scholarly journals Analysis of cerebrovascular aneurysm treatment cost: retrospective cohort comparison of clipping, coiling, and flow diversion

2018 ◽  
Vol 44 (5) ◽  
pp. E3 ◽  
Author(s):  
Spencer Twitchell ◽  
Hussam Abou-Al-Shaar ◽  
Jared Reese ◽  
Michael Karsy ◽  
Ilyas M. Eli ◽  
...  
Keyword(s):  
Health Care ◽  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Flow Diversion ◽  
High Quality ◽  
Total Cost ◽  
Cost Drivers ◽  
Discharge Disposition ◽  
Unruptured Intracranial Aneurysms ◽  
Care Costs

OBJECTIVEWith the continuous rise of health care costs, hospitals and health care providers must find ways to reduce costs while maintaining high-quality care. Comparing surgical and endovascular treatment of intracranial aneurysms may offer direction in reducing health care costs. The Value-Driven Outcomes (VDO) database at the University of Utah identifies cost drivers and tracks changes over time. In this study, the authors evaluate specific cost drivers for surgical clipping and endovascular management (i.e., coil embolization and flow diversion) of both ruptured and unruptured intracranial aneurysms using the VDO system.METHODSThe authors retrospectively reviewed surgical and endovascular treatment of ruptured and unruptured intracranial aneurysms from July 2011 to January 2017. Total cost (as a percentage of each patient’s cost to the system), subcategory costs, and potential cost drivers were evaluated and analyzed.RESULTSA total of 514 aneurysms in 469 patients were treated; 273 aneurysms were surgically clipped, 102 were repaired with coiling, and 139 were addressed with flow diverter placements. Middle cerebral artery aneurysms accounted for the largest portion of cases in the clipping group (29.7%), whereas anterior communicating artery aneurysms were most frequently involved in the coiling group (30.4%) and internal carotid artery aneurysms were the majority in the flow diverter group (63.3%). Coiling (mean total cost 0.25% ± 0.20%) had a higher cost than flow diversion (mean 0.20% ± 0.16%) and clipping (mean 0.17 ± 0.14%; p = 0.0001, 1-way ANOVA). Coiling cases cost 1.5 times as much as clipping and flow diversion costs 1.2 times as much as clipping. Facility costs were the most significant contributor to intracranial clipping costs (60.2%), followed by supplies (18.3%). Supplies were the greatest cost contributor to coiling costs (43.2%), followed by facility (40.0%); similarly, supplies were the greatest portion of costs in flow diversion (57.5%), followed by facility (28.5%). Cost differences for aneurysm location, rupture status, American Society of Anesthesiologists (ASA) grade, and discharge disposition could be identified, with variability depending on surgical procedure. A multivariate analysis showed that rupture status, surgical procedure type, ASA status, discharge disposition, and year of surgery all significantly affected cost (p < 0.0001).CONCLUSIONSFacility utilization and supplies constitute the majority of total costs in aneurysm treatment strategies, but significant variation exists depending on surgical approach, rupture status, and patient discharge disposition. Developing and implementing approaches and protocols to improve resource utilization are important in reducing costs while maintaining high-quality patient care.

Thromboelastography (TEG) results are predictive of ischemic and hemorrhagic complications in patients with unruptured intracranial aneurysms treated with flow diversion

2021 ◽  
pp. 159101992110259
Author(s):  
Kainaat Javed ◽  
Santiago R Unda ◽  
Ryan Holland ◽  
Adisson Fortunel ◽  
Rose Fluss ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Aneurysms ◽  
Statistical Significance ◽  
Alpha Angle ◽  
Flow Diversion ◽  
P Value ◽  
Hemorrhagic Complication ◽  
Unruptured Intracranial Aneurysms ◽  
Hemorrhagic Complications ◽  
Groin Hematoma

