The accuracy and cost-effectiveness of strategies used to identify peripheral artery disease among patients with diabetic foot ulcers.

BACKGROUND: Patients with diabetic foot ulcers (DFUs) should be evaluated for peripheral artery disease (PAD). We sought to estimate the overall diagnostic accuracy for various strategies that are used to identify PAD in this population. METHODS: A Markov model with probabilistic and deterministic sensitivity analyses was used to simulate the clinical events in a population of 10,000 patients with diabetes. One of 14 different diagnostic strategies was applied to those who developed DFUs. Baseline data on diagnostic accuracy of individual noninvasive tests were based on a meta-analysis of previously reported studies. The overall sensitivity and cost-effectiveness of the 14 strategies were then compared. RESULTS: The overall sensitivity of various combinations of diagnostic testing strategies ranged from 32.6% to 92.6%. Cost-effective strategies included ankle-brachial indices for all patients; skin perfusion pressures (SPPs) or toe-brachial indices (TBIs) for all patients; and SPPs or TBIs to corroborate normal pulse examination findings, a strategy that lowered leg amputation rates by 36%. Strategies that used noninvasive vascular testing to investigate only abnormal pulse examination results had low overall diagnostic sensitivity and were weakly dominated in cost-effectiveness evaluations. Population prevalence of PAD did not alter strategy ordering by diagnostic accuracy or cost-effectiveness. CONCLUSIONS: TBIs or SPPs used uniformly or to corroborate a normal pulse examination finding are among the most sensitive and cost-effective strategies to improve the identification of PAD among patients presenting with DFUs. These strategies may significantly reduce leg amputation rates with only modest increases in cost.

Cost-effectiveness of angiographic imaging in isolated perimesencephalic subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The purpose of this study is to perform a comprehensive cost-effectiveness analysis of all possible permutations of computed tomographic angiography (CTA) and digital subtraction angiography imaging strategies for both initial diagnosis and follow-up imaging in patients with perimesencephalic subarachnoid hemorrhage on noncontrast CT. METHODS: Each possible imaging strategy was evaluated in a decision tree created with TreeAge Pro Suite 2014, with parameters derived from a meta-analysis of 40 studies and literature values. Base case and sensitivity analyses were performed to assess the cost-effectiveness of each strategy. A Monte Carlo simulation was conducted with distributional variables to evaluate the robustness of the optimal strategy. RESULTS: The base case scenario showed performing initial CTA with no follow-up angiographic studies in patients with perimesencephalic subarachnoid hemorrhage to be the most cost-effective strategy ($5422/quality adjusted life year). Using a willingness-to-pay threshold of $50 000/quality adjusted life year, the most cost-effective strategy based on net monetary benefit is CTA with no follow-up when the sensitivity of initial CTA is >97.9%, and CTA with CTA follow-up otherwise. The Monte Carlo simulation reported CTA with no follow-up to be the optimal strategy at willingness-to-pay of $50 000 in 99.99% of the iterations. Digital subtraction angiography, whether at initial diagnosis or as part of follow-up imaging, is never the optimal strategy in our model. CONCLUSIONS: CTA without follow-up imaging is the optimal strategy for evaluation of patients with perimesencephalic subarachnoid hemorrhage when modern CT scanners and a strict definition of perimesencephalic subarachnoid hemorrhage are used. Digital subtraction angiography and follow-up imaging are not optimal as they carry complications and associated costs.

The costs and effects of contrast-enhanced magnetic resonance angiography and digital substraction angiography on quality of life in patients with peripheral arterial disease.

BACKGROUND: Contrast-enhanced magnetic resonance angiography (MRA) and intra-arterial digital subtraction angiography (DSA) both have a high diagnostic performance in the imaging of peripheral arterial occlusive disease (PAOD). However, little is known about the effects of initial, preoperative imaging using MRA or DSA on quality of life (QoL) in relation to costs (cost-utility). PURPOSE: To compare cost-utility of treatment strategies using either MRA or DSA as the principal imaging tool, related to QoL, in patients with PAOD. MATERIAL AND METHODS: In a prospective subgroup analysis of patients randomized between MRA and DSA (n = 79) for preoperative imaging, QoL questionnaires (SF-36) were obtained at randomization and at 4-month follow-up. Cost-effectiveness from hospital perspective was subsequently compared between groups and the difference in gained or lost QoL per € spent assessed using bootstrap analysis. RESULTS: No difference in quality of life was found. A treatment trajectory employing MRA as the principal imaging modality was almost 20% cheaper, leading to a better cost-utility ratio in favor of MRA. CONCLUSION: A treatment plan for peripheral arterial occlusive disease employing MRA versus DSA as the principal imaging modality yields a better cost/QoL ratio for MRA.

