Costs and complications of endovascular inferior vena cava filter retrieval.

OBJECTIVE: Advanced endovascular techniques are frequently used for challenging inferior vena cava (IVC) filter retrieval. However, the costs of IVC filter retrieval have not been studied. This study compares IVC filter retrieval techniques and estimates procedural costs. METHODS: Consecutive IVC filter retrievals performed at a tertiary center between 2009 and 2014 were retrospectively reviewed. Procedures were classified as standard retrieval (SR) if they required only a vascular sheath and a snare device and as advanced endovascular retrieval (AER) if additional endovascular techniques were used for retrieval. Cost data were based on hospital bills for the procedures. Patients' characteristics, filter dwell time, retrieval procedure details, complications, and costs were compared between the groups. All statistical comparisons were performed using SAS 9.3 software. RESULTS: There were 191 IVC filter retrievals (SR, 157; AER, 34) in 183 patients (mean age, 55 years; 51% male). Fifteen filters (7.9%) were placed at an outside hospital. The indications for placement were mostly therapeutic (76% vs 24% for prophylaxis). All IVC filters were retrievable, with Bard Eclipse (Bard Peripheral Vascular, Tempe, Ariz; 34%) and Cook Günther Tulip (Cook Medical, Bloomington, Ind; 24%) the most common. Venous ultrasound examination of the lower extremities of 133 patients (70%) was performed before retrieval, whereas only 5 patients (2.6%) received a computed tomography scan of the abdomen. There was no difference in the mean filter dwell time in the two groups (SR, 147.9 ± 146.1 days; AER, 161.4 ± 91.3 days; P = .49). AERs were more likely to have had prior attempts at retrieval (23.5%) compared with SRs (1.9%; P < .001). The most common AER techniques used were the wire loop and snare sling (47.1%) and the stiff wire displacement (44.1%). Bronchoscopy forceps was used in four cases (11.8%); this was the only off-label device used. AERs were more likely to require more than one venous access site for the retrieval procedure (23.5% vs 0%; P < .001). AERs were significantly more likely to have longer fluoroscopy time (34.4 ± 18.3 vs 8.1 ± 7.9 minutes; P < .001) and longer total procedural time (102.8 ± 59.9 vs 41.1 ± 25.0 minutes; P < .001) compared with SRs. The complication rate was higher with AER (20.6%) than with SR (5.2%; P = .006). Most complications were abnormal radiologic findings that did not require additional intervention. The procedural cost of AER was significantly higher (AER, $14,565 ± $6354; SR, $7644 ± $2810; P < .001) than that of SR. This translated to an average increase in cost of $6921 ± $3544 per retrieval procedure for AER. CONCLUSIONS: Advanced endovascular techniques provide a feasible alternative when standard IVC filter retrieval techniques do not succeed. However, these procedures come with a higher cost and higher rate of complications.

Higher Inpatient Mortality for Women after Intervention for Lifestyle Limiting Claudication.

