The financial evolution of endovascular aneurysm repair delivery in contemporary practice.

OBJECTIVE: The fiscal impact of endovascular repair (EVR) of aortic aneurysms and the requisite device costs have previously highlighted the tenuous long-term financial sustainability among Medicare beneficiaries. The Centers for Medicare & Medicaid Services have since reclassified EVR remuneration paradigms with new Medicare Severity Diagnosis-Related Groups (MS-DRGs) intended to better address the procedure's cost profile. The impact of this change remains unknown. The purpose of this analysis was to compare EVR-specific costs and revenue among Medicare beneficiaries both before and after this change. METHODS: All infrarenal EVRs performed in fiscal years (FYs) 2014 and 2015, before the MS-DRG change, and those performed in FYs 2017 and 2018, after the MS-DRG change, were identified using the DRG codes 238 (n = 108) and 269 (n = 84), respectively. We then identified those who were treated according to the instructions for use guidelines with a single manufacturer's device and billed to Medicare (n = 23 in FY14-15; n = 22 in FY17-18). From these cohorts, we determined total procedure technical costs, technical revenue, and net technical margin in conjunction with the hospital finance department. Results were then compared between these two groups. RESULTS: The two cohorts demonstrated similar demographic profiles (FY14-15 vs FY17-18 cohort: age, 78 years vs 74 years; median length of stay, 1.0 day vs 1.0 day). Mean total technical costs were slightly higher in the FY17-18 group ($24,511 in FY14-15 vs $26,445 in FY17-18). Graft implants continued to account for a significant portion of the total cost, with the device cost accounting for 56% of the total procedure costs in both cohorts. Net revenue was greater in the FY17-18 group by $5800 ($30,698 in FY14-15 vs $36,498 in FY17-18), resulting in an increased overall margin in the FY17-18 group compared with the FY14-15 group ($6188 in FY14-15 vs $10,053 in FY17-18). CONCLUSIONS: Device costs remain the single greatest cost driver associated with EVR delivery. DRG reclassification of EVR to address total procedure and implant costs appears to better address the requisite associated procedure costs and may thereby better support long-term fiscal sustainability of this procedure for hospitals and health systems alike.

Fenestrated endovascular aneurysm repair is financially viable at a high-volume medical center with positive hospital contribution margins and physician payment.

OBJECTIVE: To examine hospital finances and physician payment associated with fenestrated endovascular aneurysm repair (FEVAR) for complex aortic disease at a high-volume center and to compare the costs and reimbursements for FEVAR with open repair, and their trends over time. METHODS: Clinical and financial data were collected retrospectively from electronic medical and administrative records. Data for each patient included inpatient and outpatient encounters 3 months before and 12 months after the primary aneurysm operation. RESULTS: Between 2007 and 2017, 157 and 71 patients were treated with physician-modified endograft (PMEG) and Cook Zenith Fenestrated (ZFEN) repair, respectively. Twenty-one patients who were evaluated for FEVAR underwent open repair instead. The 228 FEVAR patients provided a total positive contribution margin (reimbursements minus direct costs) of $2.65 million. The index encounter (the primary aneurysm operation and hospitalization) accounted for the majority (90.6%) of the total contribution margin. The largest component (50.3%) of direct cost for FEVAR from the index encounter was implant/graft expenses. The average direct costs for FEVAR and for open repair from the index encounter were $34,688 and $35,020, respectively. The average contribution margins for FEVAR and for open repair were approximately $10,548 and $21,349, respectively, attributable to differences in reimbursement. The average direct cost for FEVAR trended down over time as cumulative experience increased. Average reimbursement for FEVAR increased after Centers for Medicare and Medicaid Services approved payments with the Investigational Device Exemption (IDE) trial for PMEG in 2011, and a new technology add-on payment for ZFEN in 2012. These factors transitioned the average contribution margin from negative to positive in 2012. The average physician payments for PMEG increased from $128 to $5848 after the start of the IDE trial. The average physician payments for ZFEN and for open repair between 2011 and 2017 were $7597 and $7781, respectively. CONCLUSIONS: FEVAR can be performed at a high-volume medical center with positive contribution margins and with comparable physician payments to open repair. At this institution, hospital reimbursement and physician payments improved for PMEG with participation in an IDE trial, while hospital direct costs decreased for both PMEG and ZFEN with accumulated experience.

Cost-minimization study of the percutaneous approach to endovascular aortic aneurysm repair.