Cost-effectiveness of diagnostic imaging modalities in symptomatic patients with lower limb peripheral arterial disease: discrete event simulation model.

Objective: Lower limb peripheral arterial disease in the symptomatic stage has a significant effect on patients´ functional disability. Before an intervention, an imaging diagnostic examination is necessary to determine the extent of the disability. This study evaluates cost-effectiveness of duplex ultrasonography (DUS), digital subtraction angiography (DSA), computed tomography angiography (CTA) and magnetic resonance angiography (MRA) in the diagnostics of symptomatic patients with lower limb peripheral arterial disease indicated for endovascular or surgical intervention. Methods: Discrete event simulation was used to capture lifetime costs and effects. Costs were calculated from the perspective of the health care payer, and the effects were calculated as quality-adjusted life year's (QALY's). The cost-effectiveness analysis was performed to pairwise compare CTA, MRA and DSA with DUS as the baseline diagnostic modality. A scenario analysis and probabilistic sensitivity analysis were carried out to evaluate the robustness of the results. Results: In the basic case, the DUS diagnostic was the least expensive modality, at a cost of EUR 10,778, compared with EUR 10,804 for CTA, EUR 11,184 for MRA, and EUR 11,460 for DSA. The effects of DUS were estimated at 5.542 QALYs compared with 5.554 QALYs for both CTA and MRA, and 5.562 QALYs for DSA. The final incremental cost-effectiveness ratio (ICER) value of all evaluated modalities was below the cost-effectiveness threshold whereas CTA has the lowest ICER of EUR 2,167 per QALY. However, the results were associated with a large degree of uncertainty, because iterations were spread across all cost-effectiveness quadrants in the probabilistic sensitivity analysis. Conclusion: For imaging diagnosis of symptomatic patients with lower limb peripheral arterial disease, CTA examination appears to be the most cost-effective strategy with the best ICER value. Baseline diagnostics of the DUS modality has the lowest costs, but also the lowest effects. DSA achieves the highest QALYs, but it is associated with the highest costs.

Computed Tomography Angiography versus Digital Subtraction Angiography as a Primary Diagnostic Tool in Nontraumatic Subarachnoid Hemorrhage: Cost-Effectiveness Analysis Study.

BACKGROUND: Digital subtraction angiography (DSA) and computed tomographic angiography (CTA) are used to identify the cause of nontraumatic subarachnoid hemorrhage (SAH). There is no consensus on which to choose as the first diagnostic tool. We aimed to compare the cost-effectiveness of CTA versus DSA as a primary tool for identifying the cause of nontraumatic SAH. METHODS: A decision analysis model was built to simulate patients undergoing DSA or CTA as a primary diagnostic tool for the cause of nontraumatic SAH. The input data for the study were extracted from literature. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the model. RESULTS: In the base case calculation, it cost $1261.82 less and yielded 0.0001 quality-adjusted life year (QALY) when DSA was used as a primary diagnostic imaging tool for nontraumatic SAH. Choosing DSA as a primary tool was cost-effective in more than 65% of iterations in probabilistic sensitivity analysis. Deterministic sensitivity analyses show when the probability of using endovascular treatment is >47.2%, choosing DSA is more cost-effective; otherwise, CTA is more optimal. CTA is more cost-effective when the cost for DSA >2.6 × CTA + $600. CONCLUSIONS: Based on current literature and our model DSA as a primary diagnostic tool for the cause of nontraumatic SAH is more cost-effective. However, in clinical practice physicians can choose either DSA or CTA according to the scale of endovascular procedures used in their center, as well as the cost correlation between CTA and DSA, which varies among institutions.