Introduction Flow diversion is an effective treatment modality for intracranial aneurysms but is associated with ischemic and hemorrhagic complications. Patients treated with flow diversion require dual antiplatelet therapy and subsequent platelet function tests. At our institution, Thromboelastography with Platelet Mapping (TEG-PM) is the test of choice. The primary objective of this study was to identify TEG parameters that are predictive of postoperative complications in patients treated with elective flow diversion. Methods This was a retrospective study of 118 patients with unruptured intracranial aneurysms treated with flow diversion. Data was collected via chart review. Bivariate analyses were performed to identify significant variables in patients who suffered an ischemic stroke or a groin hematoma. ROC curves were constructed for the TEG parameters with statistical significance. Bivariate analyses were repeated using dichotomized TEG results. Results Patients who experienced a symptomatic ischemic stroke had a history of stroke (p value = 0.007), larger aneurysm neck width (p value = 0.017), and a higher alpha angle (p value = 0.013). Cut off point for ischemic complication is 63° on ROC curve with a sensitivity of 100% and specificity of 65%. Patients who experienced a groin hematoma were no different from their healthy peers but had a lower alpha angle (p value = 0.033). Cut off point for hemorrhagic complication is 53.3° with a sensitivity of 82% and specificity of 67%. Conclusion The Alpha Angle parameter of TEG-PM has a sizeable predictive ability for both ischemic complications of the central nervous system and hemorrhagic complications of the access site after elective flow diversion.

Outcomes following aneurysmal coil embolization with intentionally shortened low-profile visible intraluminal support stent deployment

2021 ◽  
pp. 197140092110269
Author(s):  
Kenji Yatomi ◽  
Yumiko Mitome-Mishima ◽  
Takashi Fujii ◽  
Kohsuke Teranishi ◽  
Hidenori Oishi ◽  
...  
Keyword(s):  
Fluid Dynamics ◽  
Computational Fluid Dynamics ◽  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Perioperative Complications ◽  
Flow Diversion ◽  
Stent Deployment ◽  
Coverage Ratio ◽  
Low Profile ◽  
Unruptured Intracranial Aneurysms

Purpose Among all stents available for neuroendovascular therapy, the low-profile visible intraluminal support stent bears the highest metal coverage ratio. We deployed a low-profile visible intraluminal support stent with a delivery wire or/and microcatheter system push action to shorten the low-profile visible intraluminal support stent and thus achieve a flow diversion effect. We report our single-institution experience with the use of low-profile visible intraluminal support stents for intentionally shortened deployment (shortening group) and non-shortened deployment (non-shortening group) for unruptured intracranial aneurysms. Methods We retrospectively reviewed the medical records of 130 patients with 131 intracranial aneurysms who were treated with low-profile visible intraluminal support stent-assisted coil embolization from February 2016–January 2019. All perioperative complications were noted. Every 6 months, we re-examined the patients with cerebral angiography or magnetic resonance angiography. The outcomes of aneurysm occlusion were evaluated by the modified Raymond–Roy occlusion classification. We used the finite element method and computational fluid dynamics to investigate the hemodynamics after shortened low-profile visible intraluminal support stent deployment. Results Immediately after treatment, the modified Raymond-Roy occlusion classification was significantly better in the shortening group than in the non-shortening group ( p<0.05). The latest angiographic outcomes showed the same tendency. Hemodynamic analysis by computational fluid dynamics suggested an adequate flow diversion effect with the use of our intentional shortening method. Conclusions Stent-assisted coil embolization using this technique showed good results of a high complete occlusion rate and low complication rate. These findings suggest that shortened low-profile visible intraluminal support stent deployment yields a flow diversion effect and may lead to early intra-aneurysmal thrombus formation.

Comparison of Flow Diversion and Coiling for the Treatment of Unruptured Intracranial Aneurysms

2019 ◽  
Vol 128 ◽  
pp. 464-472 ◽  
Author(s):  
Wen-qiang Xin ◽  
Qi-qiang Xin ◽  
Yan Yuan ◽  
Shi Chen ◽  
Xiang-liang Gao ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Flow Diversion ◽  
Unruptured Intracranial Aneurysms

Cost analysis of a randomized trial of early palliative care (PC) in patients with metastatic non-small cell lung cancer (NSCLC).

