular coiling are cost-effective strategies for improving health outcomes and lifetime quality of life measures in patients with large or giant unruptured intracranial aneurysm.

Management of Epistaxis - A Single Centre Experience and Economic Considerations.

Epistaxis represents the most common ENT emergency and its management has been a focus of audit recently, with consideration given to the associated economic burden. The aim of our study is to evaluate the management of epistaxis in terms of treatments used, duration of stay, recurrence and cost. A retrospective review of hospital inpatient enquiry (HIPE) data from a single secondary referral centre was undertaken during a four year period. Four hundrefd and thirty-four patients were identified. The majority (n= 262, 60.3%) were male and the average age was 64.2 years. The vast majority (n=362, 83.4%) were managed non-operatively. Only 15 patients (3.4%) were managed surgically. The average length of stay was 2.5 days and did not vary greatly between the treatment groups. The recurrence rate was 8.2% (n=36). Approximate costs of packing vs EUA and cautery suggest that packing alone is more economical but more data is needed to fully compare the options.

Safety, efficacy, and cost of surgery for patients with unruptured aneurysms deemed unsuitable for endovascular therapy.

BACKGROUND: Open surgery is a frequent option given to patients with unruptured intracranial aneurysms (UIAs) unsuitable for endovascular repair. Since the risk of rupture of UIAs is generally low, we determined whether the risks and costs of surgery in this patient subset are warranted. METHODS: The safety, efficacy, and costs of minimally invasive surgery by minicraniotomy were evaluated in 102 consecutive patients with anterior circulation UIAs deemed unsuitable for endovascular repair by an interdisciplinary conference of surgeons and neurointerventionalists. Data from 107 UIA patients treated by endovascular means in the same period were used as the standard. RESULTS: Surgical patients comprised a different subset of aneurysms, with more MCA and fewer paraophthalmic aneurysms (54 vs. 6, p < 0.0001 and 4 vs. 60, p < 0.0001, for minicraniotomy and endovascular, respectively). However, surgery incurred shorter anesthesia time (197.7 vs. 149.3 min, p < 0.0001), higher rates of complete aneurysm obliteration (94.57 vs. 66.67 %, p < 0.0001), and lower overall hospital costs ($8,287 CAD vs. $17,732 CAD, p < 0.0001) than the endovascular cohort. There were no treatment-related surgical deaths, but one patient had an mRS of 3 after 6 months due to temporal lobe epilepsy and memory problems. This compared favorably with the endovascular cohort in which two patients died due to treatment (mRS = 6) and one suffered a severe stroke (mRS = 5 at 6 months). CONCLUSIONS: For patients counseled to undergo treatment but have UIAs unsuitable for endovascular repair, surgery is safe, effective, and cost-efficient.

Cost effectiveness of radioembolization compared with conventional transarterial chemoembolization for treatment of hepatocellular carcinoma.

PURPOSE: To assess cost effectiveness of radioembolization versus conventional transarterial chemoembolization. MATERIALS AND METHODS: The cost of radioembolization versus conventional transarterial chemoembolization was determined based on Medicare reimbursements. Three patient subgroups were defined based on the Barcelona Clinic Liver Cancer (BCLC) classification system (A, B, or C). Efficacy and safety outcomes after each procedure were obtained from the literature. A Monte Carlo case-based simulation was designed for 60 months in 250 patients in each subgroup. Survival was calculated based on average survival from the literature and the Monte Carlo model. The primary outcome was the cost effectiveness of radioembolization over transarterial chemoembolization by considering calculated survival. RESULTS: The costs approached $17,000 for transarterial chemoembolization versus $31,000 or $48,000 for unilobar or bilobar radioembolization, respectively. Based on the simulation, median estimated survival was greater with transarterial chemoembolization than radioembolization in BCLC-A and BCLC-B subgroups (40 months vs 30 months and 23 months vs 16 months, respectively, P = .001). However, in the BCLC-C subgroup, survival was greater with radioembolization than transarterial chemoembolization (13 months vs 17 months, P = .001). The incremental cost-effectiveness ratio of radioembolization over transarterial chemoembolization in the BCLC-C subgroup was $360 per month. The results were dependent on bilobar versus unilobar radioembolization and the total number of radioembolization procedures. CONCLUSIONS: The model suggests radioembolization costs may be justified for patients with BCLC-C disease, whereas radioembolization may not be cost effective in patients with BCLC-A disease; however, many patients with BCLC-C disease have extensive disease precluding locoregional therapies. Secondary considerations may determine treatment choice in more borderline patients (BCLC-B disease) because there is no persistent survival benefit with radioembolization.

