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Evaluating the expected budget impact and cost-effectiveness of interventional therapies used in the treatment of chronic venous disease
S224
Posters and Exhibits
Learning Objectives: To describe the technique of obtaining venous phase C-arm Cone beam computed tomography (vCBCT) To identify normal venous anatomy of portomesenteric venous system in vCBCTTo demonstrate common and uncommon venous drainage pathways and collaterals in portomesenteric venous thrombosis in vCBCT. Background: Computed tomography (CT) has long been used to demonstrate the patency of portomesenteric venous system, which comprises splenic, superior mesenteric, inferior mesenteric and portal venous systems. Though careful analysis of CT images can identify several collateral pathways in the context of multi-system portomesenteric venous thrombosis, individual drainage pathways cannot be separated on CT images. This requires catheter directed digital subtraction angiogram (DSA) of each system extended to venous phase, However the quality of such studies are often affected by multiple factors related to contrast injection parameters, patients’ factors and fluoroscopic setting resulting in limited definition. With C-arm CBCT, it is now possible to generate high quality CT images using angiographic equipment timed to collect venographic information. vCBCT can add definition to collateral pathways demonstrated on DSA, potentially increasing interpreters confidence. In this exhibit, we aim to present the technique of vCBCT and demonstrate normal and abnormal portomesenteric venous drainage pathways. Clinical Findings/Procedure Details: In this exhibit, firstly we describe what information is needed from a DSA of an individual portomesenteric system to set-up and obtain vCBCT. Secondly, we demonstrate normal portomesenteric venous anatomy on DSA and vCBCT images. Thirdly, we demonstrate the vCBCT appearance of various drainage pathways in the context of portomesenteric venous thrombosis which would include common and uncommon drainage pathways. Conclusion and/or Teaching Points: Portomesenteric venous system is an interconnected drainage pathway which can result in various alternative drainage pathways in cases of isolated thrombosis. From this exhibit, the viewer will be informed about technique of acquiring vCBCT along with normal and abnormal collateral pathways in portomesenteric venous thrombosis.
Abstract No. 521 Yakes’ AVM classification system
Posters and Exhibits
W.F. Yakes1,2; 1Vascular Malformation Center, Englewood, CO; 2Swedish Medical Center, Englewood, CO Purpose: AVMs are congenital vascular lesions that post significant treatment dilemmas. Two previous classifications systems (one is CNS AVMs; the other is peripheral AVMs) are published, yet only dealing with angioarchitecture issues. This Yakes AVM CLASSIFICATION SYSTEM defines all AVM angioarchitectures (some not described in the previous classification systems) and directs specific curative treatment strategies for each. Materials and Methods: Angioarchitectures are described as Yakes AVM Type Ia (direct AVF); Yakes AVM Type IIa (typical AVM nidus); Yakes AVM Type IIb (AVM nidus that shunts into an aneurysmal vein); Yakes AVM Type IIIa (aneurysmal vein whereby the vein wall is the nidus with single out-flow vein); Yakes AVM Type IIIb (same as Yakes Type
’
JVIR
IIIa, but with multiple outflow veins); Yakes AVM Type IV (infiltrative form of AVM permeating a tissue). Results: Yakes AVM Type I are treated by mechanical occluding devices (coils, Amplatzer Plugs, etc.). Yakes AVM Type IIa are treated by transcatheter and direct puncture ethanol (ETOH) embolization. Yakes AVM type IIb are treated same as IIa, but coiling the aneurysmal out-flow vein is also curative. Yakes AVM Type IIIa are treated by coiling the aneurysmal single out-flow vein. Yakes AVM Type IIIb are treated by coiling each out-flow vein. Yakes AVM Type IV are treated by transcatheter embolization and direct puncture embolization (50% ethanol and non-ionic contrast mixture). Conclusion: By employing the Yakes AVM classification system, specific treatments that have the potential for cure are now possible to reach AVM type. These specific treatments in the specific AVM type will also markedly reduce complication rates. Similar to the impact of the Spetzler-Martin Brain AVM Grading System determining complication rates and treatment strategies, the Yakes AVM Classification System further defines curative treatment strategies for all AVM angioarchitectures, several AVM types not previously described in the world’s literature
