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Kang J, Barnes JA, Suckow BD, Goodney PP, Columbo JA, Zwolak RM, Powell RJ, Stone DH. The financial evolution of endovascular aneurysm repair delivery in contemporary practice. J Vasc Surg 2020; 73:1062-1066. [PMID: 32707394 DOI: 10.1016/j.jvs.2020.06.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 06/19/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Jeanwan Kang
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Jonathan A Barnes
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Bjoern D Suckow
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Robert M Zwolak
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Richard J Powell
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Gupta AK, Alshaikh HN, Dakour-Aridi H, King RW, Brothers TE, Malas MB. Real-world cost analysis of endovascular repair versus open repair in patients with nonruptured abdominal aortic aneurysms. J Vasc Surg 2020; 71:432-443.e4. [DOI: 10.1016/j.jvs.2018.12.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/13/2018] [Indexed: 11/28/2022]
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Bewley BR, Servais AB, Salehi P. The evolution of stent grafts for endovascular repair of abdominal aortic aneurysms: how design changes affect clinical outcomes. Expert Rev Med Devices 2019; 16:965-980. [DOI: 10.1080/17434440.2019.1684897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | | | - Payam Salehi
- Tufts University School of Medicine, Boston, MA, USA
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
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Faccioli N, Foti G, Casagranda G, Santi E, D'Onofrio M. CEUS versus CT Angiography in the follow-up of abdominal aortic endoprostheses: diagnostic accuracy and activity-based cost analysis. Radiol Med 2018; 123:904-909. [PMID: 30084107 DOI: 10.1007/s11547-018-0926-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/25/2018] [Indexed: 02/01/2023]
Abstract
PURPOSE To evaluate diagnostic accuracy and to perform an activity-based cost analysis of contrast-enhanced ultrasonography (CEUS) compared to computed tomography (CT) during annual surveillance after abdominal aortic aneurysm repair with endovascular procedure (EVAR). MATERIALS AND METHODS This retrospective study included 137 patients in post-EVAR follow-up over a 6-year period (average post-operatory follow-up without aneurysm sac volumetric reduction). Sensitivity, specificity, positive predictive values, negative predictive values and accuracy were considered for CEUS using CT angiography (CTA) as reference standard. An activity-based cost analysis was performed to evaluate potential savings due to the introduction of CEUS as an alternative to CT, after the first year of postoperative negative controls. RESULTS CEUS reported accuracy, sensitivity, specificity, positive predictive values, negative predictive values of 97.4, 96, 100, 100 and 93.1% in the detection and characterization of endoleaks. CEUS cost was € 84.7, and CTA cost was € 157.77, with a differential cost of € 73.07; using CEUS as an alternative to CT allowed a potential saving of 50.052,95 € during follow-up. CONCLUSIONS CEUS is an accurate and cheap imaging method in post-EVAR follow-up patients, and it could be considered as a valid alternative to CTA, after the first year of negative controls, reducing the number of unnecessary CT examinations.
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Affiliation(s)
- Niccolo' Faccioli
- Department of Radiology, University of Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro, 37134, Verona, Italy.