Reinterventions for type 2 endoleaks with enlargement of the aneurismal sac after endovascular treatment of abdominal aortic aneurysms.

BACKGROUND: Type 2 endoleaks after the endovascular treatment (EVAR) of abdominal aorta aneurysms (AAAs) remain a concern for vascular surgeons, especially when they are associated with an enlargement of the persistent aneurysmal sac. The purpose of this study is to evaluate the effectiveness of secondary reinterventions for type 2 endoleaks associated with enlargement of the aneurysmal sac after EVAR. METHODS: The incidence of endoleaks, aneurysmal sac diameters, and reinterventions were collected from the clinical and radiologic data of the patients treated by EVAR for AAA with >1 year of follow-up. Patients with a type II endoleak associated with an enlargement of the aneurysmal sac were identified; their operative data and the results of the secondary procedures were recorded. The principal criterion of evaluation was the effectiveness of these reinterventions on the evolution of the diameter of the AAA. The secondary criteria were death rate related to aneurysm and the average costs of these additional procedures. RESULTS: In 232 patients treated by EVAR with an average of 2 years of follow-up (23 ± 30 months), 15 type I (6.5%), 94 type II (40.5%), and 8 type III (3.5%) endoleaks were identified. Among the 94 AAAs with a type II endoleak, 21 had a regression of the aneurysmal sac (22.5%), 46 were stable (49.5%), and 27 continued to grow (28%), including 9 because of another type of endoleak. Among the 18 patients presenting with a type II endoleak linked with an enlargement of the aneurysmal sac, 14 were treated with endovascular embolization, 1 was treated by conventional aneurysmectomy, and 3 patients were followed-up only. Among 14 patients treated by embolization, 9 (60%) presented with persistent enlargement of the aneurysmal sac after embolization, of which 5 were finally treated by conventional treatment with 1 postoperative death. The average cost per patient that required a reintervention for a type II endoleaks was €28,096 ± €30,490 ($37,530 ± $40,728). CONCLUSION: Endovascular reinterventions for type II endoleaks associated with an enlargement of the aneurysmal sac after EVAR have a poor effectiveness on the stabilization of the diameter of the AAA. These procedures involve an high cost and high rates of morbidity, which should be taken into account in their use.

A cost outcome study of varicocoele embolisation and future pregnancy in an Australian public hospital setting.

INTRODUCTION: Varicocoele is commonly encountered in males with infertility. Studies have shown that varicocoele repair (surgery or embolisation) can improve the rate of subsequent pregnancy. In Australia, there have been no studies assessing the cost of varicocoele embolisation and current practice is based on international data. This study aimed to assess the cost of varicocoele embolisation and estimate the treatment cost per pregnancy. METHODS: Retrospective cost-outcome study of patients treated by embolisation between January 2018 and 2023. A bottom-up approach was used to calculate procedure costs whereas a top-down approach was used to calculate costs for all other patient services, including direct and indirect costs. To calculate cost per pregnancy, costs were adjusted according to existing published data on the rate of pregnancy after embolisation. RESULTS: Costing data from 18 patients were included, of median age 33.5 years (range 26-60) and median varicocoele grade 2.5 (range 1-3). All patients had unilateral treatment, most commonly via right internal jugular (16 patients, 89%) and using a 0.035″ system (17 patients, 94%). The median cost for the entire treatment including procedural, non-procedural, ward and peri-procedural costs was AUD$2208.10 (USD$1405 or EUR€1314), range AUD$1691-7051. The projected cost to the healthcare system per pregnancy was AUD$5387 (USD$3429 or EUR€3207). CONCLUSION: Total varicocoele embolisation cost and the cost per-pregnancy were lower than for both embolisation and surgical repair in existing international studies. Patients undergoing varicocoele treatment should have the option to access an interventional radiologist to realise the benefits of this low-cost pinhole procedure.