BACKGROUND: Sex-related differences in outcomes have been identified in patients with peripheral artery disease (PAD). We hypothesized that women with PAD would have equivalent inpatient mortality with men after vascular intervention. METHODS: Patients with a primary diagnosis of critical limb ischemia (CLI) or lifestyle-limiting claudication (LLC) receiving endovascular (EV) or open surgical repair from 2003-2012 were identified from the Nationwide Inpatient Sample. Demographics, comorbidities, and inpatient mortality were analyzed by chi-squared tests of independence and independent-samples t-tests. Logistic regression analysis was performed to identify predictors of inpatient mortality. SPSS 24 software was used with P < 0.05 considered statistically significant. RESULTS: We identified 139,435 (59,432 women and 80,003 men) individuals meeting the aforementioned criteria. Women were older than men (71.5 years vs. 68.2, P < 0.001). There were no differences in racial distribution but women had lower rates of diabetes (38.6% vs. 39.7%, P < 0.001), chronic obstructive pulmonary disease (17.9% vs. 19.5%, P < 0.001), and coronary artery disease (38.6% vs. 47.4%, P < 0.001), while having a higher rate of hypertension (60.0% vs. 56.1%, P < 0.001). There was no sex-related difference in the rate of chronic renal failure. Women had higher inpatient mortality than men after vascular intervention (1.3% vs. 1.1%, P < 0.001). When stratified by surgical technique, women also had higher inpatient mortality after EV repair (1.0% vs. 0.8%, P < 0.05) and open repair (1.9% vs 1.3%, P < 0.001). When separated by admitting diagnosis, women with CLI had higher inpatient mortality than men after open surgery (2.3% vs. 1.9%, P < 0.05) but not after EV intervention. Women with LLC had higher inpatient mortality after both open (0.6% vs. 0.3%, P < 0.05) and EV surgery (0.3% vs. 0.1%, P < 0.05). Regression analysis revealed female sex as an independent predictor of inpatient mortality in patients with LLC (OR, 1.74; 95% CI 1.30-2.32, P < 0.001) but not CLI. CONCLUSIONS: Women had higher inpatient mortality than men after vascular intervention for PAD. Women were also older and more likely to have EV intervention than men. Subgroup analysis suggests that these sex-related differences in inpatient mortality are more pronounced in patients with LLC than with CLI. Furthermore, regression analysis shows that sex is a significant predictor for patients diagnosed with LLC but not with CLI. Treatment guidelines should include consideration of sex in their indications for revascularization, particularly for patients diagnosed with LLC.

The effect of commercial insurance policies on outcomes of venous ablation.

OBJECTIVE: The use of venous ablation (VA) for treatment of chronic venous insufficiency has exponentially increased. To limit cost and overuse, insurance companies have adopted aleatory policies. The goal of this study was to compare the policies of five major local insurance carriers and to determine whether treatment within the criteria of a certain policy is associated with improved patient outcomes. METHODS: A retrospective single-center review of patients treated with VA was performed. Demographics, comorbidities, symptoms, and clinical class (Clinical, Etiology, Anatomy, and Pathophysiology classification) were recorded. Clinical success was defined on chart review by the patients' reporting of improvement or resolution of symptoms in the leg treated on follow-up, and technical success was defined by vein closure on ultrasound. Patients underwent a telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 before and after treatment of each leg as well as effects on quality of life (QOL). The policies of Aetna, Cigna, Anthem Blue Cross Blue Shield, UnitedHealthcare, and Connecticut Care were reviewed. The clinical and technical success rates were compared when veins were treated within the criteria of each policy. A subgroup analysis looking at patients who had clinical success only was performed to determine the potential rate of denial of coverage for each policy. A multivariable analysis was performed to determine independent predictors of clinical success. RESULTS: There were 253 patients with 341 legs treated. The mean age was 58.5 ± 15.2 years (68% women). The most common symptom was pain (89.7%), with 47.8% of patients having C3 disease. The clinical success, technical success, and complication rates were 84.2%, 95.1%, and 5.6%, respectively. On survey, there was improvement of the numeric rating scale score in 84.3% of legs treated after the procedure, and 76.7% continued to experience improvement after a mean follow-up of 26.8 months. There was improvement of QOL in 76.5% of patients. There was no significant difference in procedural success, technical success, complication rate, or improvement in QOL when patients were treated within any of the five insurance policies. On multivariable analysis, there was no single policy significantly associated with clinical success. However, subgroup analysis of procedures with clinical success (n = 287) showed a significant difference between the five policies on analysis of the potential denial of coverage, ranging from 5.6% for Connecticut Care to 64.1% for UnitedHealthcare (P < .0001). CONCLUSIONS: The different insurance policies have no correlation with outcomes of VA. Policies with more stringent criteria typically restrict treatment to larger veins and deny procedures to a significant number of patients with chronic venous insufficiency who can benefit from them.

Endovascular interventions decrease length of hospitalization and are cost-effective in acute mesenteric ischemia.