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 4-4 ◽  
Author(s):  
Joseph A. Greer ◽  
Angela Tramontano ◽  
Pamela M McMahon ◽  
Areej El-Jawahri ◽  
Ravi Bharat Parikh ◽  
...  
Keyword(s):  
Health Care ◽  
Clinical Trial ◽  
Health Care Costs ◽  
Standard Care ◽  
Secondary Analysis ◽  
Cost Of Care ◽  
Average Total Cost ◽  
Total Cost ◽  
Metastatic Nsclc ◽  
Care Costs

4 Background: Several randomized, controlled trials have shown that early, integrated palliative and oncology care improves quality of life, mood, and symptom burden in patients with advanced cancers. However, the degree to which early involvement of specialty PC in the ambulatory care setting impacts the cost of care remains unknown. We investigated the health care costs for patients with metastatic NSCLC enrolled in a clinical trial of early PC. Methods: For this secondary analysis, we examined data from a randomized trial of 151 patients with newly-diagnosed metastatic NSCLC from 06/2006 to 07/2009. Patients received either early PC integrated with standard care or standard care (SC) alone. We abstracted costs for emergency and inpatient care, outpatient visits, intravenous chemotherapy, and physician services from the hospital’s accounting system. Oral chemotherapy costs were estimated based on actual drug charges for patients. To estimate hospice costs, we used Medicare reimbursement rates. For each participant, we calculated the average total cost of care per day for the entire study period as well as the total cost of care for the final 30 days prior to death. Costs differences between groups were examined with the Wilcoxon Rank-Sum Test. Results: We analyzed health care costs of the 138 patients who died by 07/15/2013 (early PC N=68; SC N=70). The mean number of days on study was longer for patients assigned to early PC (M=397, SD=360) versus SC (M=299, SD=266). Over the study period, early PC was associated with a lower average total cost per day of $117 (SD=$436) compared to SC (p=.09). In the final 30 days of life, patients in the early PC group incurred higher total costs for hospice care (Mean difference=$1,053, SD=$3,162, p=.11), while expenses for chemotherapy were less (Mean difference=$757, SD=$2,143, p=.06). No cost differences between groups met the threshold for statistical significance. Conclusions: Although this secondary analysis was inconclusive due to the lack of statistical power to examine differences in cost outcomes, the delivery of early PC for patients with metastatic NSCLC does not appear to increase health care expenses over the course of disease or at the end of life. Clinical trial information: NCT01038271.

scholarly journals Endovascular Treatment of Intracranial Aneurysms in the Flow Diverter Era: Frequency of Use and Results in a Consecutive Series of 550 Treatments in a Single Centre

2014 ◽  
Vol 20 (4) ◽  
pp. 428-435 ◽  
Author(s):  
Willem Jan van Rooij ◽  
Ratna S Bechan ◽  
Jo P. Peluso ◽  
Menno Sluzewski
Keyword(s):  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Consecutive Series ◽  
Complication Rates ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Permanent Neurological Deficit ◽  
Flow Diverters

Flow diverter devices became available in our department in 2009. We considered treatment with flow diverters only in patients with aneurysms not suitable for surgery or conventional endovascular techniques. This paper presents our preliminary experience with flow diverters in a consecutive series of 550 endovascular aneurysm treatments. Between January 2009 and July 2013, 550 endovascular treatments for intracranial aneurysms were performed. Of these, 490 were first-time aneurysm treatments in 464 patients and 61 were additional treatments of previously coiled aneurysms in 51 patients. Endovascular treatments consisted of selective coiling in 445 (80.8%), stent-assisted coiling in 68 (12.4%), balloon-assisted coiling in 13 (2.4%), parent vessel occlusion in 12 (2.2%) and flow diverter treatment in 12 (2.2%). Eleven patients with 12 aneurysms were treated with flow diverters. Two patients had ruptured dissecting aneurysms. One patient with a basilar trunk aneurysm died of acute in stent thrombosis and another patient died of brain stem ischaemia at 32 months follow-up. One patient had ischaemia with permanent neurological deficit. Two aneurysms are still open at up to 30 months follow-up. Flow diversion was used in 2% of all endovascular treatments. Both our own poor results and the high complication rates reported in the literature have converted our initial enthusiasm to apprehension and hesitancy. The safety and efficacy profile of flow diversion should discourage the use of these devices in aneurysms that can be treated with other techniques.

scholarly journals Residuals, recurrences and re-treatment after endovascular repair of intracranial aneurysms: A retrospective methodological comparison

2019 ◽  
Vol 26 (1) ◽  
pp. 45-54 ◽  
Author(s):  
Jens J Froelich ◽  
Nicholas Cheung ◽  
Johan AB de Lange ◽  
Jessica Monkhorst ◽  
Michael W Carr ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Medical Records ◽  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Flow Diversion ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
Methodological Comparison

