The cost-effectiveness of treatment of short occlusive lesions in the femoropopliteal artery: balloon angioplasty versus endarterectomy

Ambulatory Endovascular Surgery: Cost Advantage and Factors Influencing its Safe Performance

Purpose:

To perform a retrospective analysis of chronic limb ischemia and determine whether endovascular surgery can be performed safely and cost effectively on an ambulatory basis.

Methods:

Among 42 patients undergoing endovascular interventions for lower limb ischemia over a 12-month period ending October 1997, 32 (18 men, mean age 68 years, range 44 to 89) were treated solely by endovascular interventions. These patients were grouped according to time inhospital: 20 (63%) patients had endovascular procedures performed on an ambulatory basis, 7 (22%) were hospitalized for > 24 hours, and 5 (16%) required an overnight stay. The angioplasty procedures, which included placement of 21 stents, were performed in the abdominal aorta (n = 1) and the common iliac (n = 9), external iliac (n = 7), superficial femoral (n = 11), popliteal (n = 5), tibioperoneal (n = 7), and subclavian (n = 1) arteries. Hospital charges were compared for the 3 groups.

Results:

Other than the presence of coronary artery disease, there were no significant differences in demographics or risk factors among the 3 groups. Angioplasty was technically successful in all patients, and there were no procedural complications. Patients with tissue loss required hospitalization more frequently compared to those with claudication. Significantly more patients who were hospitalized had epidural anesthesia as opposed to local when compared to the ambulatory group, 43% versus 5%, respectively (p = 0.04). Excluding professional fees, mean total hospital cost differed significantly between the ambulatory group and the group of patients with a hospital stay > 24 hours ($8227 versus $40,383, respectively; p = 0.03) and between the 2 hospitalized groups ($9476 for overnight stay versus $40,383 for > 24-hour stay, p = 0.03).

Conclusions:

Peripheral endovascular interventions can be performed safely on an ambulatory basis resulting in decreased hospital cost. Patients who receive epidural anesthesia, require concomitant open vascular reconstruction, present with tissue loss, or have unstable medical conditions are more likely to require hospitalization.

Costing vascular surgery: A review of current reporting practice

OBJECTIVE

The objective of this study was to assess the level of reporting in economic studies in the area of peripheral vascular disease. Adequate reporting of data is necessary to judge the quality of economic studies by means of critical appraisal criteria.

METHODS

A systematic review of the journal literature between 1986 and the first half of 1997 was undertaken. Studies that have attempted to estimate the resource consequences of one or more vascular procedure were the focus of the review. The extent of reporting in each study was assessed by using published guidelines.

RESULTS

The review identified 30 articles from nine different countries for inclusion in the study. Of these, more than half were published in the last 2(1/2) years of the search period, indicating a recent and rapid growth in economic studies in this area. When subjected to the reporting guidelines, the studies performed rather poorly overall.

CONCLUSIONS

Although the vascular studies can be criticized for inadequate reporting of economic data, it appears from the limited evidence from elsewhere that inadequate reporting is a problem in other clinical areas. In view of the importance of reporting to the ability to critically assess studies-and thus separate the "good" from the "bad"-there is a need for reporting to improve future published studies.

Ambulatory endovascular surgery: cost advantage and factors influencing its safe performance

PURPOSE

To perform a retrospective analysis of chronic limb ischemia and determine whether endovascular surgery can be performed safely and cost effectively on an ambulatory basis.

METHODS

Among 42 patients undergoing endovascular interventions for lower limb ischemia over a 12-month period ending October 1997, 32 (18 men, mean age 68 years, range 44 to 89) were treated solely by endovascular interventions. These patients were grouped according to time inhospital: 20 (63%) patients had endovascular procedures performed on an ambulatory basis, 7 (22%) were hospitalized for > 24 hours, and 5 (16%) required an overnight stay. The angioplasty procedures, which included placement of 21 stents, were performed in the abdominal aorta (n = 1) and the common iliac (n = 9), external iliac (n =7), superficial femoral (n = 11), popliteal (n = 5), tibioperoneal (n = 7), and subclavian (n = 1) arteries. Hospital charges were compared for the 3 groups.

