Drug-eluting stent: a review and update

The development of stent has been a major advance in the treatment of obstructive coronary artery disease since the introduction of balloon angioplasty. However, neointimal hyperplasia occurring within the stent leading to in-stent restenosis is a main obstacle in the long-term success of percutaneous coronary intervention (PCI). The recent introduction of drug-eluting stents (DES) contributes a major breakthrough to interventional cardiology. Many large randomized clinical trials using DES have shown a remarkable reduction in angiographic restenosis and target vessel revascularization when compared with bare metal stents. The results of these trials also appear to be supported by evidence from everyday practice and noncontrolled clinical trials. However, the expanded applications of DES, especially in treating complex lesions such as left main trunk, bifurcation, saphenous vein graft lesions, or in-stent restenosis, are still under evaluation with ongoing studies. With the availability of different types of DES in the market, the issue of cost should not be a deterrent and DES will eventually be an economically viable option for all patients. The adoption of DES in all percutaneous coronary intervention may become a reality in the near future. In this review article, we summarize the recent development and progress of DES as well as compare and update the results of clinical trials.

Airway stenting: Applications and practice management considerations

BACKGROUND

Airway stenting is a procedure that is performed increasingly often, and the availability of metallic stents placed by flexible bronchoscopy may have contributed to the increased usage. These procedures have an impact on the required physician skill set and practice management. We review the indications for airway stenting, and how the requirement of combined therapies and technical aspects of central airway stenting pertain to practice management.

PROCEDURE

We compared several reimbursement scenarios for managing stent placement using the Centers for Medicare and Medicaid Services relative value units (RVUs) and average reimbursement amounts. We also compared the reimbursement to other commonly performed activities performed by pulmonary and critical care physicians. An analysis of Medicare facility outpatient and inpatient payment for procedures using silicone and metallic stents was also conducted.

RESULTS

Professional reimbursement is identical regardless of stent type, method of insertion, and anesthesia administered. The net facility reimbursement largely depends on stent costs. The RVUs alone are a poor comparator for the reimbursement of therapeutic bronchoscopy because of Correct Coding Initiatives edits. Considering the time necessary for performing advanced therapeutic bronchoscopy, the professional fees are not attractive. The net facility reimbursement largely depends on stent costs.

CONCLUSION

The placement of airway stents is not reimbursed at competitive rates and may even lead to a net loss for the facility. The practice management benefits of central airway therapy are probably best obtained by a multidisciplinary airway team with an established cost center structure.

Use of the U.S. and U.K. Scoring Algorithm for the EuroQol-5D in an Economic Evaluation of Cardiac Care

BACKGROUND

Most studies that have used the EuroQol-5D instrument (EQ-5D) have used a scoring algorithm based on preferences solicited from the U.K. population. An algorithm recently was developed for the U.S. population, with studies showing meaningful differences in the results obtained using the 2 algorithms. We recently published an economic evaluation assessing the use of drug-eluting stents in patients undergoing percutaneous coronary intervention (PCI).

OBJECTIVES

Using the aforementioned economic evaluation, we describe the EQ-5D utility scores resulting from use of U.S. and U.K. algorithms and explore the differences in the incremental cost-utility ratio (ICER) resulting from use of the different EQ-5D estimates.

METHODS

EQ-5D data were obtained from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart (APPROACH) disease registry. Individual responses were scored once with each algorithm. The within-individual difference was calculated (U.S. score-U.K. score). The mean, SD, and range were compared using paired t tests. The resulting ICERs were compared using probabilistic sensitivity analysis.

RESULTS

The U.K. mean was statistically different from the U.S. mean (0.83, SD 0.20 vs. 0.87, SD 0.15, P<0.001). The mean within individual difference was 0.04 with a wide range (-0.02 to +0.41). The resulting ICER are CAN $58,635 (95% confidence interval $198,248-$34,406) per quality-adjusted life year and CAN $58,229 (95% confidence interval $116,818-$38,779) per quality-adjusted life year for the U.K. and U.S. algorithms, respectively (P value: 0.07).

CONCLUSIONS

The algorithms produce quite notable differences within individuals. The effect on the mean score is less pronounced. In the context of our economic evaluation, however, the impact of using the U.S. algorithm on the ICER is negligible.