Objective Incomplete aneurysm occlusions and re-treatment rates of 52 and 10–30%, respectively, have been reported following endovascular treatment of intracranial aneurysms, raising clinical concerns regarding procedural efficacy. We compare residual, recurrence and re-treatment rates subject to different endovascular techniques in both ruptured and unruptured intracranial aneurysms at a comprehensive state-wide tertiary neurovascular centre in Australia. Methods Medical records, procedural and follow-up imaging studies of all patients who underwent endovascular treatment for intracranial aneurysms between July 2010 and July 2017 were reviewed retrospectively. Residuals, recurrences and re-treatment rates were assessed regarding initial aneurysm rupture status and applied endovascular technique: primary coiling, balloon- and stent-assisted coiling and flow diversion. Results Among 233 aneurysms, residual, recurrence and re-treatment rates were 27, 11.2 and 9.4%, respectively. Compared with unruptured aneurysms, similar residual and recurrence (p > .05), but higher re-treatment rates (4.5% vs. 19%; p < .001) were found for ruptured aneurysms. Residual, recurrence and re-treatment rates were: 13.3, 16 and 12% for primary coiling; 12, 12 and 10.7% for balloon-assisted coiling; 14.9, 7.5 and 4.5% for stent-assisted coiling; 91.9, 0 and 5.4% for flow diversion. Stent-assistance and flow-diversion were associated with lower recurrence and re-treatment rates, when compared with primary- and balloon-assisted coiling (p < .05). Conclusions Residuals and recurrences after endovascular treatment of intracranial aneurysms are less common than previously reported. Stent assistance and flow diversion seem associated with reduced recurrence- and re-treatment rates, when compared with primary- and balloon-assisted coiling. Restrained use of stents in ruptured aneurysms may be a contributing factor for higher recurrence/retreatment rates compared to unruptured aneurysms.

Technical aspects of combined intrasaccular and endoluminal flow diversion

2020 ◽  
pp. 159101992097384
Author(s):  
Timothy G White ◽  
Kevin Shah ◽  
Justin Turpin ◽  
Thomas Link ◽  
Amir R Dehdashti ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Retrospective Chart Review ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Adjunctive Treatment ◽  
Technical Aspects ◽  
Complex Aneurysms ◽  
Concurrent Use ◽  
Web Device ◽  
The Web

Introduction The concurrent use of endoluminal flow diversion with coils is a viable option when treating complex or large aneurysms. Alternatives to coil embolization as an adjunctive treatment are currently limited. The Food and Drug Administration recently approved the Woven EndoBridge (WEB) device (Microvention, Aliso Viejo, California) as an intrasaccular flow diverter for wide-neck bifurcation aneurysms. We present the technical aspects of combined WEB device plus endoluminal flow diversion for the treatment of complex wide-necked intracranial aneurysms. Methods A retrospective chart review of all patients treated via intrasaccular flow diversion at a single institution over the last 12 months was performed. Results In total, seven patients underwent treatment of eight aneurysms via combined intrasaccular and endoluminal flow diversion. Of the seven patients, six were treated in a single setting. The most common aneurysm location was the posterior communicating artery. The majority of the aneurysms required steam shaping of the Via deployment catheter to place the WEB device orthogonally to the aneurysm dome. There were no complications. Conclusions We believe this is one of the first series reporting the combined use of the WEB device and endoluminal flow diversion for the treatment of intracranial aneurysms. This series demonstrates that the concurrent use of the WEB device with endoluminal flow diversion is safe for achieving immediate aneurysm treatment and may enhance the long-term durability in complex aneurysms.

Prophylactic administration of tirofiban for preventing thromboembolic events in flow diversion treatment of intracranial aneurysms

2020 ◽  
pp. neurintsurg-2020-016878
Author(s):  
Qiaowei Wu ◽  
Qiuji Shao ◽  
Li Li ◽  
Xiaodong Liang ◽  
Kaitao Chang ◽  
...  
Keyword(s):  
Balloon Angioplasty ◽  
Intracranial Aneurysms ◽  
Dual Antiplatelet Therapy ◽  
Flow Diverter ◽  
Thromboembolic Events ◽  
Maintenance Infusion ◽  
Prophylactic Administration ◽  
Unruptured Intracranial Aneurysms ◽  
Hemorrhagic Events ◽  
Prophylactic Use