OBJECTIVE: Percutaneous access for endovascular aortic aneurysm repair (P-EVAR) is less invasive compared with surgical access for endovascular aortic aneurysm repair (S-EVAR). P-EVAR has been associated with shorter recovery and fewer wound complications. However, vascular closure devices (VCDs) are costly, and the economic effects of P-EVAR have important implications for resource allocation. The objective of our study was to estimate the differences in the costs between P-EVAR and S-EVAR. METHODS: We used a decision tree to analyze the costs from a payer perspective throughout the course of the index hospitalization. The probabilities, relative risks, and mean difference summary measures were obtained from a systematic review and meta-analysis. We modelled differences in surgical site infection, lymphocele, and the length of hospitalization. Cost parameters were derived from the 2014 National Inpatient Sample using "International Classification of Diseases, 9th Revision, Clinical Modification" codes. Attributable costs were estimated using generalized linear models adjusted by age, sex, and comorbidities. A sensitivity analysis was performed to determine the robustness of the results. RESULTS: A total of 6876 abdominal and thoracic EVARs were identified. P-EVAR resulted in a mean cost savings of $751 per procedure. The mean costs for P-EVAR were $1287 (95% confidence interval [CI], $884-$1835) and for S-EVAR were $2038 (95% CI, $757-$4280). P-EVAR procedures were converted to open procedures in 4.3% of the cases. The P-EVAR patients had a difference of -1.4 days (95% CI, -0.12 to -2.68) in the length of hospitalization at a cost of $1190/d (standard error, $298). The cost savings of P-EVAR was primarily driven by the cost differences in the length of hospitalization. In the base case, four VCDs were used per P-EVAR at $200/device. In the two-way sensitivity analysis, P-EVAR resulted in cost savings, even when 1.5 times more VCDs had been used per procedure and the cost of each VCD was 1.5 times greater. In our probabilistic sensitivity analysis, P-EVAR was the cost savings strategy for 82.6% of 10,000 Monte Carlo simulations when simultaneously varying parameters across their uncertainty ranges. CONCLUSIONS: P-EVAR had lower costs compared with S-EVAR and could result in dramatic cost savings if extrapolated to the number of aortic aneurysms repaired. Our analysis was a conservative estimate that did not account for the improved quality of life after P-EVAR.

Eligibility Rates for Ambulatory EVAR.

BACKGROUND: The current results of endovascular repair of abdominal aortic aneurysms (EVAR) and the wide use of percutaneous closure systems suggest that ambulatory treatment is feasible in selected patients. The objective of this study was to evaluate the rate of eligibility to ambulatory EVAR (EVAR-Ambu) and its potential medicoeconomic impact. METHODS: Between January 2014 and December 2016, 245 patients were operated of an abdominal aortic aneurysm (AAA) in our center. The 128 patients whose anatomy was unfavorable with EVAR, which were operated in urgency or who were classified as American society of anesthesiologists 4, were excluded from the study. The 117 remaining files were reexamined to evaluate the eligibility for EVAR-Ambu retrospectively. The patients were considered as eligible if they presented all the following criteria: (1) normal surgical risk, (2) logistic feasibility of an ambulatory procedure (home <1 hr away from the hospital, available relatives), and (3) anatomical criteria of percutaneous feasibility according to angio-computed tomography. The surgical risk was evaluated according to the French High Health Authority (HAS) and the Society for Vascular Surgery (SVS) score. The balance between costs and revenue was evaluated for each patient according to the length of stay. RESULTS: Among the 117 patients, 43 (37%) and 57 (49%) were eligible for EVAR-Ambu by percutaneous route according to whether the surgical risk was assessed according to the HAS or the SVS criteria. If a conventional surgical approach was considered as compatible with EVAR-Ambu, 12 (10%) and 13 (11%) additional patients were eligible according to whether the surgical risk was assessed according to the HAS or the SVS criteria, respectively. In terms of medicoeconomic evaluation, the cost of the initial intervention depended was mainly on the cost of the stent graft and the operating room services. The cost spent of 1 night conventional hospitalization (CH) after EVAR was 603€ per day versus 490€ in the Day Surgery Unit (DSU). In comparison, the revenue for the institution was identical for DSU and a 1-night CH. According to our estimates, the balance between revenue and expenditures amounted to +122€ per patient for EVAR-Ambu versus +10€ or +119€ per patient hospitalized 1 or 2 nights, respectively. CONCLUSIONS: EVAR-Ambu is possible in a substantial proportion of patients treated for infrarenal AAA. Its medicoeconomic interest is real for the health system although it appears low at the individual level. The safety of this approach in clinical practice must be confirmed by a prospective study in selected patients.