| | - Giovanni Foti
- Department of Radiology, University of Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro, 37134, Verona, Italy
| | - Giulia Casagranda
- Department of Radiology, University of Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro, 37134, Verona, Italy
| | - Elena Santi
- Department of Radiology, University of Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro, 37134, Verona, Italy
| | - Mirko D'Onofrio
- Department of Radiology, University of Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro, 37134, Verona, Italy
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Grant SW, Sperrin M, Carlson E, Chinai N, Ntais D, Hamilton M, Dunn G, Buchan I, Davies L, McCollum CN. Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation. Health Technol Assess 2016; 19:1-154, v-vi. [PMID: 25924187 DOI: 10.3310/hta19320] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) repair aims to prevent premature death from AAA rupture. Elective repair is currently recommended when AAA diameter reaches 5.5 cm (men) and 5.0 cm (women). Applying population-based indications may not be appropriate for individual patient decisions, as the optimal indication is likely to differ between patients based on age and comorbidities. OBJECTIVE To develop an Aneurysm Repair Decision Aid (ARDA) to indicate when elective AAA repair optimises survival for individual patients and to assess the cost-effectiveness and associated uncertainty of elective repair at the aneurysm diameter recommended by the ARDA compared with current practice. DATA SOURCES The UK Vascular Governance North West and National Vascular Database provided individual patient data to develop predictive models for perioperative mortality and survival. Data from published literature were used to model AAA growth and risk of rupture. The cost-effectiveness analysis used data from published literature and from local and national databases. METHODS A combination of systematic review methods and clinical registries were used to provide data to populate models and inform the structure of the ARDA. Discrete event simulation (DES) was used to model the patient journey from diagnosis to death and synthesised data were used to estimate patient outcomes and costs for elective repair at alternative aneurysm diameters. Eight patient clinical scenarios (vignettes) were used as exemplars. The DES structure was validated by clinical and statistical experts. The economic evaluation estimated costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) from the NHS, social care provider and patient perspective over a lifetime horizon. Cost-effectiveness acceptability analyses and probabilistic sensitivity analyses explored uncertainty in the data and the value for money of ARDA-based decisions. The ARDA outcome measures include perioperative mortality risk, annual risk of rupture, 1-, 5- and 10-year survival, postoperative long-term survival, median life expectancy and predicted time to current threshold for aneurysm repair. The primary economic measure was the ICER using the QALY as the measure of health benefit. RESULTS The analysis demonstrated it is feasible to build and run a complex clinical decision aid using DES. The model results support current guidelines for most vignettes but suggest that earlier repair may be effective in younger, fitter patients and ongoing surveillance may be effective in elderly patients with comorbidities. The model adds information to support decisions for patients with aneurysms outside current indications. The economic evaluation suggests that using the ARDA compared with current guidelines could be cost-effective but there is a high level of uncertainty. LIMITATIONS Lack of high-quality long-term data to populate all sections of the model meant that there is high uncertainty about the long-term clinical and economic consequences of repair. Modelling assumptions were necessary and the developed survival models require external validation. CONCLUSIONS The ARDA provides detailed information on the potential consequences of AAA repair or a decision not to repair that may be helpful to vascular surgeons and their patients in reaching informed decisions. Further research is required to reduce uncertainty about key data, including reintervention following AAA repair, and assess the acceptability and feasibility of the ARDA for use in routine clinical practice. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Stuart W Grant
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Matthew Sperrin
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Eric Carlson
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Natasha Chinai
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Dionysios Ntais
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Matthew Hamilton
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Graham Dunn
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Iain Buchan
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Linda Davies
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Charles N McCollum
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
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Warner CJ, Horvath AJ, Powell RJ, Columbo JA, Walsh TR, Goodney PP, Walsh DB, Stone DH. Endovascular aneurysm repair delivery redesign leads to quality improvement and cost reduction. J Vasc Surg 2015; 62:285-9. [PMID: 25935271 DOI: 10.1016/j.jvs.2015.02.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 02/26/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Endovascular aneurysm repair (EVAR) is now a mainstay of therapy for abdominal aortic aneurysm, although it remains associated with significant expense. We performed a comprehensive analysis of EVAR delivery at an academic medical center to identify targets for quality improvement and cost reduction in light of impending health care reform. METHODS All infrarenal EVARs performed from April 2011 to March 2012 were identified (N = 127). Procedures were included if they met standard commercial instructions for use guidelines, used a single manufacturer, and were billed to Medicare diagnosis-related group 238 (n = 49). By use of DMAIC (define, measure, analyze, improve, and control) quality improvement methodology (define, measure, analyze, improve, control), targets for EVAR quality improvement were identified and high-yield changes were implemented. Procedure technical costs were calculated before and after process redesign. RESULTS Perioperative services and clinic visits were identified as targets for quality improvement efforts and cost reduction. Mean technical costs before the intervention were $31,672, with endograft implants accounting for 52%. Pricing redesign in collaboration with hospital purchasing reduced mean EVAR technical costs to $28,607, a 10% reduction in overall cost, with endograft implants now accounting for 46%. Perioperative implementation of instrument tray redesign reduced instrument use by 32% (184 vs 132 instruments), saving $50,000 annually. Unnecessary clinic visits were reduced by 39% (1.6 vs 1.1 clinic visits per patient) through implementation of a preclinic imaging protocol. There was no difference in mean length of stay after the intervention. CONCLUSIONS Comprehensive EVAR delivery redesign leads to cost reduction and waste elimination while preserving quality. Future efforts to achieve more competitive and transparent device pricing will make EVAR more cost neutral and enhance its financial sustainability for health care systems.