Targeted stent use in clinical practice based on evidence from the BAsel Stent Cost Effectiveness Trial (BASKET)

AIM

It is unknown which patients benefit most from drug-eluting stents (DES) against bare-metal stents (BMS) in a long-term clinical outcome.

METHODS AND RESULTS

To address this question, data from 826 consecutive patients with angioplasty, randomized 2:1 to DES vs. BMS, with an 18-month follow-up for cardiac death/myocardial infarction (MI) and non-MI-related target-vessel revascularization (TVR) were analysed for interactions between stent type and patient/vessel characteristics predicting events. Rates of 18-month TVRs were lower with DES vs. BMS use (7.5 vs. 11.6%, P = 0.05), but similar for both stents regarding cardiac death/MI (DES, 8.4%; BMS, 7.5%; P = 0.70). Significant interactions between stent type and two multivariable event predictors were identified: small stents (<3.0 mm) and bypass graft stenting. In these patient groups together (n = 268, 32%), DES reduced non-MI-related TVR (HR = 0.44; P = 0.02) and cardiac death/MI (HR = 0.44; P = 0.04), whereas in the other 558 patients (68%) TVR rate was similar (HR = 0.75; P = 0.38) and cardiac death/MI rate increased after DES (HR = 2.07; P = 0.05).

CONCLUSION

Patients with angioplasty of small vessels or bypass grafts seem to benefit from DES use, in long-term outcome, in contrast to patients with large native vessel stenting where there might even be late harm. Still, this hypothesis needs to be tested prospectively.

Current disparities in the prices of medical materials between Japan and the United States: further investigation of cardiovascular medical devices

OBJECTIVES

Prices of medical devices in Japan were previously reported to be 2 to 4 times higher than those in the United States in 1996 and 1997. However, such data are out of date. We previously compared the market prices in early 2005 between Japan and the US for 16 items in 10 categories of medical materials, and showed that price differences still existed for all these items. However, the number of items investigated was small for each category, and generalization of the results might have been limited. The present study conducted a further investigation into price information for multiple items for each category, focusing on 5 cardiovascular devices.

METHODS

The US market price information was obtained from interviews of a healthcare provider network and 2 different group-purchasing organizations. We could obtain price information on 19 items in 5 categories. We substituted the Japanese reimbursement prices for the Japanese market prices.

RESULTS

The price ratio (Japanese reimbursement price / US market price)was 2.0-3.5 for coronary stents, 5.9-6.8 for percutaneous transluminal coronary angioplasty catheters, 2.2-3.5 for pacemakers, 1.6-2.5 for mechanical valves, and 3.4-4.7 for oxygenators.

CONCLUSIONS

The price disparities for cardiovascular devices between Japan and the US were reconfirmed. Japan's healthcare system should establish group-purchasing organizations, promote centers of clinical excellence, and abolish regulation of parallel imports and protectionism under the Japanese Pharmaceutical Affairs Law.

Bivalirudin versus heparin plus glycoprotein IIb/IIIa inhibitors in drug-eluting stent implantations in the absence of acute myocardial infarction: clinical and economic results

BACKGROUND

The use of bivalirudin in percutaneous coronary interventions has been shown to be clinically safe and effective, and may be associated with shorter hospital stays and lower costs than heparin + glycoprotein (GP) IIb/IIIa inhibition. This study compared the utilization, clinical outcomes and costs associated with the planned use of bivalirudin versus heparin + GP IIb/IIIa inhibition in drug-eluting stent (DES) patients without acute myocardial infarction (MI).

METHODS

We retrospectively studied 1,842 patients who underwent DES placement between May 2003 and December 2004. Planned treatment with heparin + GP IIb/IIIa inhibition was administered to 1,305 and planned bivalirudin alone was administered to 537 patients. Clinical follow ups (mean = 782 +/- 204 days) were obtained via telephone or mailed surveys in 1,813 patients (98.4%). Propensity analysis was utilized to adjust for between-groups baseline differences.