RESULTS

Other than the presence of coronary artery disease, there were no significant differences in demographics or risk factors among the 3 groups. Angioplasty was technically successful in all patients, and there were no procedural complications. Patients with tissue loss required hospitalization more frequently compared to those with claudication. Significantly more patients who were hospitalized had epidural anesthesia as opposed to local when compared to the ambulatory group, 43% versus 5%, respectively (p = 0.04). Excluding professional fees, mean total hospital cost differed significantly between the ambulatory group and the group of patients with a hospital stay > 24 hours ($8227 versus $40,383, respectively; p = 0.03) and between the 2 hospitalized groups ($9476 for overnight stay versus $40,383 for > 24-hour stay, p = 0.03).

CONCLUSIONS

Peripheral endovascular interventions can be performed safely on an ambulatory basis resulting in decreased hospital cost. Patients who receive epidural anesthesia, require concomitant open vascular reconstruction, present with tissue loss, or have unstable medical conditions are more likely to require hospitalization.

Is intermittent claudication improved by percutaneous transluminal angioplasty? A randomized controlled trial

PURPOSE

Percutaneous transluminal angioplasty (PTA) is an increasingly popular invasive treatment for peripheral arterial disease, but there have been very few controlled trials to justify its use. This randomized controlled clinical trial was performed to determine in patients with mild and moderate intermittent claudication differences in outcome between PTA and conventional medical treatment after 2 years.

METHODS

Six hundred patients with claudication were screened at the Peripheral Vascular Clinic, Royal Infirmary of Edinburgh. Sixty-two patients with short femoral artery stenoses or occlusions (47 patients) and iliac stenoses (15 patients) were randomized to either PTA plus medical treatment (PTA group, 30 patients) or to medical treatment alone (control group, 32 patients). Medical treatment consisted of daily low-dose aspirin and advice on smoking and exercise. Outcome measures studied were patient-reported maximum walking distance, exercise treadmill distance until onset of claudication, treadmill maximum walking distance, ankle-brachial pressure index (ABPI), quality of life (Nottingham Health Profile), and duplex ultrasound-measured extent of occlusive disease.

RESULTS

At 2 years of follow-up, the PTA group and control subjects did not differ significantly in patient-reported maximum walking, treadmill onset to claudication, treadmill maximum walking distances, or ABPI (p > 0.05). However, the PTA group had significantly fewer occluded arteries (p = 0.003) and a lesser degree of stenosis (expressed in terms of the velocity ratio; p = 0.004) in patent arteries. Quality of life was not demonstrably different between the two groups (p > 0.05).

CONCLUSIONS

Two years after PTA, patients had less extensive disease than medically treated patients, but this did not translate into a significant advantage in terms of improved walking or quality of life. There are important implications for patient management and future clinical research.

The value of duplex surveillance after endovascular intervention for femoropopliteal obstructive disease

OBJECTIVE

The objective of the present study was to assess prospectively whether serial Duplex examination was useful in identifying impending failure after endovascular interventions of the femoropopliteal arteries.

SETTING

Non-university hospital. Prospective clinical study.

METHODS

124 Patients were successfully treated by endovascular procedures during a 5 year period. The follow-up was by colour-flow Duplex examination at fixed intervals. At similar intervals clinical examination, including ankle blood pressure measurement was performed to assess the clinical/haemodynamic status of the patients according to the SVS/NAISCVS guidelines. For the diagnosis of impending failure the Duplex criterion was a peak systolic velocity ratio > 2.5 and the clinical/haemodynamic criterion was a level < +2. Actual failure of the vascular procedure was defined as the occurrence of an occlusion in the treated arterial segment or a recurrent stenosis causing symptoms severe enough to require a reintervention. No prophylactic reinterventions were performed on the basis of abnormal Duplex findings alone.

RESULTS

Abnormal Duplex findings indicating restenosis were observed in 52 patients. Duplex abnormalities predicted treatment failure with a sensitivity of 86% and a specificity of 75%, while clinical/haemodynamic assessment had a sensitivity of 93% and a specificity of 90%. The hypothetical management outcome if Duplex surveillance had been used as a basis for reintervention was assessed. It appeared that only one patient with failure would have received a redo endovascular procedure at the time he had a restenosis.

CONCLUSIONS

Clinical/haemodynamic assessment was more useful for the follow-up of endovascular interventions than Duplex surveillance.