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Affiliation(s)
- Courtney J Warner
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Alexander J Horvath
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Richard J Powell
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Teri R Walsh
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Daniel B Walsh
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Matsumura JS, Stroupe KT, Lederle FA, Kyriakides TC, Ge L, Freischlag JA, Ketteler ER, Kingsley DD, Marek JM, Massen RJ, Matteson BD, Pitcher JD, Langsfeld M, Corson JD, Goff JM, Kasirajan K, Paap C, Robertson DC, Salam A, Veeraswamy R, Milner R, Kasirajan K, Guidot J, Lal BK, Busuttil SJ, Lilly MP, Braganza M, Ellis K, Patterson MA, Jordan WD, Whitley D, Taylor S, Passman M, Kerns D, Inman C, Poirier J, Ebaugh J, Raffetto J, Chew D, Lathi S, Owens C, Hickson K, Dosluoglu HH, Eschberger K, Kibbe MR, Baraniewski HM, Matsumura J, Endo M, Busman A, Meadows W, Evans M, Giglia JS, El Sayed H, Reed AB, Ruf M, Ross S, Jean-Claude JM, Pinault G, Kang P, White N, Eiseman M, Jones R, Timaran CH, Modrall JG, Welborn MB, Lopez J, Nguyen T, Chacko JK, Granke K, Vouyouka AG, Olgren E, Chand P, Allende B, Ranella M, Yales C, Whitehill TA, Krupski WC, Nehler MR, Johnson SP, Jones DN, Strecker P, Bhola MA, Shortell CK, Gray JL, Lawson JH, McCann R, Sebastian MW, Tetterton JK, Blackwell C, Prinzo PA, Lee N, Padberg FT, Cerveira JJ, Lal BK, Zickler RW, Hauck KA, Berceli SA, Lee WA, Ozaki CK, Nelson PR, Irwin AS, Baum R, Aulivola B, Rodriguez H, Littooy FN, Greisler H, O'Sullivan MT, Kougias P, Lin PH, Bush RL, Guinn G, Cagiannos C, Pillack S, Guillory B, Cikrit D, Lalka SG, Lemmon G, Nachreiner R, Rusomaroff M, O'Brien E, Cullen JJ, Hoballah J, Sharp WJ, McCandless JL, Beach V, Minion D, Schwarcz TH, Kimbrough J, Ashe L, Rockich A, Warner-Carpenter J, Moursi M, Eidt JF, Brock S, Bianchi C, Bishop V, Gordon IL, Fujitani R, Kubaska SM, Behdad M, Azadegan R, Agas CM, Zalecki K, Hoch JR, Carr SC, Acher C, Schwarze M, Tefera G, Mell M, Dunlap B, Rieder J, Stuart JM, Weiman DS, Abul-Khoudoud O, Garrett HE, Walsh SM, Wilson KL, Seabrook GR, Cambria RA, Brown KR, Lewis BD, Framberg S, Kallio C, Barke RA, Santilli SM, d'Audiffret AC, Oberle N, Proebstle C, Lee Johnson L, Jacobowitz GR, Cayne N, Rockman C, Adelman M, Gagne P, Nalbandian M, Caropolo LJ, Pipinos II, Johanning J, Lynch T, DeSpiegelaere H, Purviance G, Zhou W, Dalman R, Lee JT, Safadi B, Coogan SM, Wren SM, Bahmani DD, Maples D, Thunen S, Golden MA, Mitchell ME, Fairman R, Reinhardt S, Wilson MA, Tzeng E, Muluk S, Peterson NM, Foster M, Edwards J, Moneta GL, Landry G, Taylor L, Yeager R, Cannady E, Treiman G, Hatton-Ward S, Salabsky B, Kansal N, Owens E, Estes M, Forbes BA, Sobotta C, Rapp JH, Reilly LM, Perez SL, Yan K, Sarkar R, Dwyer SS, Kohler TR, Hatsukami TS, Glickerman DG, Sobel M, Burdick TS, Pedersen K, Cleary P, Kansal N, Owens E, Estes M, Forbes BA, Sobotta C, Back M, Bandyk D, Johnson B, Shames M, Reinhard