RESULTS

The unadjusted data revealed similar in-hospital outcomes in both groups. After propensity adjustment, the rate of vascular complications was significantly lower in the bivalirudin-treated group (0.2% vs. 1.2%; p = 0.04). At 1 year, clinical outcomes were similar in both groups. The overall unadjusted and adjusted cost analysis revealed similar mean hospital costs (11,384 U.S. dollars vs. 11,018 U.S. dollars; p = ns) and length of stay (2.9 days vs. 2.8 days; p = ns) in both groups. The unadjusted and adjusted mean hospital costs were significantly lower in patients treated with bivalirudin versus patients who received heparin + abciximab.

CONCLUSIONS

These observations suggest that bivalirudin is a safe, cost-effective alternative to heparin + GP IIb/IIIa inhibition in patients undergoing DES in the absence of acute MI.

[Economic impact of the taxus coronary stent: implications for the Spanish healthcare system]

INTRODUCTION AND OBJECTIVES

This article examines the cost impact associated with the utilization of the Taxus drug eluting stent versus a conventional bare-metal stent for percutaneous coronary interventions in a Spanish hospital setting.

METHODS

A decision analysis model has been developed to compare the intervention and re-hospitalization costs at 12 and 24 months post-intervention. The analysis considers the general patient population and a high-risk subpopulation (diabetes, small vessel, long lesion). The analysis simulates the results of the TAXUS-IV clinical trial, in a population with similar risks, with appropriate costs, and including budget impact analyses with alternative utilization scenarios.

RESULTS

The expected average per patient hospital cost at 12 months was 6934 euros with Taxus and 6756 euros with bare-metal stent (and increase of 2.6%). At 24 months, per patient hospital cost was 6,991 euros for Taxus and 6887 euros for bare-metal stent (an increase of 1.5%). In the high-risk subpopulation, Taxus was overall cost saving as compared to bare-metal stent both at 12 months (decrease of 3.0%) and 24 months (decrease of 4.7%).

CONCLUSIONS

Use of Taxus in the overall population slightly raises treatment costs, while in patients with greater risk of restenosis the treatment cost is reduced. Given the decrease in the number of repeat revascularizations with this stent, the cost-effectiveness relationship could be acceptable in the general patient population and is dominant in the high-risk subpopulation.

Effect of hospital ownership status and payment structure on the adoption and use of drug-eluting stents for percutaneous coronary interventions

BACKGROUND

The impact of the use of drug-eluting stents in percutaneous coronary intervention (PCI) on cardiac care is still uncertain. We examined the influence of systemic factors, such as hospital ownership status, organizational characteristics and payment structure, on the use of drug-eluting stents in PCI and the effect on cardiac surgery volume.

METHODS

We conducted a cross-sectional analysis of drug-eluting stent use in 12 993 patients undergoing PCI with stenting (drug-eluting or bare-metal) and time-series regression analyses of the monthly number of cardiac surgery and PCI procedures performed using data collected from 1998 to 2004 at 13 public and private hospitals in the Emilia-Romagna region of Italy.

RESULTS

Public hospitals used drug-eluting stents more selectively than private hospitals, targeting the new device to patients at high risk of adverse events. The time-series regression analyses showed that the number of PCI procedures performed per year increased during this period, both in public (slope coefficient 36.4, 95% confidence interval [CI] 30.2 to 43.1) and private centres (slope coefficient 6.4, 95% CI 3.1 to 9.2 ). Concurrently, there was a reduction in the number of isolated coronary artery bypass graft (CABG) surgeries, although the degree of change was higher in public than in private hospitals (coefficient -16.1 v. -6.2 respectively ). The number of CABG procedures associated with valve surgery decreased in public hospitals (coefficient -5.0, 95% CI -6.1 to -3.8) but increased in private hospitals (coefficient 4.1, 95% CI 2.0 to 6.1).

INTERPRETATION

Public and private hospitals behaved differently in adopting drug-eluting stents and in using PCI with drug-eluting stents as a substitute for surgical revascularization.

The cost-effectiveness of drug-eluting stents: a systematic review

BACKGROUND

Drug-eluting stents have been seen as an attractive alternative to bare-metal stents for percutaneous coronary interventions (PCIs) because of the decreased need for revascularization. However, comparative clinical trials have shown no difference in patient outcomes, and drug-eluting stents are considerably more expensive than their bare-metal counterparts. We conducted a systematic review of all published comparative cost-effectiveness analyses to identify the factors contributing to the heterogeneity of their conclusions.

