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Maleti O, Orso M, Lugli M, Perrin M. Systematic review and meta-analysis of deep venous reflux correction in chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord 2023; 11:1265-1275.e5. [PMID: 37453548 DOI: 10.1016/j.jvsv.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 06/27/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the technical feasibility, operative techniques, safety, and efficacy outcomes of procedures aimed at correcting deep venous reflux, in patients with chronic venous insufficiency. METHODS We performed systematic literature searches in PubMed, Embase, and Web of Science from databases' inception to February 2022. We included systematic reviews, randomized controlled trials, and observational studies describing surgical procedures to treat patients with deep reflux due to primary and secondary incompetence, post-thrombotic syndrome (PTS). Proportion meta-analyses were performed for all the efficacy and safety outcomes. RESULTS We included 57 studies in the quantitative synthesis: three randomized controlled trials including 252 patients and 54 case series including 4004 patients. Studies included a median of 38 patients, with a mean age of 51 years; 52% of them were males. Forty percent of studies included 2291 patients with primary incompetence, 29% of studies included 595 patients with PTS, and 31% of studies included 1118 patients with both diseases. As for primary incompetence, pooled estimates for all procedures showed an 89% (95% confidence interval [CI], 82%-94%) of ulcer healing, 10% (95% CI, 4%-18%) ulcer recurrence, 98% (95% CI, 93%-100%) valve patency, 84% (95% CI, 78%-90%) valve competence, 0.05% (1/1904 patients) pulmonary embolism, 1% (95% CI, 0%-3%) wound infections, 5% (95% CI, 1%-9%) hematoma, 2% (95% CI, 0%-6%) lymphocele, 2% (95% CI, 1%-4%) thrombosis, 85% (95% CI, 74%-94%) pain improvement, 89% (95% CI, 65%-100%) edema improvement, and 85% (95% CI, 73%-93%) lipodermatosclerosis improvement. Patients with PTS showed less favorable outcomes: 82% (95% CI, 71%-91%) of ulcer healing, 18% (95% CI, 5%-36%) ulcer recurrence, 88% (95% CI, 78%-96%) valve patency, 78% (95% CI, 66%-88%) valve competence, no pulmonary embolism, 6% (95% CI, 0%-22%) wound infections, 6% (95% CI, 3%-10%) hematoma, 5% (95% CI, 1%-12%) lymphocele, 7% (95% CI, 1%-16%) thrombosis, 79% (95% CI, 59%-94%) pain improvement, 75% (95% CI, 61%-88%) edema improvement, and 64% (95% CI, 9%-100%) lipodermatosclerosis improvement. CONCLUSIONS The number of studies included in each meta-analysis are limited, and knowing how this element can affect the statistical power, as well as the absence of comparative control groups, it is not possible to draw definitive conclusions. Nevertheless, deep venous reconstructive surgery for reflux may increase the probability of clinical improvement in patients affected by chronic venous insufficiency. Outcomes appear to be satisfactory even if possible adjunctive procedures may be required over the course of the patient's lifetime. Consequently, a strict follow-up protocol is required to maintain outcomes. Further studies are required to evaluate deep venous reconstructive surgery for reflux particularly as to how it compares with the more recently introduced endovenous approaches.
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Affiliation(s)
- Oscar Maleti
- National reference Training Center in Phlebology, UEMS, Vascular Surgery, Cardiovascular Department Hesperia Hospital, Modena, Italy
| | - Massimiliano Orso
- Istituto Zooprofilattico Sperimentale dell'Umbria e delle Marche 'Togo Rosati', Perugia, Italy
| | - Marzia Lugli
- National reference Training Center in Phlebology, UEMS, Vascular Surgery, Cardiovascular Department Hesperia Hospital, Modena, Italy.