Racial Disparities in Endovascular Aortic Aneurysm Repair.

BACKGROUND: Racial and ethnic disparities are a critical issue in access to care within all fields of medicine. We hypothesized that analysis of a statewide administrative dataset would demonstrate disparities based on race with respect to access to this latest technology and the associated outcomes following endovascular aortic aneurysm repair (EVAR). METHODS: Utilizing de-identified data from the Florida State Agency for Health Care Administration, we identified patients based on International Classification of Diseases Ninth Revision procedure codes who underwent EVAR between the years 2000 and 2014. We then assigned these procedures with the specialty of the operating physician and then analyzed outcomes based on the race of the patient. RESULTS: We identified 36,601 EVAR procedures during the study period. The average age of the total sample was 73.38 (±9.87), with the majority of the cohort being male (n = 29,034, 81.2%). Breakdown of patients within each race category was as follows: 17,056 (47.7%) non-Hispanic Whites, 1,630 (4.6%) non-Hispanic African Americans, 16,431 (46.0%) Hispanics, and 632 (1.8%) patients identified as "other." Data analysis showed significant differences among age at presentation, sex of patient, and comorbidity score of patients at presentation. There were significant differences in outcomes based on race with respect to total hospital charges, length of stay, disposition, and payer status. CONCLUSIONS: Racial disparities were discovered with respect to EVAR treatment. African Americans present at younger ages, have the highest percentage of females requiring intervention, have the longest hospital stays, have the highest Medicaid payer source, have the highest in-hospital total charges of any racial group, and are more likely to be treated by academic practitioners. Hispanics present with the highest comorbidity scores compared to their counterparts and, along with African Americans, are more likely to be treated by nonvascular surgeons.

Aortic Surgery Outcomes of Marfan Syndrome and Ehlers-Danlos Syndrome Patients at Teaching and Nonteaching Hospitals.

BACKGROUND: Despite improvements in prevention and management, aortic aneurysm repair remains a high-risk operation for patients with Marfan syndrome (MFS) and Ehlers-Danlos syndrome (EDS). The goal of this study was to examine differences in characteristics and outcomes of patients with MFS or EDS undergoing aortic aneurysm repair at teaching versus nonteaching hospitals. METHODS: We used the National Inpatient Sample to study patients with MFS or EDS undergoing open or endovascular aortic aneurysm repair from 2000 to 2014. RESULTS: Of 3487 patients (MFS = 3375, EDS = 112), 2974 (85%) had repair at a teaching hospital. Patients who underwent repair at a teaching hospital were slightly younger than those who underwent repair at a nonteaching hospital (38 vs. 43 years, P < 0.01) but otherwise were similar in gender (29% vs. 28% female), race (70% vs. 78% white), and connective tissue disorder diagnosis (97% vs. 97% MFS, all P ≥ 0.1). There were no differences in anatomy (17% vs. 19% abdominal, 67% vs. 66% thoracic, and 15% vs. 15% thoracoabdominal, all P ≥ 0.1) or type of repair (5% vs. 5% endovascular), but patients at nonteaching hospitals were more likely to have a dissection (49% vs. 38%, P = 0.02). There was no difference in perioperative mortality (4% vs. 6%, P = 0.5) or length of stay (median 8 days vs. 7 days, P = 0.3) between teaching and nonteaching hospitals. There was also no difference in hemorrhagic (47% vs. 43%), pulmonary (9% vs. 16%), renal (12% vs. 14%), or neurologic (5% vs. 6%) complications between teaching and nonteaching hospitals, respectively (all P ≥ 0.05). In analysis stratified by anatomic extent of repair, there was a lower prevalence of pulmonary complications in thoracic aorta repairs at teaching hospitals (8.1% vs. 18.4%, P = 0.01) but a higher prevalence of hemorrhage in abdominal aortic repairs at teaching hospitals (45.6% vs. 20.6%, P = 0.04) as compared with nonteaching hospitals. CONCLUSIONS: Patients with MFS and EDS who undergo aortic aneurysm repair have their operations predominantly at teaching hospitals, but those patients who undergo repair at nonteaching hospitals do not have worse mortality or morbidity despite a higher incidence of dissection.