Abstract No. 522 Evaluating the expected budget impact and costeffectiveness of interventional therapies used in the treatment of chronic venous disease R. Carlton2, R. Mallick1, C. Campbell2, A. Raju2, M. Eaddy2, T. O’Donnell3; 1BTG International, West Conshohocken, PA; 2Xcenda, LLC, Palm Harbor, FL; 3 Brigham and Women’s Faulkner Hospital and Quincy Medical Center, Boston, MA Purpose: Varicose veins (VV) and resulting sequelae contribute to morbidity assoc w/chronic vein disorders (CVD), impacting QOL and resulting in $1B/yr. Total cost minimization and budget impact evaluation assessed 8-wk diff between Varithenas (polidocanol endovenous microfoam [PEM]) vs alternate tx for VV in US from a 3rd-party payer perspective. Materials and Methods: Tx options incl PEM, EVLA, RFA, surgery, and multi-modality tx, defined 41 tx on same day. Total cost components incl (wholesale) drug acquisition costs , pmt for professional (CMS physician fee schedule) and institutional (Hospital Outpatient Prospective Pmt System) services related to initial intervention, weighted for each modality, plus expected costs of addl interventions, weighted by corresponding rate of addl interventions, within 8-wk time frame. Evidence on rate of addl interventions for PEM came from 2 pooled, phase 3 studies, and for other modalities from US retrospective claims analysis of pts w/VV. Budget impact was modeled for hypothetical 1M member plan w/evidence-based assumptions: 76% adults, 6% chronic venous insufficiency prevalence, and 31% rate of interventional tx among pts w/dx VV, and derived in terms of total and per-member-per-month (PMPM) expenditure change given 5% initial PEM market share. Results: PEM was expected to cost $2,165 (incl $615 (28%) for addl tx) compared to $2,374 (14% for addl tx) for surgery, $2,106 (32% for addl tx) for RFA, $1,827 (38% for addl tx) for EVLA, and $2,844 (26% for addl tx) for multi-modality tx. Budget impact for 1M member hypothetical health plan was $87k or $0.01 PMPM.
JVIR
’
Posters and Exhibits
S225
Conclusion: PEM is expected to have slightly lower addl tx rates than and cost same as RFA and EVLA (performed alone) but be less costly than surgery and multi-modality tx (Z2 interventions on same day) for VV tx. Adding PEM to the formulary for a health plan is budget neutral.
Abstract No. 524 Withdrawn
Abstract No. 525
Exp 8-wk Costs, Tx Options Initial tx
Addtl tx
Expected
Total
costs
rate
addtl tx cost
expected costs
PEM EVLA
$1,550 $1,130
39.7% 52.4%
$615 $697
$2,165 $1,827
RFA
$1,430
40.0%
$676
$2,106
Surgery Multi-modality tx
$2,049 $2,107
17.9% 34.9%
$325 $737
$2,374 $2,844
Comparator
Educational Exhibit
Abstract No. 523
Skin and soft tissue findings in the vein clinic M. Englander, G. Carbonella, A. Birney, K. Mandato, G. Siskin; Radiology, Albany Medical Center Hospital, Albany, NY Learning Objectives: 1. Identify common dermatologic and soft tissue findings on the lower extremities. 2. Identify uncommon dermatologic and soft tissue findings on the lower extremities. Background: Although most patients seen in the vein clinic have abnormal veins on their legs, this may not be the only finding on physical examination. As interventional radiologists evaluating patients with varicose veins, we need to be alert to other, non-venous causes for their symptoms. Also, we need to be aware of other important incidental findings made while looking at patients’ legs. Clinical Findings/Procedure Details: This educational poster will outline common and uncommon findings on physical examination of varicose vein patients. Findings included, but are not limited to cellulitis, lymphedema, lipedema, erythema nodosum, venous malformations, skin cancers, purpura and soft tissue tumors. Conclusion and/or Teaching Points: Lower extremity pain can be the result of varicose veins and venous insufficiency, but there are other potential causes as well. Interventional radiologists need to be aware of the common and uncommon findings made during the physical examination of the lower extremities. We are in a position to make unexpected diagnoses. However, one cannot see what one does not know.