OBJECTIVE: Acute mesenteric ischemia (AMI) continues to be one of the most devastating diagnoses requiring emergent vascular intervention. There is a national trend toward increased use of endovascular procedures, with improved survival for the treatment of these patients. Our aim was to evaluate whether this trend has changed the treatment of AMI and the subsequent impact on length of hospitalization and hospitalization costs. METHODS: We identified all patients admitted for AMI from the National Inpatient Sample from 2004 to 2014 who received open surgical revascularization (OPEN) or an endovascular intervention (ENDO). Primary end points included length of hospital stay and cost of hospitalization. Our secondary end points included acute kidney injury (AKI), in-hospital mortality, and routine discharge. RESULTS: Among 10,381 discharges identified in the data set, 3833 (37%; 97.5% confidence interval [CI], 35%-39%) were male patients with a mean age of 69 years (range, 18-98 years); 4543 (44%; 97.5% CI, 41%-47%) patients were treated ENDO, and 5839 (56%; 97.5% CI, 53%-59%) patients were treated OPEN. Although a higher proportion of patients in the ENDO group (28%; 97.5% CI, 24%-31%) vs the OPEN group (14%; 97.5% CI, 11%-16%) had a moderate to severe Charlson Comorbidity Index (P < .0001), ENDO was associated with a lower mortality rate (12.3% [97.5% CI, 9.8%-14.8%] vs 33.1% [97.5% CI, 29.9%-36.2%]; P < .0001) and a lower mean hospitalization cost ($41,615 [97.5% CI, $38,663-$44,567] vs $60,286 [97.5% CI, $56,736-$63,836]; P < .0001). After propensity-adjusted logistic regression analysis, OPEN retained a significant association with higher mortality than ENDO (odds ratio, 3.0; 97.5% CI, 2.2-4.1) and with higher costs (mean, $9196; 97.5% CI, $3797-$14,595). Patients in the OPEN group had higher risk for AKI (P < .0001) and discharge to a skilled nursing facility (P < .0001) rather than home. CONCLUSIONS: Although the rate of ENDO continues to rise nationally, it still has not surpassed OPEN revascularization in the face of AMI. Patients treated endovascularly demonstrated one-third the rate of in-hospital mortality (odds ratio, 3.0; 97.5% CI, 2.2-4.1), an increased hazard ratio for discharge alive (hazard ratio, 2.27; 97.5% CI, 2.00-2.58), and a cost saving of $9196 (97.5% CI, $3797-$14,595) per hospitalization. Furthermore, they were less likely to develop AKI and to be discharged home after hospitalization.

Clinical Decision Analysis and Markov Modeling for Surgeons: An Introductory Overview.

This study addresses the use of decision analysis and Markov models to make contemplated decisions for surgical problems. Decision analysis and decision modeling in surgical research are increasing, but many surgeons are unfamiliar with the techniques and are skeptical of the results. The goal of this review is to familiarize surgeons with techniques and terminology used in decision analytic papers, to provide the reader a practical guide to read these papers, and to ensure that surgeons can critically appraise the quality of published clinical decision models and draw well founded conclusions from such reports.First, a brief explanation of decision analysis and Markov models is presented in simple steps, followed by an overview of the components of a decision and Markov model. Subsequently, commonly used terms and definitions are described and explained, including quality-adjusted life-years, disability-adjusted life-years, discounting, half-cycle correction, cycle length, probabilistic sensitivity analysis, incremental cost-effectiveness ratio, and the willingness-to-pay threshold.Finally, the advantages and limitations of research with Markov models are described, and new modeling techniques and future perspectives are discussed. It is important that surgeons are able to understand conclusions from decision analytic studies and are familiar with the specific definitions of the terminology used in the field to keep up with surgical research. Decision analysis can guide treatment strategies when complex clinical questions need to be answered and is a necessary and useful addition to the surgical research armamentarium.

Consequences of hypogastric artery ligation, embolization, or coverage.