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Moon T, O'Donnell TF, Weycker D, Iafrati M. Impact of lymphedema in the management of venous leg ulcers. Phlebology 2023; 38:613-621. [PMID: 37647614 DOI: 10.1177/02683555231197597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Lymphedema (LED) in patients with venous leg ulcers (VLU) [VLU+LED] can impair ulcer healing and predispose to cellulitis. There is little data, however, demonstrating how lymphatic dysfunction may impact the clinical course, treatment, and healthcare expenditures for VLU+LED versus VLU-LED patients. OBJECTIVE To determine how lymphatic dysfunction might influence treatment and expenditures among VLU patients in a large deidentified healthcare claims database. METHODS A retrospective cohort design and data from the IBM MarketScan Database (April 2013 to March 2019) were employed. Study population comprised VLU patients, and was stratified into two subgroups: VLU+LED (index date = date of first LED diagnosis) and VLU-LED (index dates randomly assigned to match distribution of index dates for VLU+LED). Within each subgroup, patients with <1 year of healthcare claims information before and after their index dates were excluded. Demographics, comorbidities, procedures/treatments, as well as all-cause post-index medical resource utilization and expenditures ($/patient/year) of the two groups were compared. Stabilized inverse probability treatment weights (IPTWs) were employed to adjust for differences between groups in baseline characteristics. RESULTS A total of 5466 VLU patients were identified (VLU+LED: N = 299; VLU-LED: N = 5167). Overall ambulatory encounters (AMB ENC) and their components were higher in VLU+LED, which were reflected in increased expenditures for this group (Table 1). Treatment with endovenous ablation (EVA) or stenting for venous hypertension as well as for specific measures for LED were higher in the 1-year post-index period for VLU+LED. The use of LED specific therapy was low for both groups, but a greater percentage of VLU+LED patients received therapy, which was predominantly manual lymphatic drainage (17.4%) rather than pneumatic compression (10.7%). CONCLUSIONS The clinical presence of LED in patients with VLU is a marker for a more complex disease process with more episodes of cellulitis and expenditures, but a surprisingly low specific treatment for LED.
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Affiliation(s)
- Tina Moon
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Thomas F O'Donnell
- Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA, USA
| | | | - Mark Iafrati
- Department of Vascular Surgery, Vanderbilt University, Nashville, TN, USA
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Rognoni C, Furnari A, Lugli M, Maleti O, Greco A, Tarricone R. Time-Driven Activity-Based Costing for Capturing the Complexity of Healthcare Processes: The Case of Deep Vein Thrombosis and Leg Ulcers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105817. [PMID: 37239543 DOI: 10.3390/ijerph20105817] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/17/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
Time-driven activity-based costing (TDABC) is suggested to assess costs within the value-based healthcare approach, but there is a paucity of applications in chronic diseases such as deep vein thrombosis (DVT) and leg ulcers. In this context, we applied TDABC in a cost-effectiveness analysis comparing venous stenting to compression ± anticoagulation (standard of care-SOC) from both hospital and societal perspectives in Italy. TDABC was applied to both treatments to assess costs that were included in a cost-effectiveness model. Clinical inputs were retrieved from the literature and integrated with real-world data. The Incremental Cost Utility Ratio (ICUR) of stenting compared to SOC was EUR 10,270/QALY and EUR 8962/QALY for hospital and societal perspectives, respectively. The mean cost per patient for venous stenting of EUR 5082 was higher than the Diagnosis-Related Group (DRG) reimbursement (EUR 4742). For SOC, an ulcer healing in 3 months costs EUR 1892, of which EUR 302 (16%) is borne by the patient versus a reimbursement of EUR 1132. TDABC showed that venous stenting may be cost-effective compared with SOC but that reimbursement rates may not completely cover the real costs, which are partially sustained by the patients. A more efficient policy for covering the real costs may be beneficial for both clinical centers and patients.
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Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, 20136 Milan, Italy
| | - Alessandro Furnari
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, 20136 Milan, Italy
| | - Marzia Lugli
- National Reference Training Center in Phlebology (NRTCP), Vascular Surgery-Cardiovascular Department, Hesperia Hospital, 41125 Modena, Italy
| | - Oscar Maleti
- National Reference Training Center in Phlebology (NRTCP), Vascular Surgery-Cardiovascular Department, Hesperia Hospital, 41125 Modena, Italy
| | - Alessandro Greco
- Outpatient Wound Care Centre, Local Health Care System, 03100 Frosinone, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, 20136 Milan, Italy
- Department of Social and Political Science, Bocconi University, 20136 Milan, Italy
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Khaja MS, Obi AT, Sharma AM, Cuker A, McCann SS, Thukral S, Matson JT, Hofmann LV, Charalel R, Kanthi Y, Meek ME, Meissner MH, White SB, Williams DM, Vedantham S. Optimal Medical Therapy Following Deep Venous Interventions: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel. J Vasc Interv Radiol 2021; 33:78-85. [PMID: 34563699 DOI: 10.1016/j.jvir.2021.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/11/2021] [Accepted: 09/15/2021] [Indexed: 12/17/2022] Open
Abstract
The optimal medical management of patients following endovascular deep venous interventions remains ill-defined. As such, the Society of Interventional Radiology Foundation (SIRF) convened a multidisciplinary group of experts in a virtual Research Consensus Panel (RCP) to develop a prioritized research agenda regarding antithrombotic therapy following deep venous interventions. The panelists presented the gaps in knowledge followed by discussion and ranking of research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were identified as high priority: 1) characterization of biological processes leading to in-stent stenosis/rethrombosis; 2) identification and validation of methods to assess venous flow dynamics and their effect on stent failure; 3) elucidation of the role of inflammation and anti-inflammatory therapies; and 4) clinical studies to compare antithrombotic strategies and improve venous outcome assessment. Collaborative, multicenter research is necessary to answer these questions and thereby enhance the care of patients with venous disease.