Initial experience with the AngioVac aspiration system J.T. Salsamendi, S. Bhatia, M. Doshi, M. Bordegaray, R. Arya, G. Narayanan; Radiology, University of Miami, Miami, FL Purpose: To present our experience with the AngioVac aspiration system, a new device designed for removal of intravascular material, such as thrombi and vegetations To review the available literature on AngioVac aspiration system Materials and Methods: The AngioVac system (AngioDynamics, Latham, NY) is a novel mechanical suction device that is designed for the removal of unwanted intravascular material while maintaining flow during extracorporeal circulation. It has been described for use in the retrieval of right atrial thrombus/mass, management of acute massive pulmonary embolism, treatment of symptomatic iliocaval thrombosis, protection against thrombus migration during catheter removal in right to left cardiac shunts, and removal of cardiovascular implantable device lead vegetations. The current case series describes the use of AngioVac in 6 consecutive patients. There were 3 female and 3 males (mean age, 49.6 y). In 5/6 cases, the AngioVac cannula was inserted percutaneously and the patient was placed on veno-venous bypass. In one of the cases, the cannula was inserted directly into the Fontan circuit after sternotomy and the patient was maintained on cardiopulmonary bypass. Results: Thrombus location included iliocaval (2), pulmonary arteries (PA) (1), Fontan circuit and Glenn shunt with pulmonary artery extension (1), right atrium (RA) (1), and IVC with renal vein extension (1). Near complete evacuation of thrombus was documented in 3/6 cases by angiogram, cross sectional imaging or intravascular ultrasound. Partial thrombus removal was confirmed in 3/6 patients. Reasons for subtotal thrombus removal included chronic thrombus (2) and inadequate suction cannula flow rates in the pulmonary arteries (1). 2/6 patients had access site hematomas which resolved without any interventions. PubMed search yielded 12 studies reporting experience with a total of 29 patients, which will be reviewed in a table format as provided below (Table 1). Conclusion: AngioVac is a useful tool for acute thrombus removal in the large vessels. More studies needed to establish the utility of AngioVac in treatment of intravascular and intracardiac material.
Investigators
Patients (n)
Mean age
Location of material removed
Type of material removed
Material removal
Complications
Posters and Exhibits
Table 1
Posters and Exhibits
Learning Objectives: To describe the technique of obtaining venous phase C-arm Cone beam computed tomography (vCBCT) To identify normal venous anatomy of portomesenteric venous system in vCBCTTo demonstrate common and uncommon venous drainage pathways and collaterals in portomesenteric venous thrombosis in vCBCT. Background: Computed tomography (CT) has long been used to demonstrate the patency of portomesenteric venous system, which comprises splenic, superior mesenteric, inferior mesenteric and portal venous systems. Though careful analysis of CT images can identify several collateral pathways in the context of multi-system portomesenteric venous thrombosis, individual drainage pathways cannot be separated on CT images. This requires catheter directed digital subtraction angiogram (DSA) of each system extended to venous phase, However the quality of such studies are often affected by multiple factors related to contrast injection parameters, patients’ factors and fluoroscopic setting resulting in limited definition. With C-arm CBCT, it is now possible to generate high quality CT images using angiographic equipment timed to collect venographic information. vCBCT can add definition to collateral pathways demonstrated on DSA, potentially increasing interpreters confidence. In this exhibit, we aim to present the technique of vCBCT and demonstrate normal and abnormal portomesenteric venous drainage pathways. Clinical Findings/Procedure Details: In this exhibit, firstly we describe what information is needed from a DSA of an individual portomesenteric system to set-up and obtain vCBCT. Secondly, we demonstrate normal portomesenteric venous anatomy on DSA and vCBCT images. Thirdly, we demonstrate the vCBCT appearance of various drainage pathways in the context of portomesenteric venous thrombosis which would include common and uncommon drainage pathways. Conclusion and/or Teaching Points: Portomesenteric venous system is an interconnected drainage pathway which can result in various alternative drainage pathways in cases of isolated thrombosis. From this exhibit, the viewer will be informed about technique of acquiring vCBCT along with normal and abnormal collateral pathways in portomesenteric venous thrombosis.