METHODS

We retrieved all articles published between Jan. 1, 2000, and July 31, 2006, in which the cost-effectiveness, from a third-party payer perspective, of drug-eluting stents was compared with that of bare-metal stents for PCI in unrestricted patient populations. Electronic databases, Web sites from health technology assessment groups and references of identified articles were searched. Our outcome variable was whether the study's conclusions favoured widespread use of drug-eluting stents, as assessed by 4 independent reviewers. Study characteristics such as quality, funding source, country and year of publication were extracted. Two-by-2 tables and Fisher's exact test were used to study the association between covariates and the outcome variable. A classification and regression tree (CART) model was used for multivariate analysis.

RESULTS

We identified 19 cost-effectiveness analyses. Ten were in favour of widespread use of drug-eluting stents, and 9 favoured more restrained use. Only 1 of 9 high-quality studies supported widespread use, as compared with 9 of 10 lower quality studies (p < 0.001). All of the 7 sponsored studies argued in favour of widespread use, as compared with 3 of the 12 studies without sponsorship (p = 0.003). Studies from the United States were more likely than those from other countries to endorse unlimited use (p = 0.032). A CART model with 2 covariates--study quality and sponsorship--provided the best fit (error rate 10.5%).

INTERPRETATION

Conclusions drawn by cost-effectiveness analyses of drug-eluting stents for PCI are associated with the study's quality, funding source and country of origin. Vigilance regarding these study characteristics is required when interpreting findings from cost-effectiveness analyses.

The impact of age on outcomes after coronary artery bypass surgery versus stent-assisted percutaneous coronary intervention: one-year results from the Stent or Surgery (SoS) trial

BACKGROUND

Relative outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) may differ between younger and older patients. There are no data comparing the age-related CABG versus PCI outcomes in the stent era.

METHODS

The SoS trial compared CABG (n = 500) and stent-assisted PCI (n = 488). The impact of treatment assignment on 1-year outcomes was evaluated by age < or = 65 years (n = 295, CABG; n = 298, PCI) and > 65 years (n = 205, CABG; n = 190, PCI).

RESULTS

One-year procedural outcomes were similar between treatment groups regardless of age, with the exception of more repeat revascularizations after PCI (age < or = 65, 16.1% vs 4.8%; age > 65, 19.5% vs 3.4%; both P < .001). Six and 12-month Seattle Angina Questionnaire scores improved from baseline in both age and treatment groups. However, CABG was associated with greater improvement in physical limitation, angina frequency, and quality of life in younger patients at 6 and 12 months (12-month difference in improvement between CABG and PCI: 5.6, 4.8, and 3.9 points for 3 domains), whereas in the elderly a significant benefit of CABG observed at 6 months did not persist at 12 months (12-month difference: 0.9, 1.9, and 1.4). One-year costs were significantly higher after CABG regardless of age.

CONCLUSIONS

Although PCI and CABG result in similar rates in clinical outcomes irrespective of age, younger patients reported more health status benefits from CABG as compared with PCI, whereas in older patients the 2 approaches resulted in similar 1-year health status benefits.

Cost-effectiveness of the unrestricted use of sirolimus-eluting stents vs. bare metal stents at 1 and 2-year follow-up: results from the RESEARCH Registry

AIMS

To assess the cost-effectiveness of sirolimus-eluting stents (SESs) compared with bare metal stents (BMSs) as the default strategy in unselected patients treated in the Rapamycin Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) Registry at 1 and 2-years following the procedure.