Cost-effectiveness of magnetic resonance angiography versus intra-arterial digital subtraction angiography to follow-up patients with coiled intracranial aneurysms.

BACKGROUND AND PURPOSE: To follow up patients with coiled intracranial aneurysms, magnetic resonance angiography (MRA) is a promising noninvasive alternative to current standard intra-arterial digital subtraction angiography (IA-DSA). MRA test results do not always concord with those of IA-DSA, and the impact of discrepancies on health benefits and costs is unknown. We evaluated the cost-effectiveness of follow-up with MRA vs IA-DSA to assess whether in this setting MRA may replace IA-DSA. METHODS: We studied aneurysm occlusion on MRA in addition to follow-up IA-DSA in 310 patients with 341 coiled intracranial aneurysms. The observed sensitivity (82%) and specificity (89%) of MRA for detection of reopening with IA-DSA as a reference were used as input for a Markov decision-analytic model. Other determinants were derived from the literature. We compared life expectancy, quality-adjusted life-years (QALY), costs, and expected number of events for the two strategies. RESULTS: Follow-up with MRA yielded similar life expectancy (MRA, 26.66 years; IA-DSA, 26.63 years; difference, 0.03 years; 95% CI, -0.17-0.23) and QALY (MRA, 10.96; IA-DSA, 10.95; difference, 0.01 QALY; 95% CI, -0.05-0.08) at lower costs (MRA, $7003; IA-DSA, $8241 per patient; difference, -$1238; 95% CI, -2617--36). The expected number of events was comparable except for complications from IA-DSA. CONCLUSIONS: MRA provided equivalent health benefits as IA-DSA and was cost-saving. MRA dominates and should replace routine IA-DSA to follow-up patients with coiled aneurysms.

Cost impact of diagnostic imaging for lower extremity peripheral vascular occlusive disease.

OBJECTIVE: The evaluation of peripheral vascular disease in the primary care setting is routinely performed by contrast-enhanced magnetic resonance angiography (CE-MRA) and digital subtraction angiography (DSA). However, limited data are available on the relative costs and clinical outcomes following these diagnostic procedures. The objective of this study is to assess and compare costs associated with diagnostic imaging in peripheral vascular occlusive disease (PAOD). METHODS: US veterans (n = 19,209) with CE-MRA or DSA for the assessment of PAOD from fiscal year (FY) 1999 to FY 2004. Main outcome measure(s) using the Department of Veterans Affairs' (VA) costing algorithms, cost, and log-cost of interventions (e.g., revascularization, stent, angioplasty), amputations or mortality rates within 30/90 days and 1 year of DSA or CE-MRA were compared, and adjusted for patient characteristics and disease severity using multivariate regression. Imaging modality selection bias was evaluated with propensity score, instrumental variables, and Heckman methods using untransformed costs and log-costs with smearing retransformation. RESULTS: Initial CE-MRA imaging was significantly more likely among patients with prior renal disease or bypass surgery [odds ratio (OR) > 2; P < 0.001], and less likely among patients with prior amputation, peripheral vascular disease (PVD), claudication, or other cardiovascular disease (OR < 0.7; P < 0.001). After adjusting for endogenous choice of initial imaging modality, 30-day treatment costs were US$3500-$4300 lower (P < 0.001) for patients with initial CE-MRA. Eighty-two percent of DSA imaging patients had no additional procedures or events within 30 days, and 65% at 90 days. Less than 3.2% (3.6%) of patients had any repeat imaging within 30 (90) days of initial imaging. CONCLUSIONS: Relative to DSA, CE-MRA imaging was associated with substantial treatment episode savings, beyond the US$950 direct savings in imaging cost per procedure. Substituting CE-MRA for DSA among those not planning or requiring any follow-up procedures within 30 days, could have reduced outpatient imaging costs by up to 55%, and reduced VA system costs by US$13.2 million over the six-year period.

A comparison between willingness to pay and willingness to give up time.