OBJECTIVE: Interruption of the hypogastric artery by ligation, embolization, or coverage frequently results in ischemic complications. The aim of this study was to compare the rate and risk factors for the development of ischemic complications after interruption of the hypogastric artery in obstetrics and gynecology (OBG), vascular surgery, oncology, and trauma patients. METHODS: MEDLINE, Ovid, and Scopus were searched for articles containing data of patients who underwent interruption of the hypogastric artery. Based on the indication, details of the procedure, and complications developed, data were categorized and a systematic review was done to evaluate any significant differences. RESULTS: A total of 394 patients (median age, 48.5 years) from 124 papers were included in the study; 31% of the study population was male and 69% was female. Indication for interruption was OBG related in 53.3%, vascular surgery related in 25.1%, oncology related in 17.5%, and trauma related in 4.1% of patients. Overall ischemic complication rate was 22.6%, comprising buttock claudication in 12.2%, buttock necrosis in 4.8%, erectile dysfunction in 2.7%, spinal cord ischemia in 4.0%, colonic ischemia in 2.5%, and bladder necrosis in 0.8%. Complications were fewer in patients younger than the median age of 48.5 years (12.8%) compared with those older than the median age (36.3%; P < .01), women compared with men (13.1% vs 41.7%; P < .01), OBG patients compared with vascular surgery patients (9.5% vs 37.4%; P < .01), patients after ligation compared with embolization (9.4% vs 31.0%; P < .01), and proximal interruption compared with distal interruption (19.6% vs 51.4%; P < .01). No significant difference in complications was seen after bilateral interruption compared with unilateral interruption (20.6% vs 27.1%; P > .05). Similarly, no significant difference in complication rate was seen with the type of embolization material used. Among OBG patients, ligations resulted in fewer complications compared with embolization (4.1% vs 16.7%; P < .01). Among vascular surgery patients, bilateral embolization resulted in a higher rate of complications compared with bilateral ligation (83.3% vs 30.5%; P < .01). Among oncology patients, fewer complications were seen after proximal interruption compared with distal interruption (25.5% vs 75%; P = .01). No significant differences in outcome were seen with regard to gender, laterality, and material used for embolization when patients were compared within each specialty. CONCLUSIONS: Interruption of the hypogastric artery is relatively safe in young and OBG patients compared with vascular surgery and oncology patients. Ligation of the hypogastric arteries is preferred to embolization, and proximal embolization should be preferred to distal embolization to decrease the risk of ischemic complications. Randomized controlled trials with larger sample size are needed to definitively elucidate clear risk factors for development of complications after hypogastric artery interruption.

Cost-effectiveness of endovascular repair, open repair, and conservative management of splenic artery aneurysms.

OBJECTIVE: Open repair (OPEN) and conservative management (CONS) have been the treatments of choice for splenic artery aneurysms (SAAs) for many years. Endovascular repair (EV) has been increasingly used with good short-term results. In this study, we evaluated the cost-effectiveness of OPEN, EV, and CONS for the treatment of SAAs. METHODS: A decision analysis model was developed using TreeAge Pro 2013 software (TreeAge Inc, Williamstown, Mass) to evaluate the cost-effectiveness of the different treatments for SAAs. A hypothetical cohort of 10,000 55-year-old female patients with SAAs was assessed in the reference-case analysis. Perioperative mortality, disease-specific mortality rates, complications, rupture risks, and reinterventions were retrieved from a recent and extensive meta-analysis. Costs were analyzed with the 2014 Medicare database. The willingness to pay was set to $60,000/quality-adjusted life years (QALYs). Outcomes evaluated were QALYs, costs from the health care perspective, and the incremental cost-effectiveness ratio (ICER). Extensive sensitivity analyses were performed and different clinical scenarios evaluated. Probabilistic sensitivity analysis was performed to include the uncertainty around the variables. A flowchart for clinical decision-making was developed. RESULTS: For a 55-year-old female patient with a SAA, EV has the highest QALYs (11.32; 95% credibility interval [CI], 9.52-13.17), followed by OPEN (10.48; 95% CI, 8.75-12.25) and CONS (10.39; 95% CI, 8.96-11.87). The difference in effect for 55-year-old female patients between EV and OPEN is 0.84 QALY (95% CI, 0.42-1.34), comparable with 10 months in perfect health. EV is more effective and less costly than OPEN and more effective and more expensive compared with CONS, with an ICER of $17,154/QALY. Moreover, OPEN, with an ICER of $223,166/QALY, is not cost-effective compared with CONS. In elderly individuals (age >78 years), the ICER of EV vs CONS is $60,503/QALY and increases further with age, making EV no longer cost-effective. Very elderly patients (age >93 years) have higher QALYs and lower costs when treated with CONS. The EV group has the highest number of expected reinterventions, followed by CONS and OPEN, and the number of expected reinterventions decreases with age. CONCLUSIONS: EV is the most cost-effective treatment for most patient groups with SAAs, independent of the sex and risk profile of the patient. EV is superior to OPEN, being both cost-saving and more effective in all age groups. Elderly patients should be considered for CONS, based on the high costs in relation to the very small gain in health when treated with EV. The very elderly should be treated with CONS.