METHODS AND RESULTS

A total of 508 consecutive patients with de novo lesions exclusively treated with SES were compared with 450 patients treated with BMS from the immediate preceding period. Resource use and costs of the index procedure, and clinical outcomes were prospectively recorded over a 2-year follow-up period. Follow-up costs were measured as unit costs per patient based on the incidence of clinically driven target vessel revascularization (TVR), to obtain cumulative costs at 1 and 2-years. Cost-effectiveness was measured as the incremental cost-effectiveness ratio (ICER) per TVR avoided. The use of SES cost euro 3,036 more per patient at the index procedure, driven by the price of SES. Follow-up costs after 1-year were euro 1,089 less with SES when compared with BMS, due to less TVR, resulting in a net excess cost of euro 1,968 per patient in the SES group, and reduced by a further euro 100 per patient in the second year. The incidence of death or myocardial infarction between groups was similar at 1 and 2 years. Rates of TVR in the SES and BMS groups were 3.7% vs. 10.4%, P<0.01 at 1 year, respectively; and 6.4% vs. 14.7%, P<0.001 at 2 years. The ICER per TVR avoided was euro 29,373 at 1 year, and euro 22,267 at 2 years.

CONCLUSION

The use of SES, while significantly beneficial in reducing the need for repeat revascularization, was more expensive and not cost-effective in the RESEARCH registry at either 1 or 2-years when compared with BMS. On the basis of these results, in an unselected population with 1 year of follow-up, the unit price of SES would have to be euro 1,023 in order to be cost-neutral.

Carotid Artery Stenting Versus Carotid Endarterectomy: Current Status

As operator experience and device technology continue to improve, the theoretic advantages of endovascular approaches to treat carotid occlusive disease may be closer to realization. Currently, data from controlled trials of CAS is minimal, but several multicenter RCTs comparing CAS to CEA are recruiting patients actively and preliminary results show procedural morbidity and mortality rates for CAS that compare favorably to CEA. Community-based experience with CAS continues to grow and further refinements in patient selection based on plaque morphology and other variables offer further hope that endovascular approaches to carotid occlusive disease may benefit selected patients. Given the proved efficacy and durability of CEA for treatment of extracranial carotid stenosis, surgical revascularization remains the recommended standard of care for most patients. CAS will have to be proved equivalent or superior to surgery and as cost-effective to facilitate its widespread acceptance as a treatment alternative for carotid occlusive disease.

[Drug-eluting coronary stents]

The first method of percutaneously treating a diseased vessel was developed by Dotter and Judkins in 1964. Andreas Grüntzig performed the first coronary angioplasty in 1977. In 1985 Palmaz et al. implanted the first balloon-mounted stent in a peripheral artery. Puel and Sigwart implanted the first human coronary stent in March 1986; it was a self-expanding mesh-like device. Schatz et al. applied some small modifications to the original Palmaz stent, which resulted in the first coronary stent available on the market, called Palmaz-Schatz stent. In 1987 Sigwart was the first to suggest the use of coronary stents in acute vessel occlusions during unsuccessful PTCA. Using the device it became possible to cover the intimal flap and to prevent elastic recoil. Because of the high incidence of subacute stent thromboses and the bleeding complications (aggressive anticoagulation regimens) these times the coronary stents were implanted only in order to avoid emergency CABG surgery. In 1993 BENESTENT and STRESS trials have proved that elective stent implantation can significantly reduce the incidence of restenosis. The dual antiplatelet therapy and the high pressure stent implantation technique dramatically reduced the incidence of subacute stent thrombosis. The treatment of coronary artery disease has undergone revolutionary changes in the past decade but remained the leading cause of mortality in the developed world. The most important limitation of PCI has been in-stent restenosis, which occurs in 20-40% of stent implantations. Clinically it results in recurrent ischemic episodes most often requiring repeat revascularisation (rePCI or CABG). With the use of drug-eluting stents the incidence of in-stent restenosis can be reduced dramatically, based on the currently available clinical trials it remains below 10%.

Consenso de especialistas (SBC/SBHCI) sobre o uso de stents farmacológicos: recomendações da sociedade brasileira de cardiologia/sociedade brasileira de hemodinâmica e cardiologia intervencionista ao sistema único de saúde