We compared the willingness-to-pay and willingness to give up time methods to assess preferences for digital subtraction angiography (DSA), computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Respondents were hypertensive patients suspected of having renal artery stenosis. Data were gathered using telephone interviews. Both the willingness-to-pay and willingness to give up time methods revealed that patients preferred CTA to MRA in order to avoid DSA. The agreement between willingness-to-pay and willingness to give up time responses was high (kappa 0.65-0.85). The willingness-to-pay method yielded relatively more protest answers (12%) as compared to willingness to give up time (2%). So, our results provided evidence for the comparability of willingness to pay and willingness to give up time. The high percentage of protest answers on the willingness-to-pay questions raises questions with respect to the application of the willingness-to-pay method in a broad decision-making context. On the other hand, the strength of willingness-to-pay is that the method directly arrives at a monetary measure well founded in economic theory, whereas the willingness to give up time method requires conversion to monetary units.

Repositioning of central venous access devices using a high-flow flush technique - a clinical practice and cost review.

BACKGROUND: Malpositioned central venous access device (CVAD) tip locations can cause significant mechanical and chemical vessel-related injuries and complications if left in inappropriate positions.The aim of this study is to determine the use of a high-flow flush technique (HFFT) in successful correction of malpositioned catheters into the lower superior vena cava or cavoatrial junction and provide a cost comparison to interventional/fluoroscopic-based repositioning. METHODS: This is a retrospective chart and radiographic review of all inserted CVADs found malpositioned between 1996-2014 in a multi-specialty 1000-bed tertiary trauma center in Sydney, Australia.7450 CVADs placed by a nurse-led vascular access service were reviewed. Catheters repositioned pre-2010 were excluded owing to radiology repositioning interventions. RESULTS: There were 3996 peripherally inserted central catheters (PICCs) and 3454 centrally inserted central catheters (CICCs) placed. Seventy-four were malpositioned post-2010. Of these, 53 devices were repositioned using the studied technique; 86% (46/53) of catheters were successfully repositioned on the first HFFT attempt. There was supportive evidence that device insertion side is important in potential catheter malposition. CONCLUSIONS: Clinical outcomes suggest that CICCs and PICCs may be successfully repositioned utilizing this technique, with no adverse events associated and a prospective cost saving benefit when compared to interventional-based repositioning procedures.

[Angiography: safety x economy]. / Angiografia: segurança x economia.

PURPOSE: To evaluate the safety, effectiveness, and cost of angiofluoresceinographic examination by using both the least amount of dye as well as digital equipment along with a laser photocopier. METHODS: Prospective and comparative study carried out in a group of 70 patients, who underwent an angiographic evaluation with a conventional retinographer injecting 5 ml sodium fluorescein at 10% (control group) as well as a group of 70 patients who underwent an angiographic evaluation with a digital retinographer injecting 2 ml fluorescein at 10% (study group). Arterial pressure, heart rate and oximetry were assessed prior to and after the dye injection. Organic reactions related to the examination were reported. Photograph quality as well as cost between the two techniques were compared. RESULTS: Control group patients showed a greater increase in systolic and diastolic arterial pressure. Heart rate, oximetry measurement and adverse reactions did not show any significant statistical differences between both groups. As for the quality of photographs, a better performance was noticed in the control group. As for the cost, the examination carried out in the study group required lower cost and thus saved around 54.8% per examination in relation to the control group. CONCLUSION: The examination carried out with a lower dose of fluorescein using digital equipment along with a laser photocopier provided greater stability in the systolic and diastolic arterial pressure. However, it did not have any influence on heart rate, oximetry or adverse reactions such as nausea, vomiting, syncope and rashes. The quality of photographs was poor although they enabled diagnosis as well as therapy follow-up for those who carried out the examination. Moreover, economically the above procedure represented a gain of 66.26%, against 25.81% in relation to the conventional equipment.

Evaluation for Blunt Cerebrovascular Injury: Review of the Literature and a Cost-Effectiveness Analysis.