Economic development and diabetes prevalence in MENA countries: Egypt and Saudi Arabia comparison.

Diabetes is increasing in epidemic proportions globally, exhibiting the most striking increase in third world countries with emerging economies. This phenomena is particularly evident in the Middle East and North Africa (MENA) region, which has the highest prevalence of diabetes in adults. The most concerning indirect cost of diabetes is the missed work by the adult population coupled with the economic burden of loss of productivity. The major drivers of this epidemic are the demographic changes with increased life expectancy and lifestyle changes due to rapid urbanization and industrialization. Our focus is to compare MENA region countries, particularly Egypt and Saudi Arabia, in terms of their economic development, labor force diversity and the prevalence of diabetes.

Endovascular vs. open repair of complicated acute type B aortic dissections.

Purpose : To assess the comparative effectiveness of thoracic endovascular aortic repair (TEVAR) vs. open surgical repair (OSR) of complicated acute type B aortic dissections (cABAD) using decision analysis. Methods : A decision analysis comparing TEVAR and OSR for cABAD included variables extracted from the best-available evidence. Main outcomes were quality-adjusted life years (QALYs), presented with the 95% credibility intervals (CI), and number of reinterventions over the remaining lifetime. Different clinical scenarios, including age, gender, and risk profile were analyzed. Parameter uncertainty was analyzed using probabilistic sensitivity analysis. Results : In the reference case, a cohort of 55-year-old men, TEVAR was preferred over OSR: 7.07 QALYs (95% CI 6.77 to 7.38) vs. 6.34 QALYs (95% CI 6.04 to 6.66) for OSR. The difference of 0.73 QALYs (95% CI 0.29 to 1.17) is equal to 8.5 months in perfect health. TEVAR was more effective in all analyzed cases and age groups. Perioperative mortality was the most important variable affecting the difference between OSR and TEVAR, followed by the relative risk and percentage of aortic-related complications. Total expected reinterventions were 0.43/patient (TEVAR) and 0.35/patient (OSR). Conclusion : The results of this decision model for the treatment of cABAD suggest that TEVAR is preferred over OSR. Although a higher number of reinterventions is expected, the total effectiveness of TEVAR is higher for all age groups. OSR should be reserved for patients whose aortic anatomy is unsuitable for endovascular repair.

A comparison of open and endovascular revascularization for chronic mesenteric ischemia in a clinical decision model.

OBJECTIVE: Open revascularization (OR) has been the treatment of choice for chronic mesenteric ischemia (CMI) for many years, but endovascular revascularization (EV) has been increasingly used with good short-term results. In this study, we evaluated the comparative effectiveness and cost-effectiveness of EV and OR in patients with CMI refractory to conservative management. METHODS: A Markov-state transition model was developed using TreeAge Pro 2012 (TreeAge Inc, Williamstown, Mass) to simulate a hypothetical cohort of 10,000 65-year-old female patients with CMI requiring treatment with either OR or EV. Data for the model, including perioperative and long-term overall mortality risks, disease-specific mortality risks, complications, and reintervention and patency rates, were retrieved from original studies and systematic reviews about CMI. Costs were analyzed with the 2013 Medicare database. Outcomes evaluated were quality-adjusted life-years (QALYs), costs from the health care perspective, and the incremental cost-effectiveness ratio. Extensive sensitivity analyses were performed and different clinical scenarios evaluated. Probabilistic sensitivity analysis was performed to assess robustness of the model. RESULTS: For a reference-case 65-year-old female patient with CMI and an average risk for operation, EV is preferred with 10.03 QALYs (95% credibility interval [CI], 9.76-10.29) vs 9.59 after OR (95% CI, 9.29-9.87). The difference is comparable to 5 months in perfect health: 0.44 QALY (95% CI, 0.13-0.76). For 65-year-old men, this was 8.71 QALYs (95% CI, 8.48-8.94) for EV vs 8.42 (95% CI, 8.14-8.63) for OR. Sensitivity analysis showed that for younger patients, EV results in a higher increase in QALYs compared with older patients. Total expected reinterventions per patient are 1.70 for EV vs 0.30 for OR. Total expected health care costs for the reference-case patient were $39,942 (95% CI, $28,509-$53,380) for OR and $38.217 (95% CI, $29,329-$48,309) for EV. For men, this was $39,375 (95% CI, $28,092-$52,853) for OR and $35,903 (95% CI, $27,685-$45,597) for EV. For patients younger than 60 years, EV is a more expensive treatment strategy compared with OR, but with an incremental cost-effectiveness ratio for EV of less than $60,000/QALY. For patients 60 years and older, EV dominated OR as preferential treatment because effectiveness was higher than for OR and costs were lower. CONCLUSIONS: The results of this decision analysis model suggest that EV is favored over OR for patients with CMI in all age groups. Although EV is associated with more expected reinterventions, EV appears to be cost-effective for all age groups.

