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Context: Percutaneous transluminal angioplasties (PTA) using balloon dilatation with or without stenting are performed to treat peripheral arterial occlusive disease (PAOD). Intravascular brachytherapy (IB) after PTA promises to reduce the restenosis rates. The present article addresses questions concerning medical efficacy and cost-effectiveness of IB in PAOD patients., Methods: A systematic literature search for randomized controlled studies evaluating IB in PAOD was conducted in August 2007. Information synthesis was conducted using meta-analysis. Health economic modelling was performed on the basis of clinical assumptions derived from the meta-analysis and economical assumptions derived from the German Diagnosis Related Groups (G-DRG) 2007., Results: Twelve publications covering seven studies about IB vs. no IB were included in the evaluation. IB after successful balloon dilatation showed a significant reduction in the rate of restenosis at six and/or twelve months (relative risk 0.62; 95% confidence interval: 0.46 to 0.84) and a significant delay in the time to recurrence of restenosis (17.5 vs. 7.4 months, p < 0.01). IB after stenting did not lead to significant results regarding the restenosis rates, but was more often associated with early and late occlusive thromboses. The incremental cost-effectiveness ratio per restenosis avoided for IB vs. no IB after successful balloon dilatation was--depending on the G-DRG used-Euro 8,484 and Euro 9,058, respectively. In the comparison of IB vs. no IB after stenting IB was demonstrated to be inferior to no IB., Conclusions: IB after successful balloon dilatation in PAOD can be recommended from a medical point of view. From the health economic perspective the answer is not yet clear. IB after stenting in PAOD cannot be recommended.

New medical treatment methods and procedures usually cause high additional costs. Medical progress in cardiovascular imaging may fortunately reduce costs considerably. In Innsbruck it is calculated that about 1000 euros may be saved when replacing diagnostic coronary angiography (CAG) by CT coronary angiography (CTA). If in Austria 30% of CAGs are replaced by CTAs with a 64-slice CT system, about 13 million euros may be saved provided that CAG capacities will be reduced to the same extent as CTAs are done.

Purpose: To evaluate reimbursement within the DRG-system ("diagnosis-related groups") compared with traditional reimbursement for interventional therapy of hospitalized patients., Materials and Methods: Reimbursement calculation was prospectively analyzed in two respects for 30 consecutive patients who underwent percutaneous transluminal angioplasty (PTA) of the lower extremity arteries: (1) based on the DRG-system; (2) based on the traditional system. Additional evaluation was performed for five further, typical vascular procedures on the basis of real documentation and calculation data (stenting of the carotid artery, fibrinolytic therapy of basilar artery occlusion, stenting of renal artery stenosis, angioplasty of hemodialysis-shunt stenosis and aspiration thrombectomy of an infrapopliteal arterial occlusion)., Results: In our hospital, the introduction of the DRG system would reduce reimbursement by approximately 1100 euro per PTA patient. However, the other vascular radiological procedures can be expected to increase the payments by up to 4500 euro., Conclusion: To minimize imminent reduction of reimbursement for patients with peripheral PTA, complete documentation and economical patient management is mandatory. Payment may increase significantly for patients with the other reported vascular interventional procedures.

The use of drugeluting stents (DES) has tackled the "Achilles' heel" of percutaneous coronary interventions (PCI) like no innovation before: the restenosis following initially successful PCI of de novo stenoses. Today, with DES, the pivotal clinical parameter TVF (target vessel failure) is in the upper single- digit range for "standard" lesions and 16% for long lesions. Numerous studies have assessed the effects of various antiproliferative and antiinflammatory substances, like Sirolimus, Tacrolimus, Everolimus, ABT-578, Biolimus, Paclitaxel, QP2 as well as of other drugs, like Dexamethasone, 17-beta-Estradiol, Batimastat, Actinomycin-D, Methotrexat, Angiopeptin, Tyrosinkinase inhibitors, Vincristin, Mitomycin, Cyclosporin, and also the C-myc antisense technology (Resten-NG, AVI-4126). At the time of this analysis, four DES are CE-certified and commercially available in Europe: The Cypher stent, releasing Sirolimus from a polymer (Cordis, J&J), the Taxus stent, releasing Paclitaxel from a polymer (Boston-Scientific), the V-Flex stent, releasing Paclitaxel without a polymer (Cook) and the Dexamet stent, releasing Dexamethasone from a PC coating (Abbott). Since more DES will be CE-certified soon, an increasing challenge vexes interventional cardiologists and health care providers: Which DES should be chosen for routine patient care?A prerequisite for assessing the efficacy of DES are randomized, controlled trials. Registries, even with strong monitoring, are limited by the known restrictions, comparing data to historical controls. At the time of this analysis, only three drugs had proven their efficacy in 13 randomized studies in 5669 patients: Paclitaxel, Sirolimus and Everolimus, with 3815 patients in Paclitaxel studies, 1748 patients in Sirolimus studies and 106 patients in Everolimus studies. For further analysis, it makes sense to divide the primary endpoints into non-clinical and clinical endpoints. Non-clinical primary endpoints are usually angiographic parameters, like the percentage of DS (diameter stenosis, ASPECT, ELUTES), the instent LLL (late lumen loss, RAVEL, FUTURE-II), the in-stent MLD (minimal lumen diameter, E-SIRIUS, C-SIRIUS) or, like in TAXUS-II, the IVUS-determined percentage of volume obstruction. Clinical primary endpoints were either MACE (major adverse cardiac events, TAXUS-I, FUTUREI), TVF (target vessel failure, DELIVER-I, SIRIUS) or TVR (target vessel revascularization, TAXUS-IV und TAXUS-VI). As ASPECT, ELUTES and DELIVER-I have shown, even a statistically significant effect on an angiographic primary endpoint does not necessarily translate into a significant clinical effect, which is completely absent in some such cases. Since it is not the goal of PCI to improve angiographic parameters but rather to improve patients' outcome, the choice of DES for routine treatment should be based on the results of randomized controlled studies with a clinical primary endpoint at an appropriate time interval. At the present time, these criteria have been met by only the Cypher and the Taxus stents.