BACKGROUND AND PURPOSE: Evaluation for blunt cerebrovascular injury has generated immense controversy with wide variations in recommendations regarding the need for evaluation and the optimal imaging technique. We review the literature and determine the most cost-effective strategy for evaluating blunt cerebrovascular injury in trauma patients. MATERIALS AND METHODS: A comprehensive literature review was performed with data extracted to create a decision-tree analysis for 5 different strategies: anticoagulation for high-risk (based on the Denver screening criteria) patients, selective DSA or CTA (only high-risk patients), and DSA or CTA for all trauma patients. The economic evaluation was based on a health care payer perspective during a 1-year horizon. Statistical analyses were performed. The cost-effectiveness was compared through 2 main indicators: the incremental cost-effectiveness ratio and net monetary benefit. RESULTS: Selective anticoagulation in high-risk patients was shown to be the most cost-effective strategy, with the lowest cost and greatest effectiveness (an average cost of $21.08 and average quality-adjusted life year of 0.7231). Selective CTA has comparable utility and only a slightly higher cost (an average cost of $48.84 and average quality-adjusted life year of 0.7229). DSA, whether performed selectively or for all patients, was not optimal from both the cost and utility perspectives. Sensitivity analyses demonstrated these results to be robust for a wide range of parameter values. CONCLUSIONS: Selective CTA in high-risk patients is the optimal and cost-effective imaging strategy. It remains the dominant strategy over DSA, even assuming a low CTA sensitivity and irrespective of the proportion of patients at high-risk and the incidence of blunt cerebrovascular injury in high-risk patients.

The Utility of Dual-Energy Computed Tomographic Angiography for the Evaluation of Brain Aneurysms After Surgical Clipping: A Prospective Study.

OBJECTIVE: The purpose of this prospective study was to compare a novel dual-energy computed tomographic angiography (DECTA) method for postoperative assessment of clipped brain aneurysms to detect aneurysm remnants and parent artery patency, with catheter-based digital subtraction angiography (DSA). METHODS: Patients who underwent microsurgical cerebral aneurysm repair were prospectively evaluated after surgery by both DECTA and conventional DSA. CTA was performed using a novel dual-energy method with single source and fast kilovoltage switching (Gemstone Spectral Imaging [GSI]). DSA was performed using biplanar cerebral angiography. An experienced neuroradiologist and a neurosurgeon, both blinded to the original radiologic results, reviewed the images. RESULTS: On DSA, 8 of 15 aneurysms (53%) had a remnant after clipping. All of these remnants were <2 mm except for 1. The only residual aneurysm >2 mm was clearly detected by GSI CTA. Of those 7 DSA-confirmed <2-mm remnants, 5 were detected by GSI CTA. Metal artifacts compromised the image quality in 2 patients. The sensitivity and specificity of GSI CTA for remnant aneurysm <2-mm detection in single clip-treated patients were 100%. In all patients, these were 71.4 % and 100%, respectively. GSI CTA was 100% sensitive and 77% specific to detect parent vessel compromise, with associated positive and negative predictive values of 60% and 100%, respectively. CONCLUSIONS: DECTA is a promising noninvasive alternative to conventional catheter-based angiography for identification of aneurysm remnants and assessment of adjacent arteries after surgical clipping of brain aneurysms treated by 2 or fewer clips. It allows for a more rapid image acquisition than DSA, is more cost effective, and is widely available at clinical centers.

Imaging of carotid artery stenosis: clinical efficacy and cost-effectiveness.

PURPOSE: To determine the most accurate, safe, and cost-effective imaging protocol for selecting patients for carotid endarterectomy. METHODS: The actual costs of carotid angiography, ultrasound, and MR angiography were calculated. The diagnostic accuracy with different confidence levels was assessed for carotid ultrasound and MR angiography in 45 patients. The cost-effectiveness and theoretical impact on patient outcome of hypothetical screening models were compared. RESULTS: Ultrasound before angiography is more effective and considerably cheaper than performing angiography in all patients presenting with transient ischemic attacks ($25 216 versus $48 708 imaging costs per one prevented stroke). When the more costly MR angiography was used to select patients for angiography the slightly higher diagnostic accuracy did not result in a greater number of prevented strokes. As the only preoperative scrutiny, the combination of ultrasound and MR angiography would have resulted in a greater number of prevented strokes than invasive angiography (27.9 versus 23.3) but at the expense of unnecessary surgery (6.6% of all surgeries). CONCLUSIONS: Ultrasound followed by confirmatory angiography is a cost-effective way to image patients suspected of carotid artery stenosis. MR angiography may become cost effective and lead to a better final patient outcome only when it can reliably replace invasive angiography as the preoperative examination.