Editor's Choice - A Study of the Cost-effectiveness of Fenestrated/branched EVAR Compared with Open Surgery for Patients with Complex Aortic Aneurysms at 2 Years.

OBJECTIVES: The aim was to assess the cost-effectiveness of fenestrated and branched stent grafts (f/b EVAR) compared with open surgical repair (OSR) in thoraco-abdominal or complex abdominal aortic aneurysms (TAAA/AAA) at 2 years. METHODS: Two matched cohorts of patients with TAAA or complex AAA were compared after a follow-up of two years. Patients included in the WINDOW French multicentre prospective registry were treated by f/b EVAR, and OSR patients were extracted from the French national hospital discharge database. All cause mortality was assessed along with readmissions and hospital costs. The association between treatment and 2 year mortality was assessed by uni/multivariate Cox regression analyses using pre- and post-operative characteristics. Incremental cost-effectiveness ratios (ICER) were estimated for para/juxtarenal AAA, and infra- and supra-diaphragmatic TAAA. RESULTS: A total of 268 high risk patients were treated by f/b EVAR and 1678 average or low risk patients were treated with OSR during the same period. Mortality did not significantly differ between the groups (14.9% vs. 11.8%, p = .150) and multivariate Cox regressions did not find an association between 2 year mortality and treatment. Similar proportions of patients were readmitted at least once (69.7% with f/b EVAR vs. 64.2% with OSR, p = .096) but f/b EVAR patients had more readmissions on average (2.2 vs. 1.7, p = .001). Two year hospital costs were higher in the f/b EVAR group (€46,039 vs. €22,779, p < .001). At 2 years, f/b EVAR was dominated (more expensive and less effective), except in the supra-diaphragmatic TAAA subgroup with an ICER of €42,195,800 per death averted. CONCLUSIONS: f/b EVAR in high risk patients offers similar 2 year mortality to OSR performed in lower risk patients but at a higher cost. The cost is mainly driven by the cost of the stent graft, which is not compensated for by lower healthcare resource consumption. Further studies are necessary to evaluate the cost-effectiveness in low risk f/b EVAR patients who may experience fewer complications.

Underutilization of Routine Ultrasound Surveillance after Endovascular Aortic Aneurysm Repair.

BACKGROUND: Since 2009, the Society for Vascular Surgery has advocated annual surveillance imaging with ultrasound (US) after the first postoperative year for uncomplicated endovascular aneurysm repairs (EVARs). We sought to describe diffusion of US into long-term routine surveillance and to estimate potential cost savings among Medicare beneficiaries after EVAR. METHODS: Using Medicare claims data, we identified patients receiving EVAR from 2002 to 2010 and included only those who did not subsequently have reinterventions, late aneurysm-related complications, or death. We collected all relevant postoperative imaging (computed tomography [CT] and US) through 2011. Patients with follow-up less than 1 year were excluded. We estimated cost savings with increased use of US after the first postoperative year. RESULTS: The cohort comprised 24,615 patients with a mean follow-up of 3.9 ± 2.3 years. Mean number of images decreased from 2.23 in the first postoperative year to 0.31 in the 10th year. Utilization of US at the first postoperative year remained low but increased from 15.2% in 2003 to 28.8% in 2011 (P < 0.001). By the 10th postoperative year, the proportion of patients receiving US increased from 8.2% to 37.8%, while use of CT only remained high but decreased from 60.8% to 42.1%. Mean cost of surveillance imaging was $2,132/CT and $234/US. Performing US in 50-75% of patients beginning 1 year after EVAR would decrease costs by 14-48%/year. This translates to a mean cost savings of $338-$1135 per imaged patient per year, with an estimated savings to Medicare of $155 million to $305 million over 10 years. CONCLUSIONS: CT remains the primary modality of surveillance for up to 10 years after EVAR for patients without reinterventions or aneurysm-related complications. Increasing the use of US and decreasing the use of CT would save cost without compromising outcomes.

Surgeon leadership in the coding, billing, and contractual negotiations for fenestrated endovascular aortic aneurysm repair increases medical center contribution margin and physician reimbursement.

