Applying a Computer-based Warfarin Management System at a Large Tertiary Cardiovascular Center in Iran.

BACKGROUND: Regarding adjustments to warfarin dosage, numerous studies have shown that computerized methods are superior to those based on personal experience. OBJECTIVES: To report the efficacy of a computer-based warfarin management system (WMS) in the Iranian population. METHODS: By utilizing the existing dosing algorithms and obtaining expert opinions, we developed a computer-based WMS at a large tertiary cardiovascular center. The time in therapeutic range (TTR) and the number of international normalized ratio (INR) tests of clinic patients were compared before and after the implementation of WMS. RESULTS: Overall, 803 patients with 5407 INR tests were included in the before phase and 679 patients with 4189 INR tests in the after phase. The mean TTR was 57.3% before and 59% after WMS implementation (mean difference, 1.64, 95% CI: -1.12 to 4.40). In the before phase, the mean number of INR tests was 6.7, which dropped to 6.1 tests in the after phase (mean difference, -0.61, 95% CI: -0.97 to -0.24). Only 54.5% of the warfarin dosing prescriptions were consistent with the dosing recommendations of the WMS, and adherence to the WMS was poorest in the highest INR target range. CONCLUSIONS: For the first time in Iran, we demonstrated that a computerized system was as effective as a traditional experience-based method to monitor INR in VKA-anticoagulated patients. Furthermore, it could reduce both the number of INR tests and that of visits.

Aortic Arch Debranching and Thoracic Endovascular Aortic Repair (TEVAR) for Type B Aortic Dissection.

BACKGROUND: Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD. METHODS: A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant. RESULTS: A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n = 10) and 29.3% (n = 17). CONCLUSIONS: Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions.

Outcomes of chronic total occlusion percutaneous coronary intervention from the RAIAN (RAjaie - Iran) registry.

OBJECTIVE: While most of the evidence in CTO interventions emerge from Western and Japanese studies, few data have been published up today from the Middle East. Objective of this study was to evaluate technical success rates and clinical outcomes of an Iranian population undergoing CTO PCI in a tertiary referral hospital. Moreover, we sought to evaluate the efficacy of our CTO teaching program. METHODS: This is a retrospective single-center cohort study including 790 patients who underwent CTO PCI performed by operators with different volumes of CTOs PCI performed per year. According to PCI result, all patients have been divided into successful (n = 555, 70.3 %) and unsuccessful (n = 235, 29.7 %) groups. Study endpoints were Major Adverse Cardiovascular Events and Health Status Improvement evaluated using the Seattle Angina Questionnaire at one year. RESULTS: A global success rate of 70 % for antegrade and 80 % for retrograde approach was shown despite the lack of some CTO-dedicated devices. During the enrollment period, the success rate increased significantly among operators with a lower number of CTO procedures per year. One-year MACE rate was similar in both successful and unsuccessful groups (13.5 % in successful and 10.6 % in unsuccessful group, p = 0.173). One year patients' health status improved significantly only in successful group. CONCLUSIONS: No significant differences of in-hospital and one-year MACE were found between the successful and unsuccessful groups. Angina symptoms and quality of life significantly improved after successful CTO PCI. The RAIAN registry confirmed the importance of operator expertise for CTO PCI success.

Prevalence and associated factors of chronic venous disease among the modern Iranian urban population.