Abstract No. 521 Yakes’ AVM classification system
Posters and Exhibits
W.F. Yakes1,2; 1Vascular Malformation Center, Englewood, CO; 2Swedish Medical Center, Englewood, CO Purpose: AVMs are congenital vascular lesions that post significant treatment dilemmas. Two previous classifications systems (one is CNS AVMs; the other is peripheral AVMs) are published, yet only dealing with angioarchitecture issues. This Yakes AVM CLASSIFICATION SYSTEM defines all AVM angioarchitectures (some not described in the previous classification systems) and directs specific curative treatment strategies for each. Materials and Methods: Angioarchitectures are described as Yakes AVM Type Ia (direct AVF); Yakes AVM Type IIa (typical AVM nidus); Yakes AVM Type IIb (AVM nidus that shunts into an aneurysmal vein); Yakes AVM Type IIIa (aneurysmal vein whereby the vein wall is the nidus with single out-flow vein); Yakes AVM Type IIIb (same as Yakes Type
’
JVIR
IIIa, but with multiple outflow veins); Yakes AVM Type IV (infiltrative form of AVM permeating a tissue). Results: Yakes AVM Type I are treated by mechanical occluding devices (coils, Amplatzer Plugs, etc.). Yakes AVM Type IIa are treated by transcatheter and direct puncture ethanol (ETOH) embolization. Yakes AVM type IIb are treated same as IIa, but coiling the aneurysmal out-flow vein is also curative. Yakes AVM Type IIIa are treated by coiling the aneurysmal single out-flow vein. Yakes AVM Type IIIb are treated by coiling each out-flow vein. Yakes AVM Type IV are treated by transcatheter embolization and direct puncture embolization (50% ethanol and non-ionic contrast mixture). Conclusion: By employing the Yakes AVM classification system, specific treatments that have the potential for cure are now possible to reach AVM type. These specific treatments in the specific AVM type will also markedly reduce complication rates. Similar to the impact of the Spetzler-Martin Brain AVM Grading System determining complication rates and treatment strategies, the Yakes AVM Classification System further defines curative treatment strategies for all AVM angioarchitectures, several AVM types not previously described in the world’s literature
Abstract No. 522 Evaluating the expected budget impact and costeffectiveness of interventional therapies used in the treatment of chronic venous disease R. Carlton2, R. Mallick1, C. Campbell2, A. Raju2, M. Eaddy2, T. O’Donnell3; 1BTG International, West Conshohocken, PA; 2Xcenda, LLC, Palm Harbor, FL; 3 Brigham and Women’s Faulkner Hospital and Quincy Medical Center, Boston, MA Purpose: Varicose veins (VV) and resulting sequelae contribute to morbidity assoc w/chronic vein disorders (CVD), impacting QOL and resulting in $1B/yr. Total cost minimization and budget impact evaluation assessed 8-wk diff between Varithenas (polidocanol endovenous microfoam [PEM]) vs alternate tx for VV in US from a 3rd-party payer perspective. Materials and Methods: Tx options incl PEM, EVLA, RFA, surgery, and multi-modality tx, defined 41 tx on same day. Total cost components incl (wholesale) drug acquisition costs , pmt for professional (CMS physician fee schedule) and institutional (Hospital Outpatient Prospective Pmt System) services related to initial intervention, weighted for each modality, plus expected costs of addl interventions, weighted by corresponding rate of addl interventions, within 8-wk time frame. Evidence on rate of addl interventions for PEM came from 2 pooled, phase 3 studies, and for other modalities from US retrospective claims analysis of pts w/VV. Budget impact was modeled for hypothetical 1M member plan w/evidence-based assumptions: 76% adults, 6% chronic venous insufficiency prevalence, and 31% rate of interventional tx among pts w/dx VV, and derived in terms of total and per-member-per-month (PMPM) expenditure change given 5% initial PEM market share. Results: PEM was expected to cost $2,165 (incl $615 (28%) for addl tx) compared to $2,374 (14% for addl tx) for surgery, $2,106 (32% for addl tx) for RFA, $1,827 (38% for addl tx) for EVLA, and $2,844 (26% for addl tx) for multi-modality tx. Budget impact for 1M member hypothetical health plan was $87k or $0.01 PMPM.