BACKGROUND: Fenestrated endovascular aneurysm repair (FEVAR) allows endovascular treatment of thoracoabdominal and juxtarenal aneurysms previously outside the indications of use for standard devices. However, because of considerable device costs and increased procedure time, FEVAR is thought to result in financial losses for medical centers and physicians. We hypothesized that surgeon leadership in the coding, billing, and contractual negotiations for FEVAR procedures will increase medical center contribution margin (CM) and physician reimbursement. METHODS: At the UMass Memorial Center for Complex Aortic Disease, a vascular surgeon with experience in medical finances is supported to manage the billing and coding of FEVAR procedures for medical center and physician reimbursement. A comprehensive financial analysis was performed for all FEVAR procedures (2011-2015), independent of insurance status, patient presentation, or type of device used. Medical center CM (actual reimbursement minus direct costs) was determined for each index FEVAR procedure and for all related subsequent procedures, inpatient or outpatient, 3 months before and 1 year subsequent to the index FEVAR procedure. Medical center CM for outpatient clinic visits, radiology examinations, vascular laboratory studies, and cardiology and pulmonary evaluations related to FEVAR were also determined. Surgeon reimbursement for index FEVAR procedure, related adjunct procedures, and assistant surgeon reimbursement were also calculated. All financial analyses were performed and adjudicated by the UMass Department of Finance. RESULTS: The index hospitalization for 63 FEVAR procedures incurred $2,776,726 of direct costs and generated $3,027,887 in reimbursement, resulting in a positive CM of $251,160. Subsequent related hospital procedures (n = 26) generated a CM of $144,473. Outpatient clinic visits, radiologic examinations, and vascular laboratory studies generated an additional CM of $96,888. Direct cost analysis revealed that grafts accounted for the largest proportion of costs (55%), followed by supplies (12%), bed (12%), and operating room (10%). Total medical center CM for all FEVAR services was $492,521. Average surgeon reimbursements per FEVAR from 2011 to 2015 increased from $1601 to $2480 while the surgeon payment denial rate declined from 50% to 0%. Surgeon-led negotiations with the Centers for Medicare & Medicaid Services during 2015 resulted in a 27% increase in physician reimbursement for the remainder of 2015 ($2480 vs $3068/case) and a 91% increase in reimbursement from 2011 ($1601 vs $3068). Assistant surgeon reimbursement also increased ($266 vs $764). Concomitant FEVAR-related procedures generated an additional $27,347 in surgeon reimbursement. CONCLUSIONS: Physician leadership in the coding, billing, and contractual negotiations for FEVAR results in a positive medical center CM and increased physician reimbursement.

Incremental Cost of Emergency Versus Elective Surgery.

OBJECTIVE: To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery. BACKGROUND: Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist. METHODS: Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Discharge-level weights were applied to analyses. RESULTS: A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565-$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures. CONCLUSIONS: Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs.

Echocardiography screening of siblings of children with bicuspid aortic valve.

BACKGROUND AND OBJECTIVE: Left heart defects, such as bicuspid aortic valve (BAV), are heritable. Consensus guidelines have recommended echocardiographic screening of first-degree relatives. The utility of this approach in siblings of children with BAV is not known. The objective of this study is to evaluate the yield of routine screening of siblings of children with BAV and undertake an economic analysis of this practice. METHODS: Siblings of children with BAV who underwent echocardiographic screening in a single pediatric cardiology practice were identified. The anatomic features and hemodynamics of siblings newly diagnosed with BAV were recorded. A Markov model was constructed to determine cost-effectiveness ratios, and sensitivity analyses were performed. RESULTS: There were 207 screened siblings of 181 children with BAV. The median age at screening was 7 years. BAV was identified in 21 (10.1%) of siblings screened. The median peak Doppler gradient was 18 mm Hg. Aortic insufficiency was mild or less in all. The mean cost to diagnose BAV in a sibling was $2109 per new case found. The estimated mean cost to avert a single aortic dissection in the third or fourth decade of life was $363 911. The estimated cost per life-year saved was $74 884 and ranged from $17 461 to $1 136 536 in sensitivity analysis. CONCLUSIONS: Echo screening among siblings of those with BAV is effective and inexpensive and may lower the risk of the complications of such as dissection, although it comes at a moderate cost relative to benefits gained. Screening of siblings should be incorporated into clinical care.

Cost-effectiveness of endovascular versus open repair of acute complicated type B aortic dissections.