Cost Savings on Inpatient Hospitalization for Middle Meningeal Artery Embolization in the Setting of Increased Case Volume and Low Complications Rate.

BACKGROUND: Middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematomas (cSDHs) is becoming increasingly prevalent. It is essential to optimize the safety and cost effectiveness of the postprocedural management. In this study, we examined our cases over time to determine the most appropriate postprocedural destination. METHODS: This is a retrospective study of patients who underwent MMA embolization for cSDH at our institution. The study cohort was divided into 2 groups based on the year of embolization. Baseline characteristics, postprocedural complications, and length of stay were compared. Patients with shorter intensive care unit (ICU) stay were also compared to those with longer stay. Univariate statistical analysis was performed. RESULTS: 92 MMA embolizations for cSDH have been performed at our institution, of which 36 (39.1%) were done between 2019 and 2022 and 56 (60.9%) after 2023. No patients experienced stroke, cranial nerve palsy, or intraparenchymal hemorrhage after embolization. All but 5 patients were admitted to the ICU postembolization, of which 59 (64.1%) were downgraded after one day. Factors associated with a longer ICU stay included preoperative location (P = 0.002) and need for surgery (P = 0.02). Of those who came from home or nonmonitored bed, 82% were downgraded from the ICU in less than 2 days. The average cost of one night in the ICU, intermediate care, and nonmonitored unit was $3671.75, $2605.22, and $2303.81 respectively. CONCLUSIONS: MMA embolization for cSDH is a safe procedure with low rate of procedure-related complications. In carefully selected patients, the necessity ICU admission postoperatively should be weighed against better hospital resource utilization.

Validity of the Cost-Effectiveness of Middle Meningeal Artery Embolization Following Hematoma Evacuation for Initial Chronic Subdural Hematoma.

BACKGROUND: Despite numerous articles about middle meningeal artery embolization (MMAE) highlighting its efficacy and safety for recurrent chronic subdural hematoma (CSDH), the appropriateness of adjunctive MMAE after hematoma evacuation for initial CSDH remains unclear from a cost-effectiveness perspective. METHODS: Patients with CSDH were enrolled in this study and were prospectively divided into 2 groups: the "conventional treatment" group, which was treated with hematoma evacuation alone, and the "MMAE" group, which was treated with adjunctive MMAE after hematoma evacuation. The proportion of patients requiring retreatment, length of hospital stay, economic costs, and modified Rankin Score were compared between the 2 groups. RESULTS: In this study, 53 cases were included, with 30 classified into the conventional treatment group and 23 classified into the MMAE group. In the conventional treatment group, the proportion of patients who required surgical retreatment was higher than that in the MMAE group (16.7% vs. 8.7%). The relative risk was 0.522 (95% confidence interval, 0.111-2.45). Although the addition of MMAE increased the cost per hospitalization by 26%, the increase in cost per patient was limited to 12%, owing to the reduction in patients who relapsed and required a second hospitalization. The increase in cost was not statistically significant. The MMAE group had a significantly higher proportion of patients with favorable outcomes (modified Rankin Score 0-2) (56.7% vs. 87.0%, P = 0.0328). CONCLUSIONS: By minimizing the increase in hospitalization days and procedure costs, MMAE following hematoma evacuation for initial CSDH could decrease the retreatment rate and balance the total medical costs associated with MMAE.