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Affiliation(s)
- Minhaj S Khaja
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, Virginia.
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Aditya M Sharma
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health, Charlottesville, Virginia
| | - Adam Cuker
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara S McCann
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, Virginia
| | - Siddhant Thukral
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - John T Matson
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, Virginia
| | - Lawrence V Hofmann
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Resmi Charalel
- Department of Radiology, Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Yogendra Kanthi
- Laboratory of Vascular Thrombosis and Inflammation, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Mary E Meek
- Division of Interventional Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mark H Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Sarah B White
- Department of Radiology, Division of Vascular and Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David M Williams
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
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Kolluri R, Lugli M, Villalba L, Varcoe R, Maleti O, Gallardo F, Black S, Forgues F, Lichtenberg M, Hinahara J, Ramakrishnan S, Beckman JA. An estimate of the economic burden of venous leg ulcers associated with deep venous obstruction. Vasc Med 2021; 27:63-72. [PMID: 34392750 PMCID: PMC8808361 DOI: 10.1177/1358863x211028298] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Venous leg ulcers (VLU) embody the most severe stage of the broad spectrum of
chronic venous disease. Approximately 40% of patients with VLU present with
the underlying deep venous disease (DVD). Although the data are scarce,
these deep venous disease-related VLU (DRV) are thought to have higher
recurrence rates and a substantial economic burden. The objective of this
study was to assess the economic burden of DRV across Australia, France,
Germany, Italy, Spain, the UK, and the USA. Methods: A comprehensive literature review was undertaken to identify publications
documenting the incidence and prevalence of VLU and DRV, medical resource
utilization, and associated costs of DRV. Findings from this literature
review were used to estimate the economic burden of illness, including
direct medical costs over a 12-month interval following initial presentation
of a newly formed DRV. Results: Total annual incidence of new or recurrent DRV in Australia, France, Germany,
Italy, Spain, UK, and the US are estimated at 122,000, 263,000, 345,000,
253,000, 85,000, 230,000, and 643,000 events, respectively, in 2019.
Incidence ranges from 0.73 to 3.12 per 1000 persons per year. The estimated
annual direct medical costs for patients managed conservatively in these
geographies total ~ $10.73 billion (USD) or $5527 per person per year. Conclusion: The availability of published data on the costs of VLU care varies widely
across countries considered in this analysis. Although country-specific VLU
practice patterns vary, there is a uniform pattern of high-cost care.
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Affiliation(s)
- Raghu Kolluri
- Department of Internal Medicine, Riverside Methodist Hospital/OhioHealth, Columbus, OH, USA
| | - Marzia Lugli
- Department of Cardiovascular Surgery, Hesperia Hospital, Modena, Emilia-Romagna, Italy
| | - Laurencia Villalba
- Department of Vascular Surgery, Vascular Care Centre, Wollongong, NSW, Australia
| | - Ramon Varcoe
- Department of Surgery, University of New South Wales, Sydney, NSW, Australia
| | - Oscar Maleti
- Department of Cardiovascular Surgery, Hesperia Hospital, Modena, Emilia-Romagna, Italy
| | - Fernando Gallardo
- Department of Vascular Surgery, Hospital Quironsalud, Marbella, Spain
| | - Stephen Black
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fannie Forgues
- Centre de Phlébologie Interventionnelle, Région de Toulouse, Clinique Pasteur, Toulouse, France
| | | | | | | | - Joshua A Beckman
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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