OBJECTIVES: Chronic venous disease (CVD) of the lower extremities is one of the common venous diseases in different populations, with a wide range of clinical manifestations and undetermined exact prevalence owing to different population characteristics and measurement methods. This study aimed to estimate the prevalence of CVD among the modern Iranian urban population and determine its associated risk factors. METHODS: The Heart Assessment and Monitoring in Rajaie Hospital study, a longitudinal population-based cohort, aims to investigate the baseline prevalence and the 10-year incidence of cardiovascular diseases and associated risk factors in the adult population aged 30 to 75 years with no overt cardiovascular diseases in Tehran. Two instructed interventional cardiologists performed CVD evaluation using the Clinical-Etiology-Anatomy-Pathophysiology classification. CVD was graded as C1 to C6, and chronic venous insufficiency (CVI) as C3 to C6. A multivariable regression model was used to analyze the association between CVD and prespecified covariates of age, sex, body mass index (≥30 kg/m2), smoking, hypertension, diabetes mellitus, physical activity, dyslipidemia, and delivery method. RESULTS: CVD prevalence among 1176 participants was 36.5% (95% confidence interval [CI], 33.8-39.3) and was higher in women than men (44.2% vs 23.5%). CVI prevalence was only 0.7% (95% CI, 0.3-1.3). Multivariable analysis showed that advanced age (odds ratio [OR], 1.06; 95% CI, 1.04-1.08), female sex (OR, 2.98; 95% CI, 2.14-4.14), and body mass index of ≥30 (OR, 1.36; 95% CI, 1.03-1.81) were independently associated with CVD. Physical activity (OR, 0.77; 95% CI, 0.58-1.02) was nearly protective, whereas other factors, including traditional cardiovascular risk factors, had no meaningful association with CVD. CONCLUSIONS: Our findings showed that CVD was prevalent in the modern Iranian urban population. However, considering the very low prevalence of the higher stages of the disease, the benefit of mass screening is debatable, and better risk discriminators should be investigated.

Cross-cultural validity of the Pulmonary Embolism Quality of Life questionnaire in the quality of life survey after pulmonary embolism: A Persian-speaking cohort.

Background: The Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire is the first disease-specific scale for assessing the quality of life in patients with a history of pulmonary embolism (PE). Objectives: To assess the cross-cultural validity and reliability of the disease-specific PEmb-QoL questionnaire. Methods: The Persian version was prepared through the forward and backward translation of the English questionnaire. Six months after the diagnosis of acute PE, consecutive Persian-speaking patients were asked to complete the PEmb-QoL, the generic 36-item Short Form (SF-36) questionnaires and undertake a 6-minute walk test (6MWT). Acceptability was assessed via item missing rate, reproducibility by the test-retest method, and internal consistency reliability by Cronbach's α and McDonald's ω coefficients. Convergence validity was assessed using the Spearman rank correlation between scores of PEmb-QoL, SF-36, and 6MWT. The questionnaire structure was evaluated through exploratory factor analysis. Results: Ninety-six patients with a confirmed diagnosis of PE completed the questionnaires. The Persian version of PEmb-QoL had good internal consistency (α = 0.95, 3-factor ω = 0.96), inter-item correlation (0.3-0.62), item-total correlation (0.38-0.71), reproducibility (test-retest ICC with 25 participants = 0.92-0.99), and good discriminant validity. Convergence validity was confirmed by the moderate-to-high correlations between PEmb-QoL and SF-36 scores, and a good correlation between the "limitation in daily activities" dimension of the PEmb-QoL questionnaire and 6MWT results. Exploratory factor analysis suggested a 3-component structure with functional (items 1h, 4b-5d, 6, 8, 9i, and 9j), symptoms (1b-h, 7, and 8), and emotional (5a, 6, and 9a-h) components. Conclusion: The Persian version of the PEmb-QoL questionnaire is valid and reliable for measuring the disease-specific quality of life in patients with PE.

Post-Pulmonary Embolism Impairment Six Months after Acute Pulmonary Embolism: A Prospective Registry.

BACKGROUND: Little evidence is available on post-pulmonary embolism impairment (PPEI), a recently defined complication of pulmonary embolism (PE) encompassing dysfunctional clinical and imaging parameters. In the present study, we sought to evaluate its frequency with a focus on the main components. METHODS: In this prospective registry, we included patients with a confirmed diagnosis of acute PE and focused on those with initial right ventricular (RV) dysfunction. Their baseline, pre-discharge, and 6 month follow-up clinical and imaging characteristics were recorded. The main study outcomes were incomplete RV functional recovery, exercise capacity limitations (based on the 6 minute walk test), and their combination, which defines PPEI, within six months of acute PE. RESULTS: Of 170 consecutive patients with a confirmed diagnosis of acute PE, 123 accepted to participate in the follow-up study, of whom 87 had initial RV dysfunction. The 6 month rates of incomplete RV functional recovery, signs of an intermediate-to-high echocardiographic probability of PH, and exercise limitations were observed in 58.6, 32.1, and 45.9%, respectively. A total of 22 (25.2%; 95% CI 15.5-34.4%) patients had PPEI. The RV/LV ratio and the fractional area change on discharge after acute PE were more often impaired among patients with incomplete RV recovery, exercise limitations, and a high probability of PH at 6 months. In contrast, an initial impaired RV diastolic function indices appeared to characterize patients with a limited exercise capacity at 6 months. DISCUSSION: PPEI affects one fourth of patients surviving acute PE with half of them presenting with RV dysfunction or exercise limitations.