Background: An adapted system of 'Diagnosis Related Groups' (DRG's) will be introduced for Germany at the beginning of 2003. This article focuses on the structure of the Australian DRG system (AR-DRG 4.1) regarding the diseases of the cardiovascular system and corresponding cost weights in Germany (G-DRG 1.0)., Methods: Cardiac diagnoses, procedures and cost weights (with a different base rate) were compared between the Australian and German DRG's., Results: Categories and procedures for diagnostics and therapies are shown regarding coronary interventions, electrophysiological strategies including implantation of pacemakers and cardioverter/ defibrillators, hybrid treatment modalities, transcatheter closure of interatrial/-ventricular communications as well as interventions during intensive care treatment.

Stent angioplasty has become a routine procedure in endovascular therapy. The indication must be evaluated in direct comparison with balloon angioplasty and vascular surgery. Technical and clinical success rates in various vascular regions must be considered as well as the costs induced by stent implantation. Stents for iliac artery disease are indicated after failed or complicated balloon angioplasty. If accepted indications for endovascular treatment are closely followed, we can expect a stent rate of approximately 40%. For the femoropopliteal segment stent angioplasty is only acceptable for very selected cases, mostly severe dissections; stenting of these vessels is not generally accepted. This review summarizes indications, technical and clinical success rates of stent angioplasty for peripheral arterial disease.

Management of acute myocardial infarction in patients presenting with ST-segment elevation has evolved considerably over the past decades. In this review, we will limit the discussion to STEMI, and describe some recent developments and new insights into the evidence base of various therapeutic options. We will address the contemporary antithrombotic approach to treatment of this disorder. The controversy regarding optimal treatment of ACS, whether invasive or conservative, is discussed. This seems all the mandatory more as many study populations are not directly comparable, and some therapies are nowhere at hand. Progressively important cost-benefit considerations are another aspect that makes the assessment of the evidence claimed difficult.

Purpose: Analysis of costs for vascular radiological interventions on a per patient basis and comparison with reimbursement based on GOA (Gebührenordnung für Arzte) and DKG-NT (Deutsche Krankenhausgesellschaft-Nebenkostentarif)., Material and Methods: The ten procedures most frequently performed within 12 months were evaluated. Personnel costs were derived from precice costs per hour and estimated procedure time for each intervention. Costs for medical devices were included. Reimbursement based on GOA was calculated using the official conversion factor of 0.114 DM for each specific relative value unit and a multiplication factor of 1.0. The corresponding conversion factor for DKG-NT, determined by the DKG, was 0.168 DM., Results: A total of 832 interventional procedures were included. Marked differences between calculated costs and reimbursement rates were found. Regarding the ten most frequently performed procedures, there was a deficit of 1.06 million DM according GOA data (factor 1.0) and 0.787 million DM according DKG-NT. The percentage of reimbursement was only 34.2 (GOA; factor 1.0) and 51.3 (DKG-NT), respectively., Conclusion: Reimbursement of radiological interventional procedures based on GOA and DKG-NT data is of limited value for economic controlling purposes within a hospital.

Considerations about the relation between benefit and expenses are also gaining increasing importance in interventional radiology. This review aims at providing a survey about the published data concerning economical analyses of some of the more frequently employed interventions in radiology excluding neuroradiological and coronary interventions. Because of the relative scarcity of literature in this field, all identified articles (n = 46) were included without selection for methodological quality. For a number of radiological interventions the cost-effectiveness has already been demonstrated, e. g., PTA of femoropopliteal and iliac artery stenoses, stenting of renal artery stenoses, placement of vena-cava filters, as well as metal stents in malignant biliary and esophageal obstructions. Conflicting data exist for the treatment of abdominal aortic aneurysms. So far, no analysis could be found that directly compares bypass surgery versus PTA + stent in iliac arteries.

