Cost-effectiveness of new cardiac and vascular rehabilitation strategies for patients with coronary artery disease

Objective: Peripheral arterial disease (PAD) often hinders the cardiac rehabilitation program. The aim of this study was evaluating the relative cost-effectiveness of new rehabilitation strategies which include the diagnosis and treatment of PAD in patients with coronary artery disease (CAD) undergoing cardiac rehabilitation. Data Sources: Best-available evidence was retrieved from literature and combined with primary data from 231 patients. Methods: We developed a Markov decision model to compare the following treatment strategies: 1. cardiac rehabilitation only; 2. ankle-brachial index (ABI) if cardiac rehabilitation fails followed by diagnostic work-up and revascularization for PAD if needed; 3. ABI prior to cardiac rehabilitation followed by diagnostic work-up and revascularization for PAD if needed. Quality-adjusted-life years (QALYs), life-time costs (US $), incremental cost-effectiveness ratios (ICER), and gain in net health benefits (NHB) in QALY equivalents were calculated. A threshold willingness-to-pay of$75 000 was used. Results: ABI if cardiac rehabilitation fails was the most favorable strategy with an ICER of $44 251 per QALY gained and an incremental NHB compared to cardiac rehabilitation only of 0.03 QALYs (95$75 000/ QALY. After sensitivity analysis, a combined cardiac and vascular rehabilitation program increased the success rate and would dominate the other two strategies with total lifetime costs of $30 246 a quality-adjusted life expectancy of 3.84 years, and an incremental NHB of 0.06 QALYs (95%CI:-0.24, 0.46) compared to current practice. The results were robust for other different input parameters. Conclusion: ABI measurement if cardiac rehabilitation fails followed by a diagnostic work-up and revascularization for PAD if needed are potentially cost-effective compared to cardiac rehabilitation only

A simplified surgical approach for left ovarian vein transposition for the treatment of pelvic venous disease from nutcracker syndrome

Nutcracker syndrome is becoming increasingly recognized as a cause of chronic pelvic pain. Several treatment options have been used, including renal vein or ovarian vein transposition to the more distal inferior vena cava and renal vein stenting. Concerned about the major scope of the surgical procedures as well as the implantation of a foreign body that must function for six to seven decades, we undertook to develop an all autogenous simpler surgical solution for the treatment of nutcracker syndrome. In 2013, we began performing left ovarian vein transposition to the left iliac vein. In our initial report, we used a minimally invasive robotic approach. For the past several years, we have used a simplified open approach to left ovarian vein transposition that takes advantage of the fact that the left ovarian vein naturally courses over the iliac vein. We have found this surgical treatment of nutcracker syndrome provides excellent relief from the associated symptoms