OBJECTIVE: This study weighed the cost and benefit of thoracic endovascular aortic repair (TEVAR) vs open repair (OR) in the treatment of an acute complicated type B aortic dissection by (TBAD) estimating the cost-effectiveness to determine an optimal treatment strategy based on the best currently available evidence. METHODS: A cost-utility analysis from the perspective of the health system payer was performed using a decision analytic model. Within this model, the 1-year survival, quality-adjusted life-years (QALYs), and costs for a hypothetical cohort of patients with an acute complicated TBAD managed with TEVAR or OR were evaluated. Clinical effectiveness data, cost data, and transitional probabilities of different health states were derived from previously published high-quality studies or meta-analyses. Probabilistic sensitivity analyses were performed on uncertain model parameters. RESULTS: The base-case analysis showed, in terms of QALYs, that OR appeared to be more expensive (incremental cost of €17,252.60) and less effective (-0.19 QALYs) compared with TEVAR; hence, in terms of the incremental cost-effectiveness ratio, OR was dominated by TEVAR. As a result, the incremental cost-effectiveness ratio (ie, the cost per life-year saved) was not calculated. The average cost-effectiveness ratio of TEVAR and OR per QALY gained was €56,316.79 and €108,421.91, respectively. In probabilistic sensitivity analyses, TEVAR was economically dominant in 100% of cases. The probability that TEVAR was economically attractive at a willingness-to-pay threshold of €50,000/QALY gained was 100%. CONCLUSIONS: The present results suggest that TEVAR yielded more QALYs and was associated with lower 1-year costs compared with OR in patients with an acute complicated TBAD. As a result, from the cost-effectiveness point of view, TEVAR is the dominant therapy over OR for this disease under the predefined conditions.

Occlusion of the internal iliac artery prior EVAR: comparison of coils and plugs.

PURPOSE: We compared occlusion of the internal iliac artery (IIA) using coils or the Amplatzer vascular plug (AVP) II prior to endovascular aortic aneurysm repair. MATERIALS AND METHODS: Occlusion of the IIA was performed in 32 patients (aged 74 ± 8 years) using coils (N = 17) or the AVP II (N = 15). We retrospectively compared procedural data, initial success, and clinical outcome in a 12-month follow-up. RESULTS: Occlusion was successful in all patients without detection of an endoleak after 12 months. Procedure time and fluoroscopy time for coils versus plugs were 77 ± 35 versus 43 ± 13 minutes and 36 ± 19 versus 18 ± 8 minutes, respectively (P < .003). Incidence of initial buttock claudication (BC) for coils versus plugs was 47% versus 27% and was significantly more severe after coil occlusion (P = .03). After a 12-month follow-up, 2 patients of each group reported of mild BC. CONCLUSION: Occlusion of the IIA is safe and effective using coils or plugs. Initial BC is significantly more severe when coils are used, but after a 12-month follow-up, there is no significant difference. Using a plug is associated with a significant reduction of procedure time and radiation exposure.

Surveillance after EVAR based on duplex ultrasound and abdominal radiography.

INTRODUCTION: Computed tomography angiography (CTA) is considered the gold standard imaging technique for surveillance following endovascular aneurysm repair (EVAR). Limitations of CTA include cost, risk of contrast nephropathy and radiation exposure. A modified surveillance protocol involving annual duplex ultrasound (DUS) and abdominal radiography (AXR) was introduced, with CTA performed only if abnormalities were identified or DUS was undiagnostic. METHODS: Prospective records were maintained on patients undergoing infra-renal EVAR at a UK, tertiary referral centre. All patients enrolled with at least one-year follow-up were reviewed. Primary outcomes identified were aneurysm rupture and aneurysm-related complications. Secondary outcomes included number of CTAs avoided and cost. RESULTS: Median follow-up was 36 months (range 12-57) for 194 patients. The total number of sets of surveillance imaging was 412 of which 70 (17%) required CTA. Abnormalities were found in 30 patients, 18 confirmed by CTA. Eleven patients required secondary intervention, three initially identified by AXR, three by DUS, three by both DUS and AXR, and two by CTA following undiagnostic DUS. No patient presented with rupture or aneurysm-related complications not identified by modified surveillance. Mean annual savings were €223. CONCLUSION: EVAR surveillance based on DUS and AXR is feasible and safe. The complimentary nature of AXR and DUS is demonstrated.

Duplex ultrasound imaging alone is sufficient for midterm endovascular aneurysm repair surveillance: a cost analysis study and prospective comparison with computed tomography scan.