The authors review percutaneous coronary intervention (PCI) evolution and its growing application in myocardial revascularization for patients with coronary heart disease in Brazil and worldwide. PCI was introduced in 1977 using only the catheter balloon. Limitations of this method (acute occlusion and coronary restenosis) led to the adoption of coronary stents and more recently the advent of drug-eluting stents2, which were developed to drastically reduce restenosis rates. These developments allowed the exponential growth of percutaneous coronary intervention (PCI) procedures in Brazil which have replaced many bypass surgery procedures and have become the gold standard for the majority of symptomatic patients suffering from coronary artery disease. The preference for this procedure gained new dimensions in 2000 when the Brazilian Public Healthcare System (SUS) began reimbursing for stent procedures. This measure exemplified the importance of the Public Healthcare System's participation in incorporating medical advances and offering a high standard of cardiovascular treatment to a large portion of the Brazilian population. It is emphasized that prevention of in-stent restenosis is complex due to its unpredictable and ubiquitous occurrence. Control of this condition improves quality of life and reduces the recurrence of angina pectoris, the need to perform new revascularization procedures and hospital readmissions. The overall success of the drug-eluting stents has proven to be reliable and consistent in overcoming restenosis and has some beneficial impact for all clinical and angiographic conditions. This paper discusses the adoption and criteria for the use of drug-eluting stents in other countries as well as the recommendations established by the Brazilian Society of Interventional Cardiology for their reimbursement by SUS. The incorporation of new healthcare technology involves two distinct stages. During the first stage, the product is registered with the National Health Surveillance Agency (ANVISA). During this stage the interested company submits to the regulatory agency, results from clinical studies that demonstrate the efficacy and safety of the new device or pharmaceutical product. Frequently, in addition to clinical studies, approval records for clinical use from the regulatory agencies of other countries, mainly the United States of America and the European Community are also submitted. The successful completion of this stage means that the medication or device may be prescribed or used by the physicians in Brazil. The second stage in the incorporation of new healthcare technology involves the reimbursement or financing of the treatment that was approved in the previous stage based on its efficacy and safety. This stage can be more complex than the first one since the new technology, whether a substitution for established treatment methods or the introduction of a new treatment concept, are usually more expensive. The incorporation of new technology requires a cost-effectiveness analysis so that fund administrators can make decisions based on the universal scenario of limited resources to finance healthcare with treatments that are more and more burdensome. The difficulties of funding management are aggravated by medical and social ethical implications that arise when a treatment is approved based on its efficacy and safety but is not made available to patients who could benefit greatly from it. In Brazil, assessment methods for the incorporation of new technology based on reimbursement or financing have not been fully developed for either the private healthcare plans or the Brazilian Public Healthcare System (SUS). The implementation of new technology in both healthcare systems is a slow process and frequently the implementation is a result of the requirements of patients or the organizations that represent them and at times is the result of legal proceedings or political pressure imposed by physicians and their respective scientific societies. Our objective is to review the evolution of percutaneous coronary intervention (PCI) in Brazil and its current status in view of the advent of drug-eluting stents, the growing participation of drug-eluting stents in myocardial revascularization to treat patients with coronary heart disease, as well as, to compare the regulatory standards from Brazil and other countries regarding the incorporation and recommendations for the use of this new technology.

Interventional Nephrology in a Federal Hospital: Economics of Health Care

Interventional nephrology is now an accepted subspecialty of nephrology that is revolutionizing the standard of care for renal failure patients. Interventional nephrology deals with the placement of tunneled cuffed catheters (TCCs) and maintenance of permanent vascular accesses, thus assisting in timely care. Prior to 2000 most end-stage renal disease (ESRD) patients from the Overton Brooks Veterans Affairs Medical Center (OBVAMC) were referred to an outlying hospital for TCC placement and endovascular procedures (EVPs) of permanent dialysis access. The referral process was cumbersome for the patients and expensive to the Medicine Service. OBVAMC started an interventional nephrology service in 2000. The current study reports the financial benefits of starting an interventional nephrology service at our institution. All procedures performed during the period from April 2000 to April 2004 were analyzed. The procedures were performed in the cardiac catheterization laboratory. The total payment (physician's and hospital fees) to the referral hospital for procedures prior to April 2000 was used to estimate the average savings to the Medicine Service over the last 4 years. A total of 129 TCCs and 43 EVPs were performed during this period. The estimated expense to OBVAMC would have been US dollars 603,978 for TCCs and US dollars 288,100 for EVPs based on charges prior to April 2000. The actual expense to the hospital, including facility fees and disposables, was US dollars 156,013. The net savings to OBVAMC over the last 4 years was US dollars 736,065. Interventional nephrology provided to a small population of renal failure patients in a tertiary federal health care facility has resulted in huge savings for the hospital. Increasing awareness of this procedural aspect of nephrology benefits not only the patients, but also helps ease the financial burden of ever-escalating health care costs.