A clinical decision model for selecting the most appropriate therapy for uncomplicated chronic dissections of the descending aorta.

OBJECTIVE: The optimal treatment for patients with uncomplicated chronic Stanford type B aortic dissections (chTBADs) is still matter of debate. The purpose of this study was to design a decision tool to guide the surgeon in determining the preferred treatment option. METHODS: A Markov decision-analysis model compared chTBAD patients treated with initial open surgical repair (OSR), thoracic endovascular aortic repair (TEVAR), and optimal medical therapy (OMT), followed during follow-up by OSR (OMT-OSR) or TEVAR (OMT-TEVAR), if indicated. Procedural risks, aortic growth and rupture rates, outcomes, and quality of life values were derived from the best available evidence in the literature. A chTBAD treatment strategy decision tool was developed, including the four key variables of age, sex, surgical risk, and maximum initial aortic diameter. Primary outcome was quality-adjusted life-years (QALYs). RESULTS: For the reference patient cohort, 55-year-old men with chTBAD with a maximum aortic diameter of 5.0 cm, medium risk for surgery, and a threshold for surgery of 6.0 cm during follow-up, OSR yielded higher QALYs, with 10.06 QALYs (95% credibility interval [CI], 9.52-10.56 QALYs) vs 9.92 QALYs (95% CI, 9.23-10.58 QALYs) after TEVAR and 9.64 QALYs (95% CI, 9.38-9.88 QALYs) and 9.40 QALYs (95% CI, 9.11-9.69 QALYs) for OMT-OSR and OMT-TEVAR. The difference between OSR and OMT-OSR was 0.42 QALYs (95% CI, 0.01-0.81 QALYs) and between TEVAR and OMT-TEVAR was 0.52 QALYs (95% CI, 0.04-0.68 QALYs). This showed that intervention is preferred over OMT. A change of the four variables resulted in a change of preferred treatment. In general, OSR was the preferred treatment in younger patients with a larger aortic diameter and in low-risk patients. TEVAR was preferred in elderly patients with large aortic diameter and if the aortic diameter threshold for repair decreased. OMT was the optimal therapy in high-risk patients, elderly patients, or in patients with small aortic diameters. CONCLUSIONS: This decision-analysis model shows that there is no "one-size-fits-all" treatment for uncomplicated chTBADs. For the reference patient cohort, intervention is preferred over OMT. Age is the most important deciding factor, followed by initial aortic diameter. Immediate OSR is the preferred treatment option in younger patients with a large initial aortic diameter and in low-risk patients. Immediate TEVAR is preferred in elderly patients with a large initial aortic diameter and in patients with a lower threshold for OSR. OMT should be considered in high-risk patients, in patients with small initial aortic diameters, and in patients aged >80 years, unless their initial aortic diameter is >5.5 cm. However, the differences in some patient groups are clinically insignificant, allowing a major role for patient preferences and hospital-specific considerations. This clinical decision model may guide chTBAD treatment.

Decision analysis model of open repair versus endovascular treatment in patients with asymptomatic popliteal artery aneurysms.