Intraoperative prebypass arteriography for infrageniculate revascularization.

BACKGROUND: Selection of the optimal distal target for infrageniculate arterial revascularization remains difficult in patients with multilevel occlusive disease due to poor visualization of the distal vasculature by preoperative arteriography. Prebypass, intraoperative arteriography (IOA) with direct injection of contrast into the infrageniculate arteries may improve distal arterial visualization and bypass target selection. METHODS: One hundred fourteen extremities in 104 consecutive patients requiring infrageniculate bypass were prospectively studied. All patients underwent preoperative contrast arteriography (CA) of the aortoiliac and lower extremity arteries using iodinated and/or CO2 contrast and digital subtraction techniques. IOAs were obtained at operation to confirm the adequacy of the distal runoff from the predicted bypass target and to identify potentially superior targets. The preoperative plan formulated from the CA was compared to the actual procedure performed based on the IOA. The CA and IOA were also independently reviewed postoperatively by two blinded vascular surgeons to determine the number of patent vessel segments visualized and the number of segments with <50% stenosis. RESULTS: Revascularization was done in 105 of 114 extremities (92%), whereas amputation was required as the initial procedure in 9 patients (8%). The IOA altered the operative plan based on the CA in 27 of 144 patients (24%). Changes in the planned bypass procedures included selection of a more distal anastomotic site in 13 of 102 patients (13%), selection of a more proximal anastomotic site in 4 of 102 (4%), selection of a different artery for the distal anastomosis in 3 of 102 (3%), and amputation rather than bypass in 2 of 102 patients (2%) with no suitable distal bypass target on the IOA. The IOA also resulted in bypass rather than planned amputation in 5 of 12 patients (42%) deemed unreconstructable on the preoperative CA. A mean of 13 minutes was required for IOA and an adequate study was obtained on the first attempt in 98 of 144 patients (86%). On postoperative review, more patent vessel segments but fewer segments with <50% stenosis were identified on the IOA compared to the CA. CONCLUSIONS: Prebypass intraoperative arteriography facilitates selection of the optimal distal bypass target during infrageniculate revascularization and can result in initial limb salvage in select patients deemed unreconstructable by preoperative contrast arteriography.

Colour flow Doppler ultrasound of the carotid bifurcation: can it replace routine angiography before carotid endarterectomy?

The objective of this study was to assess the diagnostic accuracy of colour flow Doppler ultrasound (CFD) and its potential to replace digital subtraction angiography (DSA) before carotid endarterectomy (CEA). All patients undergoing CFD of the carotid bifurcation in our department over a period of 1-1/2 years for whom both CFD and DSA results were available were included in the study. We evaluated the feasibility of CFD, its diagnostic accuracy and its potential to diagnose clinically significant stenosis (50%, 70% and 90% NASCET type diameter stenosis) compared with DSA. 225 carotid bifurcations in 116 patients met the criteria for evaluation (biplane arterial DSA without superimposition). Data analysis yielded the following diagnostic performance of CFD: sensitivity for a 50% stenosis 91.4% (95% confidence interval (CI) 83.3--96.2%), specificity 93.2% (95% CI 87.1--96.8%) and accuracy 92.4% (95% CI 88.4--95.4%); sensitivity for a 70% stenosis 89.2% (95% CI 81.9--94.1%), specificity 96.2% (95% CI 90.5--98.6%) and accuracy 92.4% (95% CI 88.4--95.4%). In 9 of 116 cases, carotid angiography was used to evaluate inconclusive CFD results. DSA disclosed relevant information not suspected by CFD in only 1 of the 116 cases. Thus, 91% (106/116) of the angiographies could have been dispensed with without loss of information. One major stroke occurred during diagnostic DSA. We conclude that DSA of the carotid arteries is unnecessary when CFD is unequivocal. The diagnostic gain of DSA must be counterweighted against its potential risks.

[Vascular diagnosis with color-coded duplex sonography. A cost-benefit analysis]. / Gefässdiagnostik mit der farbkodierten Duplexsonographie. Eine Kosten-Nutzen-Analyse.