JVIR
’
Posters and Exhibits
S225
Conclusion: PEM is expected to have slightly lower addl tx rates than and cost same as RFA and EVLA (performed alone) but be less costly than surgery and multi-modality tx (Z2 interventions on same day) for VV tx. Adding PEM to the formulary for a health plan is budget neutral.
Abstract No. 524 Withdrawn
Abstract No. 525
Exp 8-wk Costs, Tx Options Initial tx
Addtl tx
Expected
Total
costs
rate
addtl tx cost
expected costs
PEM EVLA
$1,550 $1,130
39.7% 52.4%
$615 $697
$2,165 $1,827
RFA
$1,430
40.0%
$676
$2,106
Surgery Multi-modality tx
$2,049 $2,107
17.9% 34.9%
$325 $737
$2,374 $2,844
Comparator
Educational Exhibit
Abstract No. 523
Skin and soft tissue findings in the vein clinic M. Englander, G. Carbonella, A. Birney, K. Mandato, G. Siskin; Radiology, Albany Medical Center Hospital, Albany, NY Learning Objectives: 1. Identify common dermatologic and soft tissue findings on the lower extremities. 2. Identify uncommon dermatologic and soft tissue findings on the lower extremities. Background: Although most patients seen in the vein clinic have abnormal veins on their legs, this may not be the only finding on physical examination. As interventional radiologists evaluating patients with varicose veins, we need to be alert to other, non-venous causes for their symptoms. Also, we need to be aware of other important incidental findings made while looking at patients’ legs. Clinical Findings/Procedure Details: This educational poster will outline common and uncommon findings on physical examination of varicose vein patients. Findings included, but are not limited to cellulitis, lymphedema, lipedema, erythema nodosum, venous malformations, skin cancers, purpura and soft tissue tumors. Conclusion and/or Teaching Points: Lower extremity pain can be the result of varicose veins and venous insufficiency, but there are other potential causes as well. Interventional radiologists need to be aware of the common and uncommon findings made during the physical examination of the lower extremities. We are in a position to make unexpected diagnoses. However, one cannot see what one does not know.
Initial experience with the AngioVac aspiration system J.T. Salsamendi, S. Bhatia, M. Doshi, M. Bordegaray, R. Arya, G. Narayanan; Radiology, University of Miami, Miami, FL Purpose: To present our experience with the AngioVac aspiration system, a new device designed for removal of intravascular material, such as thrombi and vegetations To review the available literature on AngioVac aspiration system Materials and Methods: The AngioVac system (AngioDynamics, Latham, NY) is a novel mechanical suction device that is designed for the removal of unwanted intravascular material while maintaining flow during extracorporeal circulation. It has been described for use in the retrieval of right atrial thrombus/mass, management of acute massive pulmonary embolism, treatment of symptomatic iliocaval thrombosis, protection against thrombus migration during catheter removal in right to left cardiac shunts, and removal of cardiovascular implantable device lead vegetations. The current case series describes the use of AngioVac in 6 consecutive patients. There were 3 female and 3 males (mean age, 49.6 y). In 5/6 cases, the AngioVac cannula was inserted percutaneously and the patient was placed on veno-venous bypass. In one of the cases, the cannula was inserted directly into the Fontan circuit after sternotomy and the patient was maintained on cardiopulmonary bypass. Results: Thrombus location included iliocaval (2), pulmonary arteries (PA) (1), Fontan circuit and Glenn shunt with pulmonary artery extension (1), right atrium (RA) (1), and IVC with renal vein extension (1). Near complete evacuation of thrombus was documented in 3/6 cases by angiogram, cross sectional imaging or intravascular ultrasound. Partial thrombus removal was confirmed in 3/6 patients. Reasons for subtotal thrombus removal included chronic thrombus (2) and inadequate suction cannula flow rates in the pulmonary arteries (1). 2/6 patients had access site hematomas which resolved without any interventions. PubMed search yielded 12 studies reporting experience with a total of 29 patients, which will be reviewed in a table format as provided below (Table 1). Conclusion: AngioVac is a useful tool for acute thrombus removal in the large vessels. More studies needed to establish the utility of AngioVac in treatment of intravascular and intracardiac material.
Investigators
Patients (n)
Mean age
Location of material removed
Type of material removed
Material removal
Complications
Posters and Exhibits
Table 1