Ethnic & Sex Disparities in Type B Aortic Dissection Patients Undergoing Thoracic Endovascular Aortic Repair: An International Perspective.

BACKGROUND: There has been a revolution in the management of type B aortic dissection (TBAD) over the last 2 decades due to the increasing development of endovascular techniques, with the prime example being thoracic endovascular aortic repair (TEVAR). However, many controversies concerning the use of TEVAR in TBAD exist. For instance, there is little available evidence suggesting any differences in demographics, disease characteristics, intervention technicalities, and clinical outcomes between males and females as well as different ethnicities when undergoing TEVAR for TBAD, both in the short and long term. Also, there is no risk prediction model/tool available. The objective of this international study is to describe and delineate the disparities between male and female patients of different ethnicities in terms of demographics, disease and interventional characteristics, and clinical outcomes. METHODS: Over 17 years a total of 58 TBAD patients were admitted to 2 tertiary vascular centres and treated using TEVAR. Mortality, postoperative complications and reintervention data were recorded for the first 30 days after the procedure as well as during follow-up. Follow-up for all patients lasted until the study endpoint or until a patient's death. Data were analysed retrospectively using IBM SPSS statistical package 26 for Windows. RESULTS: The mean age was similar between the 2 groups, with the majority of patients in both being Caucasian. More than half of the males had complicated TBAD, while the majority of females were classed as having uncomplicated disease. The most commonly utilized proximal and distal landing zone for the TEVAR stent graft was zone 2 and zone 4, respectively. The mean proximal stent diameter was significantly larger in males compared to females (P = 0.004). The difference in mean distal diameter between the 2 groups was insignificant (P = 0.721). The mean total stent coverage of the thoracic aorta was 251.3 mm in male patients compared to 291.2 mm in females (P = 0.203). A total of 32 patients underwent adjunctive procedures. Seven (17%) of the males had one or more postoperative complications compared to 2 (12%) females. Nine (22%) males underwent a reintervention procedure post TEVAR compared to only 1 (6%) female (P = 0.136). Overall, males had a mortality rate of 24% (n = 10) compared to 41% of females (n = 7) (P = 0.201). Estimated survival of males and females post TEVAR was 80.4 ± 9.6 months and 69.7 ± 14.4 months (P = 0.428). For the total population, the number of stent grafts was inversely correlated with mortality. CONCLUSIONS: Despite the favourable clinical outcomes achieved by TEVAR in TBAD, there remains a grey area concerning its management. Thus, it is important to perform risk stratification of individual patients using their demographics and comorbidities, particularly scrutinizing patient sex and ethnic origin, when considering intervention for TBAD to achieve optimum results.

Catheter-Directed Thrombolysis vs Anticoagulation in Patients With Acute Intermediate-High-risk Pulmonary Embolism: The CANARY Randomized Clinical Trial.

