Editor's choice. A randomized controlled trial of the fascia suture technique compared with a suture-mediated closure device for femoral arterial closure after endovascular aortic repair.

OBJECTIVES: The aim was to investigate whether the fascia suture technique (FST) can reduce access closure time and procedural costs compared with the Prostar technique (Prostar) in patients undergoing endovascular aortic repair and to evaluate the short- and mid-term outcomes of both techniques. METHODS: In this two center trial, 100 patients were randomized to access closure by either FST or Prostar between June 2006 and December 2009. The primary endpoint was access closure time. Secondary outcome measures included access related costs and evaluation of the short- and mid-term complications. Evaluation was performed peri- and post-operatively, at discharge, at 30 days and at 6 months follow up. RESULTS: The median access closure time was 12.4 minutes for FST and 19.9 minutes for Prostar (p < .001). Prostar required a 54% greater procedure time than FST, mean ratio 1.54 (95% CI 1.25-1.90, p < .001) according to regression analysis. Adjusted for operator experience the mean ratio was 1.30 (95% CI 1.09-1.55, p = .005) and for patient body mass index 1.59 (95% CI 1.28-1.96, p < .001). The technical failure rate for operators at proficiency level was 5% (2/40) compared with 28% (17/59) for those at the basic level (p = .003). The proficiency level group had a technical failure rate of 4% (1/26) for FST and 7% (1/14) for Prostar, p = 1.00, while corresponding rates for the basic level group were 27% (6/22) for FST and 30% (11/37) for Prostar (p = .84). There was a significant difference in cost in favor of FST, with a median difference of €800 (95% CI 710-927, p < .001). CONCLUSIONS: In aortic endovascular repair FST is a faster and cheaper technique than the Prostar technique.

The next 10 years in the management of peripheral artery disease: perspectives from the 'PAD 2009' Conference.

OBJECTIVES: To briefly inform on the conclusions from a conference on the next 10 years in the management of peripheral artery disease (PAD). DESIGN OF THE CONFERENCE: International participation, invited presentations and open discussion were based on the following issues: Why is PAD under-recognised? Health economic impact of PAD; funding of PAD research; changes of treatment options? Aspects on clinical trials and regulatory views; and the role of guidelines. RESULTS AND CONCLUSIONS: A relative lack of knowledge about cardiovascular risk and optimal management of PAD patients exists not only among the public, but also in parts of the health-care system. Specialists are required to act for improved information. More specific PAD research is needed for risk management and to apply the best possible evaluation of evidence for treatment strategies. Better strategies for funding are required based on, for example, public/private initiatives. The proportion of endovascular treatments is steadily increasing, more frequently based on observational studies than on randomised controlled trials. The role of guidelines is therefore important to guide the profession in the assessment of most relevant treatment.

Costs in follow-up of endovascularly repaired abdominal aortic aneurysms. Magnetic resonance imaging with MR angiography versus EUROSTAR protocols.

AIM: Endovascular repair of abdominal aortic aneurysms (AAA) necessitates a long-term follow-up. These patients are often old and renal insufficiency is not unusual. Cost-effectiveness needs to be addressed in evaluating methods of follow-up. The aim of this study was to compare costs of 5 years follow-up with magnetic resonance imaging with contrast enhanced three-dimensional magnetic resonance angiography (MRI/MRA) with follow-up using CT with DSA, or CTA. We also assessed the impact of contrast media induced (CMI) nephropathy on follow-up costs. METHODS: We have implemented Swedish costs of CT with DSA, and CTA on the reported follow-up examinations from the EUROSTAR progress report 2000. The costs of follow-up with CT with DSA, or CTA were compared to a follow-up protocol with MRI/MRA. A cost analysis including a risk analysis of CMI nephropathy was made between MRI/MRA and CT with DSA, or CTA. RESULTS: Excluding the risk of CMI nephropathy, the 5 years follow-up cost in Euro ( ) with MRI/MRA ( 5715) is substantially higher than CT with DSA ( 3 095) or CTA ( 3573). The cost analysis favours MRI/MRA if the risk of CMI nephropathy from CT with DSA, or CTA is more than 5%. CONCLUSION: MRI/MRA can be cost-effective for follow-up of endovascularly repaired AAA depending on the risk of CMI nephropathy for CT with DSA, and CTA. MRI/MRA should be the method of choice for patients with pre-existing renal insufficiency.

Chronic venous disorders of the leg: epidemiology, outcomes, diagnosis and management. Summary of an evidence-based report of the VEINES task force. Venous Insufficiency Epidemiologic and Economic Studies.

BACKGROUND: To critically review the classification, epidemiology, outcomes, diagnosis and treatment of chronic venous disorders of the leg (CVDL), to issue evidence-based recommendations, and to identify areas requiring further research. METHODS: Articles identified by an extensive literature search were scored by members of an international task force. Only those articles with a moderate or strong rating for internal validity were retained. RESULTS: A scoring system weighing CVDL severity according to the probability of ulcer occurrence is proposed. Epidemiological data on the frequency of CVDL and its risk factors are reviewed. The following items are evaluated: costs associated with treatment; clinical outcomes related to CVDL and its treatment; available generic and disease-specific measures of quality of life; diagnostic procedures used to detect venous reflux; and efficacy of available treatments. CONCLUSIONS: CVDL is an important public health problem, based on its prevalence, cost and impact on quality of life. High-priority areas for research on CVDL are identified.