RL, Thomas SC, Hunter GC, Leon LR, Westerband A, Guerra RJ, Riveros M, Mills JL, Hughes JD, Escalante AM, Psalms SB, Day NN, Macsata R, Sidawy A, Weiswasser J, Arora S, Jasper BJ, Dardik A, Gahtan V, Muhs BE, Sumpio BE, Gusberg RJ, Spector M, Pollak J, Aruny J, Kelly EL, Wong J, Vasilas P, Joncas C, Gelabert HA, DeVirgillio C, Rigberg DA, Cole L. Costs of repair of abdominal aortic aneurysm with different devices in a multicenter randomized trial. J Vasc Surg 2015; 61:59-65. [DOI: 10.1016/j.jvs.2014.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 08/01/2014] [Indexed: 10/24/2022]
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Licker M, Christoph E, Cartier V, Mugnai D, Murith N, Kalangos A, Aldenkortt M, Cassina T, Diaper J. Impact of anesthesia technique on the incidence of major complications after open aortic abdominal surgery: a cohort study. J Clin Anesth 2013; 25:296-308. [PMID: 23685100 DOI: 10.1016/j.jclinane.2013.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 01/06/2013] [Accepted: 01/17/2013] [Indexed: 01/27/2023]
Abstract
STUDY OBJECTIVE To determine the risk factors of perioperative complications and the impact of intrathecal morphine (ITM) in major vascular surgery. DESIGN Retrospective analysis of a prospective cohort. SETTINGS Operating room, intensive care unit, and Postanesthesia Care Unit of a university hospital. MEASUREMENTS Data from 595 consecutive patients who underwent open abdominal aortic surgery between January 1997 and December 2011 were reviewed. Data were stratified into three groups based on the analgesia technique delivered: systemic analgesia (Goup SA), thoracic epidural analgesia (Group TEA), and intrathecal morphine (Group ITM). Preoperative patient characteristics, perioperative anesthetic and medical interventions, and major nonsurgical complications were recorded. MAIN RESULTS Patients managed with ITM (n=248) and those given thoracic epidural analgesia (n=70) required lower doses of intravenous (IV) sufentanil intraoperatively and were extubated sooner than those who received systemic analgesia (n=270). Total inhospital mortality was 2.9%, and 24.4% of patients experienced at least one major complication during their hospital stay. Intrathecal morphine was associated with a lower risk of postoperative morbidity (OR 0.51, 95% CI 0.28 - 0.89), particularly pulmonary complications (OR 0.54, 95% CI 0.31 - 0.93) and renal dysfunction (OR 0.52, 95% CI 0.29 - 0.97). Other predictors of nonsurgical complications were ASA physical status 3 and 4 (OR 1.94, 95% CI 1.07 - 3.52), preoperative renal dysfunction (OR 1.61, 95% CI 1.01 - 2.58), prolonged surgical time (OR 1.78, 95% CI 1.16 - 2.78), and the need for blood transfusion (OR 1.77, 95% CI 1.05 - 2.99). CONCLUSIONS This single-center study showed a decreased risk of major nonsurgical complications in patients who received neuraxial analgesia after abdominal aortic surgery.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital, CH-1211 Geneva, Switzerland.