BackgroundFlow diverter (FD) is widely used in the treatment of intracranial aneurysms. However, thromboembolic events (TEs) continue to be the major complications during the periprocedural phase. To evaluate the safety and efficacy of the prophylactic use of tirofiban, combined with the conventional dual antiplatelet therapy (DAT), as a new antiplatelet protocol in patients with intracranial aneurysms treated with FDs.MethodsAt least 3–5 days before the procedure, daily DAT were administrated to the patients. Tirofiban was administered as an intravenous bolus (5 µg/kg) over a 3 min period during or immediately after FD deployment, followed by a 0.05 µg/kg/min maintenance infusion for 24–48 hours. Periprocedural TEs and hemorrhagic events (HEs) were recorded.ResultsA total of 331 patients were included, including 229 (69.2%) who received tirofiban administration (tirofiban group) and 102 (30.8%) who received only DAT (non-tirofiban group). Periprocedural TEs occurred in 12 (3.6%) patients, including eight (7.8%) in the non-tirofiban group and four (1.7%) in the tirofiban group. In multivariate analysis, patients receiving tirofiban administration had significantly lower TEs as compared with those who received only DAT (P=0.004). Balloon angioplasty and longer procedure time (>137 min) were also risk factors for TEs. Also, no increase was observed in the rate of HEs related to tirofiban administration.ConclusionsThe current study suggested that prophylactic administration of tirofiban combined with conventional oral DAT seems safe and efficient for preventing TEs during FD treatment of unruptured intracranial aneurysms. Balloon angioplasty and prolonged procedure are associated with a high risk of TEs.

Flow Diversion Endovascular Treatment Improves Headaches in Patients with Unruptured Intracranial Aneurysms

2020 ◽  
Vol 140 ◽  
pp. e140-e147
Author(s):  
Georgios A. Maragkos ◽  
Sarah Cordell ◽  
Santiago Gomez-Paz ◽  
Laura E. Dodge ◽  
Mohamed M. Salem ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Flow Diversion ◽  
Unruptured Intracranial Aneurysms

Periprocedural complications of second-generation flow diverter treatment using Pipeline Flex for unruptured intracranial aneurysms: a systematic review and meta-analysis

2019 ◽  
Vol 11 (8) ◽  
pp. 817-824 ◽  
Author(s):  
Kartik Dev Bhatia ◽  
Hans Kortman ◽  
Emanuele Orru ◽  
Jesse M Klostranec ◽  
Vitor M Pereira ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Intracranial Aneurysms ◽  
Second Generation ◽  
Meta Analysis ◽  
Major Complication ◽  
Flow Diverter ◽  
Major Complications ◽  
Unruptured Intracranial Aneurysms ◽  
Symptomatic Intracranial Hemorrhage

BackgroundFlow diverters are a breakthrough treatment for large and giant intracranial aneurysms but carry a risk of periprocedural death or major stroke. Pipeline Flex is a second-generation device that is thought to have lower complication rates because of improvements in the delivery system as well as increased operator experience. Our objective was to analyze the risk of periprocedural death or major complications using Pipeline Flex for unruptured intracranial aneurysms.MethodsA systematic search of three databases was performed for studies of ≥10 treatments using Pipeline Flex for unruptured intracranial aneurysms (2014–2019) using PRISMA guidelines. Random effects meta-analysis was used to pool the rates of periprocedural (<30 days) death, major ischemic stroke, symptomatic intracranial hemorrhage, and minor stroke/transient ischemic attack.ResultsWe included eight studies reporting 901 treatments in 879 patients. Periprocedural mortality (<30 days) was 0.8% (5/901; 95% CI 0.4% to 1.5%; I2=0%). Rate of major complications (death, major ischemic stroke, or symptomatic intracranial hemorrhage) was 1.8% (14/901; 95% CI 1.0% to 2.7%; I2=0%). Aneurysm size ≥10 mm was a statistically significant predictor of a major complication (OR 6.4; 95% CI 2.0 to 20.7; p=0.002). Risk of a major complication in aneurysms <10 mm was 0.9% (95% CI 0.3% to 1.7%; I2=0%). The meta-analysis was limited by the predominance of anterior circulation aneurysms.ConclusionTreatment of unruptured intracranial aneurysms using the Pipeline Flex flow diverter has a low periprocedural risk of death (0.8%) or major complication (1.8%). The risk of a major complication is significantly higher for large/giant aneurysms (4.4%) and is very low for aneurysms <10 mm (0.9%).

Sign in / Sign up

Export Citation Format

Share Document