OBJECTIVE: Repair is indicated of asymptomatic popliteal artery aneurysms (aPAAs) that are >2 cm. Endovascular PAA repair with covered stents (stenting) is increasingly used. It is, however, unclear when an endovascular approach is preferred to traditional open repair with great saphenous vein bypass (GSVB). The goal of this study was to assess the treatment options for aPAAs using decision analysis. METHODS: A Markov model was developed and a hypothetic cohort of patients with aPAAs was analyzed. GSVB, stenting, and nonoperative management with optimal medical treatment (OMT) were compared. Operative mortality, patency rates, quality-of-life values, and costs were determined by comprehensive review of the best available evidence. The main outcome was quality-adjusted life-years (QALYs). Secondary outcomes were cost-effectiveness and number of reinterventions. RESULTS: For a 65-year-old male patient with a 2.0-cm aPAA and without significant comorbidities, probabilistic sensitivity analysis shows that intervention is preferred over OMT (5.77 QALYs, 95% credibility interval [CI], 5.43-6.11; OMT). GSVB treatment for this patient results in slightly higher QALYs than stent placement, with a predicted 8.43 QALYs (GSVB: 95% CI, 8.21-8.64) vs 8.07 QALYs (stenting: 95% CI, 7.84-8.29), a difference of 0.36 QALYs (95% CI, 0.14-0.58). Furthermore, costs are higher for stenting ($40,464; 95% CI, $34,814-$46,242) vs GSVB ($21,618; 95% CI, $15,932-$28,070), and more reinterventions are required after stenting (1.03 per patient) vs GSVB (0.52 per patient), making GSVB the preferred strategy for all outcomes considered. Stenting is preferred in patients who are at high risk for open repair (>6% 30-day mortality) or if the 5-year primary patency rates of stenting increase to 80%. For very old patients (>95 years) and patients with a very short life expectancy (<1.5 years), OMT yields higher QALYs. CONCLUSIONS: GSVB is the preferred treatment in 65-year-old patients with aPAAs for all outcomes considered. However, patients at high risk for open repair or without suitable vein should be considered as candidates for endovascular repair. Very elderly patients and patients with a short life expectancy are best treated with OMT. Further improvement of endovascular techniques that increase patency rates of endovascular stents could make this the preferred therapy for more patients in the future.

Contemporary assessment of foot perfusion in patients with critical limb ischemia.

Significant progress in limb salvage for patients with peripheral arterial disease and critical limb ischemia has occurred in the past 2 decades. Improved patient outcomes have resulted from increased knowledge and understanding of the disease processes, as well as efforts to improve revascularization techniques and enhance patient care after open and endovascular procedures. An imaging modality that is noninvasive, fast, and safe would be a useful tool for clinicians in assessing lower-extremity perfusion when planning interventions. Among the current and emerging regional perfusion imaging modalities are transcutaneous oxygen monitoring, hyperspectral imaging, indocyanine green dye-based fluorescent angiography, nuclear diagnostic imaging, and laser Doppler. These tests endeavor to delineate regional foot perfusion to guide directed revascularization therapy in patients with critical limb ischemia and foot ulceration.

Application of Porter's Five Forces Model and generic strategies for vascular surgery: should be stuck in the middle?

There are many stakeholders in the vascular marketplace from clinicians to hospitals, third party payers, medical device manufacturers and the government. Economic stress, threats of policy reform and changing health-care delivery are adding to the challenges faced by vascular surgeons. Use of Porter's Five Forces analysis to identify the sources of competition, the strength and likelihood of that competition existing, and barriers to competition that affect vascular surgery will help our specialty understand both the strength of our current competition and the strength of a position that our specialty will need to move to. By understanding the nature of the Porter's Five Forces as it applies to vascular surgery, and by appreciating their relative importance, our society would be in a stronger position to defend itself against threats and perhaps influence the forces with a long-term strategy. Porter's generic strategies attempt to create effective links for business with customers and suppliers and create barriers to new entrants and substitute products. It brings an initial perspective that is convenient to adapt to vascular surgery in order to reveal opportunities.Vascular surgery is uniquely situated to pursue both a differentiation and high value leadership strategy.