Importance: The optimal treatment of intermediate-high-risk pulmonary embolism (PE) remains unknown. Objective: To assess the effect of conventional catheter-directed thrombolysis (cCDT) plus anticoagulation vs anticoagulation monotherapy in improving echocardiographic measures of right ventricle (RV) to left ventricle (LV) ratio in acute intermediate-high-risk PE. Design, Setting, and Participants: The Catheter-Directed Thrombolysis vs Anticoagulation in Patients with Acute Intermediate-High-Risk Pulmonary Embolism (CANARY) trial was an open-label, randomized clinical trial of patients with intermediate-high-risk PE, conducted in 2 large cardiovascular centers in Tehran, Iran, between December 22, 2018, through February 2, 2020. Interventions: Patients were randomly assigned to cCDT (alteplase, 0.5 mg/catheter/h for 24 hours) plus heparin vs anticoagulation monotherapy. Main Outcomes and Measures: The proportion of patients with a 3-month echocardiographic RV/LV ratio greater than 0.9, assessed by a core laboratory, was the primary outcome. The proportion of patients with an RV/LV ratio greater than 0.9 at 72 hours after randomization and the 3-month all-cause mortality were among secondary outcomes. Major bleeding (Bleeding Academic Research Consortium type 3 or 5) was the main safety outcome. A clinical events committee, masked to the treatment assignment, adjudicated clinical outcomes. Results: The study was prematurely stopped due to the COVID-19 pandemic after recruiting 94 patients (mean [SD] age, 58.4 [2.5] years; 27 women [29%]), of whom 85 patients completed the 3-month echocardiographic follow-up. Overall, 2 of 46 patients (4.3%) in the cCDT group and 5 of 39 patients (12.8%) in the anticoagulation monotherapy group met the primary outcome (odds ratio [OR], 0.31; 95% CI, 0.06-1.69; P = .24). The median (IQR) 3-month RV/LV ratio was significantly lower with cCDT (0.7 [0.6-0.7]) than with anticoagulation (0.8 [0.7-0.9); P = .01). An RV/LV ratio greater than 0.9 at 72 hours after randomization was observed in fewer patients treated with cCDT (13 of 48 [27.0%]) than anticoagulation (24 of 46 [52.1%]; OR, 0.34; 95% CI, 0.14-0.80; P = .01). Fewer patients assigned to cCDT experienced a 3-month composite of death or RV/LV greater than 0.9 (2 of 48 [4.3%] vs 8 of 46 [17.3%]; OR, 0.20; 95% CI, 0.04-1.03; P = .048). One case of nonfatal major gastrointestinal bleeding occurred in the cCDT group. Conclusions and Relevance: This prematurely terminated randomized clinical trial of patients with intermediate-high-risk PE was hypothesis-generating for improvement in some efficacy outcomes and acceptable rate of major bleeding for cCDT compared with anticoagulation monotherapy and provided support for a definitive clinical outcomes trial. Trial Registration: ClinicalTrials.gov Identifier: NCT05172115.

Cardiac device to plug an aorto-bronchial fistula.

BACKGROUND: Post-coarctoplasty aortic pseudoaneurysms constitute a lethal problem occurring in up to 38% of patients with a history of aortic coarctation surgical repair. Such pseudoaneurysms are prone to rupture if managed conservatively and high mortality and morbidity if treated with open surgery. Therefore, the endovascular approach has been proposed for their management. CASE REPORT: We describe a patient with a post-coarctoplasty aortic pseudoaneurysm complicated by an aortobronchial fistula. The case was treated via the endovascular approach (thoracic endovascular aortic repair and endovascular coarctoplasty) with an atrial septal defect occluder device. CONCLUSIONS: Endovascular repair is a feasible, safe, and promising treatment for thoracic aortic pseudoaneurysms secondary to coarctation repair.

A rare case of left inferior vena cava presenting with May-Thurner syndrome.

BACKGROUND: May-Thurner anomaly is characterized as external venous compression by the arterial framework against hard bony structures. This chronic anatomical lesion infrequently leads to deep vein thrombosis in the lower extremity, and it may lead to leg swelling as a long-term post-thrombotic complication. Left iliac vein compression may not be as uncommon as was previously thought, and it typically occurs in women more than men. Congenital anomalies of venous tree are not rare; they exist in 8.7% of the general population. CASE-PRESENTATION: We herein present the first case of right-sided May Thurner Syndrome in a patient with IVC anomalies. In our patient, both common iliac veins formed the left-sided IVC, which extended to the hemiazygos vein and the superior vena cava. Additionally, there was a right-sided suprarenal IVC, which extended to the right atrium. CONCLUSION: Understanding the proper anatomy in May-Thurner syndrome helps in better decision making for management of disease pathophysiology.

Variceal Veins Embolization and Left Renal Vein Stenting in a Patient with Combined Nutcracker and May-Thurner Syndrome.

Nutcracker syndrome is defined as a compression of left renal vein leading to symptomatic hematuria and flank pain. There are very few reports about its association with May-Thurner syndrome that is related to compression of left iliac vein causing severe leg edema. We are reporting a rare case of a patient having both conditions successfully treated with sequential percutaneous interventions. This case and treatment options are discussed in detail.