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Cost–Effectiveness at Two Years in the VA Open versus Endovascular Repair Trial. Eur J Vasc Endovasc Surg 2012; 44:543-8. [DOI: 10.1016/j.ejvs.2012.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 10/02/2012] [Indexed: 11/23/2022]
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Tillman B, Hardin-Young J, Shannon W, Russell AJ, Parenteau NL. Meeting the need for regenerative therapies: translation-focused analysis of U.S. regenerative medicine opportunities in cardiovascular and peripheral vascular medicine using detailed incidence data. TISSUE ENGINEERING PART B-REVIEWS 2012; 19:99-115. [PMID: 23031078 DOI: 10.1089/ten.teb.2011.0678] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Cardiac and vascular diseases represent one of the most substantial medical areas for the applications of regenerative medicine. Despite advances in endovascular repair, surgical intervention, and disease management, atherosclerosis and heart failure continue to be prominent health problems. This report analyzes the regenerative medicine treatment opportunities in both cardiovascular and peripheral vascular repair, examining the treatment opportunities for tissue-engineered vascular grafts as well as cell-based therapies. U.S. hospital discharge data were used to generate a detailed estimate of the relative target populations for cardiac and vascular disease. Gap analyses were performed for vascular access, small caliber vascular grafts, and cell-based therapies for revascularization and heart failure. The analysis compared current alternatives, gaps in medical need, and what a tissue-engineered or regenerative alternative should achieve for optimum medical and commercial feasibility. Although the number of coronary bypass grafts vastly outnumbered peripheral grafts, a detailed consideration of re-grafts and the success of first grafts combined with gap analysis (GAP) leads us to conclude that peripheral vascular disease is the more commercially feasible and attractive target opportunity for engineered small caliber grafts for the foreseeable future. Cardiac bypass would need substantial long-term clinical experience, which could be a significant hurdle. Vascular access, often regarded as a first-in-man indication, is an excellent opportunity for an engineered graft as an alternative to arteriovenous fistula that could overcome complications associated with a prosthetic graft. The GAP also suggests that for heart failure, cellular therapies should link near-term changes in repair, such as improvement in cardiac output and reduced scarring with limiting progression of the disease, reducing the need for complex pharmacologic management, and reducing rates of hospitalization. Naturally, researchers must determine where their technology and know-how can be applied most effectively, but it is clear from our analysis that an astute strategy in the use of science and technology will be important to successful translation in this space.
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Affiliation(s)
- Bryan Tillman
- The McGowan Institute of Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Stroupe KT, Lederle FA, Matsumura JS, Kyriakides TC, Jonk YC, Ge L, Freischlag JA. Cost-effectiveness of open versus endovascular repair of abdominal aortic aneurysm in the OVER trial. J Vasc Surg 2012; 56:901-9.e2. [DOI: 10.1016/j.jvs.2012.01.086] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Revised: 01/19/2012] [Accepted: 01/26/2012] [Indexed: 11/26/2022]
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Tarride JE, Blackhouse G, De Rose G, Bowen JM, Nakhai-Pour HR, O'Reilly D, Xie F, Novick T, Hopkins R, Goeree R. Should endovascular repair be reimbursed for low risk abdominal aortic aneurysm patients? Evidence from ontario, Canada. Int J Vasc Med 2011; 2011:308685. [PMID: 21748018 PMCID: PMC3124872 DOI: 10.1155/2011/308685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 04/15/2011] [Accepted: 04/16/2011] [Indexed: 11/25/2022] Open
Abstract
Background. This paper presents unpublished clinical and economic data associated with open surgical repair (OSR) in low risk (LR) patients and how it compares with EVAR and OSR in high risk (HR) patients with an AAA > 5.5 cm. Design. Data from a 1-year prospective observational study was used to compare EVAR in HR patients versus OSR in HR and LR patients. Results. Between 2003 and 2005, 140 patients were treated with EVAR and 195 with OSR (HR: 52; LR: 143). The 1-year mortality rate with EVAR was statistically lower than HR OSR patients and comparable to LR OSR patients. One-year health-related quality of life was lower in the EVAR patients compared to OSR patients. EVAR was cost-effective compared to OSR HR but not when compared to OSR LR patients. Conclusions. Despite a similar clinical effectiveness, these results suggest that, at the current price, EVAR is more expensive than open repair for low risk patients.