The reduction of acute complications and late restenosis compared to conventional PTCA has led to a rapid increase in stent implantation as initial treatment for coronary stenosis. As a result, in-stent restenosis has become an important clinical and economical problem, especially the diffuse form, which is much more likely to reappear. In order to compare the consequences of initial stenting and initial angioplasty, we developed an analytic model, considering the differences between diffuse and focal in-stent restenosis. The simulation based on the optimized therapeutic proceeding following an elective 1-vessel revascularization of a 60-year-old patient, dealing with probabilities for acute complications and late restenosis taken from the literature and in-hospital costs obtained from 200 elective interventions. In the stent group 71.0% of patients were free of any target lesion-related event, compared to 60.2% in the PTCA group. Catheter reintervention was necessary for 32.1% of the patients initially treated with angioplasty and for 17.6% of the initially stented patients, whereas 7.7% of the stent patients had to undergo elective bypass surgery as final treatment compared to 2.8% in the PTCA arm. Long-term medical costs for initial stenting (6,237 Euros) were 14% higher than for conventional PTCA (5,345 Euros). Taking also into consideration the indirect costs (loss of productivity) for a collective with an employment rate of 50%, the difference between stent implantation (9,067 Euros) and angioplasty (8,581 Euros) is smaller. Initial treatment of coronary stenosis by stent implantation decreases the rate of repeat revascularization compared to initial PTCA, but there is a greater likelihood that elective bypass surgery will become necessary. This difference in following treatment is related to the occurrence of diffuse in-stent restenosis. When calculating the long-term costs stenting still appeared to be more expensive than PTCAA because the savings in following costs can not compensate for the higher primary in-hospital costs. An empirical study which collects cost data in different hospitals as well as in the outpatient setting over 1 year is necessary to confirm this preliminary result.

By the end of the eighties mesh stents were implanted in malignant stenoses of the biliary and pancreatic ducts for the first time. In the following years, self-expanding as well as balloon-expandable mesh stents were increasingly implanted in malignant stenoses by radiologists or interventional gastroenterologists, either percutaneously or endoscopically retrograde. In randomized comparative studies different teams showed relevant advantages of this new type of prosthesis in comparison to the commonly used plastic stents. Especially the significantly lower rate of late complications and longer patency rates speak in favor of the mesh stents. The higher cost of the mesh stent makes it important to carefully select patients before implantation, to let patients with potentially longer survival time profit from the advantages of the procedure. Expandable mesh stents were successfully implanted in benign stenoses of the biliopancreatic ducts as well, although the lack of randomized comparative studies makes a final assessment difficult. Concluding from already presented results, there might be a new therapeutical option for selected patients with benign stenoses of the biliopancreatic ducts.

Economic evaluation of medical treatment in terms of costs and utility has gained increasing interest within the medical community and in political discussions. In particular this applies for highly prevalent diseases such as coronary artery disease, still the most common cause of death in the western world. Health economy studies can be performed from different perspectives (e.g., hospital, insurance company, society) and with various approaches (e.g., cost-utility analysis, cost minimization). Those will be discussed for the primary prevention of myocardial infarction, coronary stent implantation, and for rehabilitation programs after myocardial infarction, serving as examples. Health-economical analyses provide data to compare treatment strategies beyond a certain speciality. However, economic evaluation is only one step within the medical assessment process and does not per se imply the political allocation of financial resources.

Clinical testing of endovascular therapy of aortic aneurysm is at present going on in various hospitals. Because of their restricted budgets, breaking even is not possible for hospitals realising this method of treatment. Amongst technical difficulties, legal questions and the lack of long-term studies, the common use of this expensive method is complicated by unsolved financing. According to section 26 of the "Bundespflegesatzverordnung", a pilot study can be financed by the health insurances for a limited period, to evaluate the type of treatment with respect to its scientific and economic implications. This should result in an inclusion of the costs in the budget of "Sonderentgelte" and "Fallpauschalen". Even in times of low budgets medical progress must be available.

With TPCD best results are gained with large diameter endoprostheses. In this instance special duodenoscopes with a working channel of 3.2 or 4.2 mm are needed for the implantation of 10 or 12 French endoprostheses. Alternatively, using the non-transendoscopic technique large diameter endoprostheses of 14 or more French can be implanted independently from the diameter of the working channel with conventional endoscopes. We have used this method developed at our institution in 1204 patients since 1982 and compared its results with 192 patients in whom the transendoscopic technique with 7-10 French endoprostheses was administered. The success-rate (non-transendoscopic technique 94 vs transendoscopic technique 79%), early complications (5 vs 11%), method-specific mortality (0.3 vs 1%), in-hospital mortality (3.6 vs 21%) and late complications (19 vs 33%) are clearly in favour of the non-transendoscopic approach. The higher rate of early complications and consecutively higher in-hospital mortality of the transendoscopic method with 7-10 French endoprostheses was mainly due to frequent episodes of early cholangitis due to insufficient biliary drainage. The higher success-rate of the non-transendoscopic approach is method specific ("Prothesenleger" guidable). A change of the endoscope is not necessary in contradiction to the transendoscopic method. Additional costs of special duodenoscopes that can be used neither for ERCP nor sphincterotomy are superfluous.(ABSTRACT TRUNCATED AT 250 WORDS)