Reliability and validity of a satisfaction questionnaire on virtual education in the coronavirus disease 2019 pandemic era aimed at cardiology faculty members.

BACKGROUND: In the coronavirus disease 2019 pandemic era, clinical programs and mandatory hands-on activities have been supplanted by remote teaching to maintain the fundamental capabilities of medical training and to furnish medical students with quality education. Nonetheless, the satisfaction of faculty members with this training method in the current pandemic has yet to be assessed. The aim of this study was to design a Persian questionnaire with appropriate validity and reliability on cardiology professors' satisfaction level with virtual education. MATERIALS AND METHODS: In this cross-sectional study, a questionnaire was devised drawing upon scientific sources and Iranian medical educators' expertise. Seventeen faculty members in various specialties evaluated the questionnaire concerning face and content validity. Content validity was assessed through the calculation of the content validity ratio (CVR) (values >0.62 were considered acceptable) and the content validity index (CVI) (values >0.79 were considered acceptable), construct validity was evaluated through principal component factor analysis by the Kaiser-Meyer-Olkin (KMO) statistic and Bartlett's sphericity test, internal reliability was measured through the calculation of Cronbach's alpha coefficient, and consistency was appraised through the use of test-retest reliability at two different time points. RESULTS: The questionnaire had a reliability rate of 95%, indicating high internal validity. Concerning test-retest reliability, the intraclass correlation coefficient was 0.96 (P < 0.001), demonstrating relatively good stability. The CVI was 0.81, and the CVR was 0.85. The KMO measure of sampling adequacy was 0.954, indicating the acceptability of the degree of common variance among the all items. CONCLUSIONS: This Persian questionnaire on virtual education aimed at cardiology faculty members in the current pandemic with its low question count and appropriate domains had high reliability and validity. By knowing the level of professors' satisfaction with the new method of education, it is possible to take steps to better provide specialized medical education to cardiology residents.

Cardiac solution for a vascular scenario!

BACKGROUND: Ascending aortic pseudoaneurysms (AAPs) constitute a rare, albeit potentially dangerous, condition that occurs in up to 13% of patients after cardiac or aortic surgeries. For patients with a history of cardiac surgery, repeat thoracotomy poses additive risks. The high morbidity and mortality rates associated with the surgical management of AAPs have led to the development of transcatheter approaches. CASE REPORT: We report a case of AAP percutaneous closure at the site of aortic cannulation with an ASO device in a post-CABG 65-year-old man, who refused surgery. CONCLUSION: The use of the Amplatzer Atrial Septal Defect Occluder (ASO) device represents an acceptable alternative to surgery in treatment of Ascending aortic pseudoaneurysms.

Balloon-Expandable Cheatham-Platinum Stents Versus Self-Expandable Nitinol Stents in Coarctation of Aorta: A Randomized Controlled Trial.

OBJECTIVES: This study sought to compare the safety and efficacy of the balloon-expandable stent (BES) and the self-expandable stent (SES) in the endovascular treatment of coarctation of aorta. BACKGROUND: Coarctoplasty with stents has conferred promising results. Although several nonrandomized studies have approved the safety and efficacy of the BES and the SES, no high-quality evidence exists for this comparison. METHODS: In the present open-label, parallel-group, blinded endpoint randomized pilot clinical trial, adult patients with de novo native aortic coarctation were randomized into Cheatham-platinum BES and uncovered nitinol SES groups. The primary outcome of the study was a composite of procedural and vascular complications. The secondary outcomes of the study consisted of the incidence of aortic recoarctation, thoracic aortic aneurysm/pseudoaneurysm formation, and residual hypertension at a 12-month follow-up. RESULTS: Among 105 patients who were screened between January 2017 and December 2019, 92 eligible patients (32 women [34.8%]) with a median age of 30 years (IQR: 20-36 years) were randomized equally into the BES and SES groups. The composite of procedural and vascular complications occurred in 10.9% of the BES group and 2.2% of the SES group (odds ratio: 0.18; 95% CI: 0.02-1.62; P = 0.20). Aortic recoarctation occurred in 5 patients (5.4%), 3 patients (6.5%) in the BES group and 2 patients (4.3%) in the SES group (odds ratio: 0.65; 95% CI: 0.10-4.09; P = 0.64). Only 1 patient (1.1%) was complicated by aortic pseudoaneurysm. Hypertension control was achieved in 50% of the study population, with an equal distribution in the 2 study groups at the 12-month follow-up. CONCLUSIONS: Both the BES and the SES were safe and effective in the treatment of native coarctation.