OBJECTIVE: Early in our experience with endovascular aortic aneurysm repair (EVAR) we performed both serial computed tomography scans and duplex ultrasound (DU) imaging in our post-EVAR surveillance regimen. Later we conducted a prospective study with DU imaging as the sole surveillance study and determined cost savings and outcome using this strategy. METHODS: From September 21, 1998, to May 30, 2008, 250 patients underwent EVAR at our hospital. Before July 1, 2004, EVAR patients underwent CT and DU imaging performed every 6 months during the first year and then annually if no problems were identified (group 1). We compared aneurysm sac size, presence of endoleak, and graft patency between the two scanning modalities. After July 1, 2004, patients underwent surveillance using DU imaging as the sole surveillance study unless a problem was detected (group 2). CT and DU imaging charges for each regimen were compared using our 2008 health system pricing and Medicare reimbursements. All DU examinations were performed in our accredited noninvasive vascular laboratory by experienced technologists. Statistical analysis was performed using Pearson correlation coefficient. RESULTS: DU and CT scans were equivalent in determining aneurysm sac diameter after EVAR (P < .001). DU and CT were each as likely to falsely suggest an endoleak when none existed and were as likely to miss an endoleak. Using DU imaging alone would have reduced cost of EVAR surveillance by 29% ($534,356) in group 1. Cost savings of $1595 per patient per year were realized in group 2 by eliminating CT scan surveillance. None of the group 2 patients sustained an adverse event such as rupture, graft migration, or limb occlusion as a result of having DU imaging performed as the sole follow-up modality. CONCLUSION: Surveillance of EVAR patients can be performed accurately, safely, and cost-effectively with DU as the sole imaging study.

CT colonography to screen for colorectal cancer and aortic aneurysm in the Medicare population: cost-effectiveness analysis.

OBJECTIVE: CT colonography (CTC) is a recommended test for colorectal cancer (CRC) screening according to the updated 2008 American Cancer Society guidelines. CTC can also accurately detect abdominal aortic aneurysm (AAA). This collaborative gastroenterology-radiology project evaluated the cost-effectiveness and clinical efficacy of CTC in the Medicare population. MATERIALS AND METHODS: A computerized Markov model simulated the development of CRC and AAA in a hypothetical cohort of 100,000 U.S. adults > or = 65 years old. Screening with CTC at 5- and 10-year intervals using a 6-mm size threshold for polypectomy was compared with primary optical colonoscopy screening every 10 years and with no screening. Base case costs for CTC and optical colonoscopy were $674 and $795, respectively. The costs of the imaging workup for extracolonic findings at CTC were also included. RESULTS: CTC resulted in 7,786 and 7,027 life-years gained at 5- and 10-year intervals, respectively, compared with 6,032 life-years gained with 10-year optical colonoscopy. The increase in overall efficacy with CTC was primarily due to prevention of AAA rupture because CRC prevention and CRC detection rates were similar for CTC and optical colonoscopy. All three strategies were highly cost-effective compared with no screening, with an incremental cost-effectiveness ratio (ICER) of $6,088, $1,251, and $1,104 per life-year gained for 5-year CTC, 10-year CTC, and 10-year optical colonoscopy strategies, respectively. The ICER of 5-year CTC and 10-year CTC versus optical colonoscopy was $23,234 and $2,144 per life-year gained, respectively. CONCLUSION: Because of its ability to simultaneously screen for both CRC and AAA, CTC is a highly cost-effective and clinically efficacious screening strategy for the Medicare population.

Optimal clinical pathway for the patient with type B acute aortic dissection.

BACKGROUND: The traditional medical treatment for type B acute aortic dissection (AAD) is widely accepted, but the optimal clinical pathway has not been confirmed. Methods and Results From admissions over the past 12 years, 210 patients with uncomplicated type B AAD were divided into 2 groups: Conventional therapy group (CG) of 90 who were treated by 7 days of bed rest and intravenous antihypertensive agents and the Clinical pathway group (CPG) of 120 who were treated by early rehabilitation. In the CPG, patients were administered oral medication from the first day after onset and took a short walk from the third day after onset. The incidence of respiratory complications, and of delirium, was significantly decreased in the CPG. Early mortality was similar: 3.3% and 2.5%, respectively. The diameter of the aorta had not enlarged in either group 1 month later. Conclusions The clinical pathway of treatment for uncomplicated type B AAD was safer and better for preventing early complications and cost benefit.