Tannenbaum and metal stents in the palliative treatment of malignant distal bile duct obstruction: a comparative study of patency and cost effectiveness

BACKGROUND

Stent clogging is the major limitation of palliative treatment for malignant biliary obstruction. Metal stents have much better patency than plastic stents, but are more expensive. Preliminary data suggest that the recently designed plastic (Tannenbaum) stent has better duration of patency than the polyethylene stent. This study aimed to compare the efficacy and cost effectiveness between the Tannenbaum stent without side holes and the uncovered metal stent for patients with malignant distal common bile duct obstruction.

METHODS

In this study, 47 patients (median age, 73 years, range, 56-86 years) with inoperable malignant distal common bile duct strictures were prospectively randomized to receive either a Tannenbaum stent (n = 24) or an uncovered self-expandable metal stent (n = 23). The patients were clinically evaluated, and biochemical tests were analyzed if necessary until their death or surgery for gastric outlet obstruction. Cumulative first stent patency and patient survival were compared between the two groups. Cost-effectiveness analysis also was performed for the two study groups.

RESULTS

The two groups were comparable in terms of age, gender, and diagnosis. The median first stent patency was longer in the metal group than in the Tannenbaum stent group (255 vs 123.5 days; p = 0.002). There was no significant difference in survival between the two groups. The total cost associated with the Tannenbaum stents was lower than for the metal stents (17,700 vs 30,100 euros; p = 0.001), especially for patients with liver metastases (3,000 vs 6,900 euros; p < 0.001).

CONCLUSIONS

Metal stent placement is an effective treatment for inoperable malignant distal common bile duct obstruction, but Tannenbaum stent placement is a cost-saving strategy, as compared with metal stent placement, especially for patients with liver metastases and expected short survival time.

Clinical outcomes and cost comparison of carotid artery angioplasty with stenting versus carotid endarterectomy

BACKGROUND

Recently, carotid angioplasty with stenting (CAS) has evolved as an alternative to carotid endarterectomy (CEA) for the treatment of carotid occlusive disease. Some concerns have arisen regarding the high cost of stents and neuroprotection devices, which may inflate the overall procedural costs relative to CEA. We report here a review and analysis contrasting the clinical outcomes and associated hospital costs incurred for patients treated with either CAS or CEA.

METHODS

Ninety-four consecutive patients with surgically amenable carotid stenosis were offered CAS or CEA. Forty-six patients elected CAS, and 48 patients underwent CEA. CAS was performed with the Smart Precise or Acculink stents, and all procedures included neuroprotection (Filter Wire or Accunet). CEA was performed with patients under general anesthesia with routine shunting and with Dacron or bovine pericardium patches. Clinical outcomes such as perioperative mortality, major adverse events (myocardial infarction, stroke, and death), length of stay, and the incidence of hemodynamic instability were analyzed. Total costs, indirect costs, and direct procedural costs associated with hospitalization were also reviewed.

RESULTS

CAS was associated with a shorter length of stay compared with CEA (1.2 vs 2.1 days; P = .02). Differences in perioperative mortality (0% vs 2%; P = NS), major adverse events (2% vs 10%; P = .36), strokes (2% vs 4%; P = NS), myocardial infarctions (0% vs 4%; P = .49), and hypotension necessitating pressor support (21% vs 18%; P = NS) were not statistically significant. By using cost to charge ratio methodology according to the Medicare report, CAS was associated with higher total procedural costs (US dollars 17,402 vs US dollars 12,112; P = .029) and direct costs (US dollars 10,522 vs US dollars 7227; P = .017). The differences in indirect costs were not significant (US dollars 6879 vs US dollars 4885; P = .063).

CONCLUSIONS

CAS with neuroprotection was associated with clinical outcomes equivalent to those with CEA but had higher total hospital costs. These higher costs reflect the addition of expensive devices that have improved the technical success and the clinical outcomes associated with CAS.