The evaluation of efficacy of atmospheric pressure plasma in diabetic ulcers healing: A randomized clinical trial.

The aim of this study is to evaluate the efficacy and safety of cold atmospheric plasma (CAP) as a novel therapy for diabetic foot ulcers. This was an investigator-blinded, randomized controlled trial of 14 weeks (6 weeks of treatment and 8 weeks of follow-up). Twenty patients with diabetic foot ulcers were divided into two groups: the control group receiving standard wound care and the plasma group, which received CAP twice a week for six consecutive weeks in addition to standard wound care. The ulcer size, amount of exudate, and wound grading were determined weekly. Cold plasma was produced by applying a high voltage (4.5 kV) and a high frequency (22 kHz) to helium gas. Exudate from wounds treated with CAP showed a significant reduction in the third week after complete treatment (p = 0.039). The wound grading of the ulcers improved by the sixth week (p = 0.019), and the sizes of ulcers significantly decreased in the plasma group at the end of the treatment period (p = 0.007). In this randomized clinical trial, CAP was an effective treatment option for diabetic foot ulcers in terms of wound surface reduction and antibacterial effects.

Cost-effectiveness of a population-based AAA screening program for men over 65 years old in Iran.

BACKGROUND: Screening program tend to recognized patients in their early stage and consequently improve health outcomes. Cost-effectiveness of the abdominal aortic aneurysm (AAA) screening program has been scarcely studied in developing countries. We sought to evaluate the cost-effectiveness of a screening program for the abdominal aortic aneurysm (AAA) in men aged over 65 years in Iran. METHODS: A Markov cohort model with 11 mutually exclusive health statuses was used to evaluate the cost-effectiveness of a population-based AAA screening program compared with a no-screening strategy. Transitions between the health statuses were simulated by using 3-month cycles. Data for disease transition probabilities and quality of life outcomes were obtained from published literature, and costs were calculated based on the price of medical services in Iran and the examination of the patients' medical records. The outcomes were life-years gained, the quality-adjusted life-year (QALY), costs, and the incremental cost-effectiveness ratio (ICER). The analysis was conducted for a lifetime horizon from the payer's perspective. Costs and effects were discounted at an annual rate of 3%. Uncertainty surrounding the model inputs was tested with deterministic and probabilistic sensitivity analyses. RESULTS: The mean incremental cost of the AAA screening strategy compared with the no-screening strategy was $140 and the mean incremental QALY gain was 0.025 QALY, resulting in an ICER of $5566 ($14,656 PPP) per QALY gained. At a willingness-to-pay of 1 gross domestic product (GDP) per capita ($5628) per QALY gained, the probability of the cost-effectiveness of AAA screening was about 50%. However, at a willingness-to-pay of twice the GDP per capita per QALY gained, there was about a 95% probability for the AAA screening program to be cost-effective in Iran. CONCLUSIONS: The results of this study showed that at a willingness-to-pay of 1 GDP per capita per QALY gained, a 1-time AAA screening program for men aged over 65 years could not be cost-effective. Nevertheless, at a willingness-to-pay of twice the GDP per capita per QALY gained, the AAA screening program could be cost-effective in Iran. Further, AAA screening in high-risk groups could be cost-effective at a willingness-to-pay of 1 GDP per capita per QALY gained.

Spontaneous Intramural Esophageal Hematoma Secondary to Thrombolysis in the Setting of Pulmonary Embolism.

Intramural hematoma of the esophagus (IHE) represents a rare condition on the spectrum of esophageal injuries. The most common symptoms are hematemesis, epigastric pain or retrosternal chest pains, odynophagia, and dysphagia. Early recognition of IHE is important as it may mimic other diseases such as myocardial infarction, pulmonary embolism, Mallory-Weiss tears, Boerhaave's syndrome, ruptured aortic aneurysms, and aortic dissection. Computed tomography is the preferred investigation method, and treatment is usually conservative. We herein present 2 cases of IHE associated with catheter-directed thrombolysis in the setting of pulmonary embolism.