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Affiliation(s)
- Jean-Eric Tarride
- Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton and Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada L8P 1H1
| | - Gord Blackhouse
- Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton and Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada L8P 1H1
| | - Guy De Rose
- Division of Vascular Surgery, Department of Surgery, London Health Sciences Centre (LHSC), London, ON, Canada
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, University of Western Ontario, London, ON, Canada
| | - James M. Bowen
- Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton and Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada L8P 1H1
| | - Hamid Reza Nakhai-Pour
- Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton and Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada L8P 1H1
| | - Daria O'Reilly
- Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton and Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada L8P 1H1
| | - Feng Xie
- Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton and Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada L8P 1H1
| | - Teresa Novick
- Division of Vascular Surgery, Department of Surgery, London Health Sciences Centre (LHSC), London, ON, Canada
| | - Robert Hopkins
- Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton and Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada L8P 1H1
| | - Ron Goeree
- Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton and Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada L8P 1H1
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13
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Paraskevas KI, Mikhailidis DP, Andrikopoulos V, Bessias N, Bell SPRF. Should the size threshold for elective abdominal aortic aneurysm repair be lowered in the endovascular era? Yes. Angiology 2010; 61:617-9. [PMID: 20823073 DOI: 10.1177/0003319710375084] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
According to current international guidelines, patients with infrarenal or juxtarenal abdominal aortic aneurysms (AAAs) measuring > or = 5.5 cm should undergo repair to reduce the risk of rupture. The 5.5-cm-diameter threshold is the size when the AAA rupture rate balances the mortality rates of elective open surgical AAA repair (3%). Endovascular AAA repair (EVAR) is associated with lower perioperative mortality and complication rates compared with open surgical repair. This debate addresses the issue whether the current size threshold for elective AAA repair needs to be lowered in the endovascular era. This paper supports the position that the size threshold for AAA repair should be lowered in the endovascular era.
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Paraskevas KI, Bessias N, Giannoukas AD, Mikhailidis DP. Endovascular Abdominal Aortic Aneurysm Repair (EVAR) Procedures: Counterbalancing the Benefits With the Costs. Vasc Endovascular Surg 2010; 44:319-20. [DOI: 10.1177/1538574410362119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is associated with lower 30-day mortality rates compared with open repair. Despite that, there are no significant differences in mortality rates between the two procedures at 2 years. On the other hand, EVAR is associated with considerably higher costs compared with open repair. The lack of significant long-term differences between the two procedures together with the substantially higher cost of EVAR may question the appropriateness of EVAR as an alternative to open surgical repair in patients fit for surgery. With several thousands of AAA procedures performed worldwide, the employment of EVAR for the management of all AAAs irrespective of the patient’s surgical risk may hold implications for several national health economies. The lower perioperative mortality and morbidity rates associated with EVAR should thus be counterbalanced against the considerable costs of these procedures.
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Affiliation(s)
| | - Nikolaos Bessias
- Department of Vascular Surgery, Red Cross Hospital, Athens, Greece
| | - Athanasios D. Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, University of Thessaly Medical School, Larissa, Greece
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry (Vascular Disease Prevention Clinic), Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
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Gleason TG. Endoleaks After Endovascular Aortic Stent-Grafting: Impact, Diagnosis, and Management. Semin Thorac Cardiovasc Surg 2009; 21:363-72. [DOI: 10.1053/j.semtcvs.2009.11.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2009] [Indexed: 11/11/2022]
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Gasser TC, Martufi G, Auer M, Folkesson M, Swedenborg J. Micromechanical Characterization of Intra-luminal Thrombus Tissue from Abdominal Aortic Aneurysms. Ann Biomed Eng 2009; 38:371-9. [DOI: 10.1007/s10439-009-9837-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Accepted: 11/06/2009] [Indexed: 10/20/2022]
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Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, Timaran CH, Upchurch GR, Veith FJ. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2-49. [PMID: 19786250 DOI: 10.1016/j.jvs.2009.07.002] [Citation(s) in RCA: 453] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 07/06/2009] [Accepted: 07/06/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Elliot L Chaikof
- Department of Surgery, Emory University, Atlanta, Ga 30322, USA.