In a retrospective study over two years, the costs of 2909 CCDS examinations were compared with 1893 digital subtraction angiograms. The cost of each CCDS examination was calculated as 147 DM and each DSA examination with intra-arterial contrast medium, or for shunt angiography was 709 DM. By using CCDS, it was possible to reduce the cost of angiographic examinations by 177,000 DM per year.

[Contrast media in peripheral angiography: does cost reduction mean loss of quality and safety? A reevaluation based on a randomized double-blind comparative study of ioxaglate versus iopromide]. / Kontrastmittel in der peripheren Angiographie: Bedeutet Kostenreduktion Verlust an Qualität und Sicherheit? Eine Reevaluierung anhand einer randomisierten Doppelblind-Vergleichsstudie von Ioxaglat versus Iopromid.

PURPOSE: To evaluate whether meglumine-sodium-ioxaglate (Hexabrix) and iopromide (Ultravist) are identically appropriate for peripheral angiography. Outcome variables were pain, image quality and adverse events. METHODS: Sixty patients were included in a randomised double-blind study. In all patients an intraarterial digital subtraction angiography (i.a. DSA) of iliac and peripheral arteries was performed. RESULTS: Analysis of the study revealed no significant difference between both contrast media in terms of the main and additional outcome variables. In comparison to iopromide, ioxaglate caused milder pain sensations (VAS 4.70 vs. 7.76, p = 0.25). Mild adverse events were observed more frequently in ioxaglate angiography (11% vs. 0%, p = 0.1). CONCLUSION: Both contrast media seem to be appropriate for peripheral angiography using DSA technique. Ioxaglate causes a cost reduction of about 20-35%. However, an increase of mild adverse reactions up to 11% to 15% has to be accepted.

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

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

Carotid bifurcation stenosis: a comparative study between MR angiography and duplex scanning with respect to digital subtraction angiography.

PURPOSE: This study compared sensitivity, specificity and diagnostic accuracy of Echoduplex and Magnetic Resonance Angiography (MRA) in the evaluation of carotid bifurcation stenosis. MATERIAL AND METHODS: Twenty-five patients with clinical signs suggestive for cerebrovascular insufficiency (CVI) were studied with Duplex scan, MRA and Digital Subtraction angiography (DSA). Gold standard was the angiographic examination. RESULTS: on equal value of sensitivity (80.5%), MRA showed 96% specificity versus 81% of Duplex scan, 89.4% diagnostic accuracy versus 80.9% for Duplex scan. As for stenosis over 31%, the value of sensitivity did not change i.e., 80.5%; MRA showed 100% specificity versus 97.1% for Duplex, 91.2% diagnostic accuracy versus 89.1% respectively. These values compared by the test for categorial analysis and correspondence analysis (p < 0.05) did not indicate any statistically significant difference. DISCUSSION: on the basis of our experience and as shown by current literature [2, 12] we can state that both MR-angiography and Duplex scan fail in quantifying correctly carotid stenosis with consequent over- and underestimation [3, 4]. However, they can be considered effective diagnostic procedures in a screening program [12, 16]; they are accurate, safe and accepted by the population. CONCLUSIONS: on the basis of the cost in planning the screening of a population at risk for CVI, Duplex scanning is still to be considered the elective procedure.

Safety, efficacy, and cost of intraoperative indocyanine green angiography compared to intraoperative catheter angiography in cerebral aneurysm surgery.

Intraoperative angiography in cerebrovascular neurosurgery can drive the repositioning or addition of aneurysm clips. Our institution has switched from a strategy of intraoperative digital subtraction angiography (DSA) universally, to a strategy of indocyanine green (ICG) videoangiography with DSA on an as-needed basis. We retrospectively evaluated whether the rates of perioperative stroke, unexpected postoperative aneurysm residual, or parent vessel stenosis differed in 100 patients from each era (2002, "DSA era"; 2007, "ICG era"). The clip repositioning rate for neck residual or parent vessel stenosis did not differ significantly between the two eras. There were no differences in the rate of perioperative stroke or rate of false-negative studies. The per-patient cost of intraoperative imaging within the DSA era was significantly higher than in the ICG era. The replacement of routine intraoperative DSA with ICG videoangiography and selective intraoperative DSA in cerebrovascular aneurysm surgery is safe and effective.