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Paraskevas KI. Regarding “Cost-effectiveness analysis of elective endovascular repair compared with open surgical repair of abdominal aortic aneurysms for patients at a high surgical risk: A 1-year patient-level analysis conducted in Ontario, Canada”. J Vasc Surg 2009; 49:277; author reply 277-8. [DOI: 10.1016/j.jvs.2008.07.092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Revised: 07/26/2008] [Accepted: 07/31/2008] [Indexed: 10/21/2022]
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Tarride JE, Blackhouse G, De Rose G, Novick T, Bowen JM, Hopkins R, O'Reilly D, Goeree R. Cost-effectiveness analysis of elective endovascular repair compared with open surgical repair of abdominal aortic aneurysms for patients at a high surgical risk: A 1-year patient-level analysis conducted in Ontario, Canada. J Vasc Surg 2008; 48:779-87. [DOI: 10.1016/j.jvs.2008.05.064] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 05/19/2008] [Accepted: 05/19/2008] [Indexed: 10/21/2022]
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Endovascular Aortic Aneurysm Repair (EVAR) Has Significantly Lower Perioperative Mortality in Comparison to Open Repair: A Systematic Review. Asian J Surg 2008; 31:119-23. [DOI: 10.1016/s1015-9584(08)60071-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Gasser TC, Görgülü G, Folkesson M, Swedenborg J. Failure properties of intraluminal thrombus in abdominal aortic aneurysm under static and pulsating mechanical loads. J Vasc Surg 2008; 48:179-88. [PMID: 18486417 DOI: 10.1016/j.jvs.2008.01.036] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Revised: 01/10/2008] [Accepted: 01/12/2008] [Indexed: 01/08/2023]
Abstract
OBJECTIVES It has been suggested that mechanical failure of intraluminal thrombus (ILT) could play a key role in the rupture of abdominal aortic aneurysms (AAAs), and in the present study, this hypothesis has been investigated. An in vitro experimental approach has been proposed, which provides layer-specific failure data of ILT tissue under static and pulsatile mechanical loads. METHODS In total, 112 bone-shaped test specimens are prepared from luminal, medial, and abluminal layers of eight ILTs harvested during open elective AAA repair. Three different types of mechanical experiments, denoted as control test, ultimate strength test, and fatigue test were performed in Dulbecco's modified eagle's medium (DMEM) supplemented with fetal calf serum, L-ascorbic acid, and antibiotics at 37 degrees C and pH 7.0. In detail, fatigue tests, which are experiments, where the ILT tissue is loaded in pulsatile manner, were carried out at three different load levels with a natural frequency of 1.0 Hz. RESULTS ILT's ultimate strength (156.5 kPa, 92.0 kPa, and 47.7 kPa for luminal, medial, and abluminal layers, respectively) and referential stiffness (62.88 kPa, 47.52 kPa, and 41.52 kPa, for luminal, medial, and abluminal layers, respectively) continuously decrease from the inside to the outside. ILT tissue failed within less than 1 hour under pulsatile loading at a load level of 60% ultimate strength, while a load level of about 40% ultimate strength did not cause failure within 13.9 hours. CONCLUSIONS ILT tissue is vulnerable against fatigue failure and shows significant decreasing strength with respect to the number of load cycles. Hence, after a reasonable time of pulsating loading ILT's strength is far below its ultimate strength, and when compared with stress predictions from finite element (FE) studies, this indicates the likelihood of fatigue failure in vivo. Failure within the ILT could propagate towards the weakened vessel wall behind it and could initialize AAA failure thereafter.
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Affiliation(s)
- T Christian Gasser
- Department of Solid Mechanics, Royal Institute of Technology (KTH), Stockholm, Sweden.
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Mani K, Björck M, Lundkvist J, Wanhainen A. Similar Cost for Elective Open and Endovascular AAA Repair in a Population-Based Setting. J Endovasc Ther 2008; 15:1-11. [DOI: 10.1583/07-2258.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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