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4/14/2016 FINANCIAL DISCLOSURE FINANCIAL DISCLOSURE How Far - - PowerPoint PPT Presentation

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4/14/2016 FINANCIAL DISCLOSURE FINANCIAL DISCLOSURE How Far Should We Go with the Endovascular Treatment of Advanced PAD in the Era of Health Care Reform? An Endocompetent Vascular Surgeons View I Have No Financial Relationships to

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SLIDE 1

4/14/2016 1 Bruce A. Perler, MD, MBA Bruce A. Perler, MD, MBA

How Far Should We Go with the Endovascular Treatment

  • f Advanced PAD in the Era of Health Care Reform?

An Endocompetent Vascular Surgeon’s View

FINANCIAL DISCLOSURE FINANCIAL DISCLOSURE I Have No Financial Relationships to Disclose I Have No Financial Relationships to Disclose

J Vasc Surg, 2009 J Vasc Surg, 2009

Peripheral Revascularization (Medicare): 1996 - 2006 Peripheral Revascularization (Medicare): 1996 - 2006

J Vasc Surg, 2009 J Vasc Surg, 2009

Endovascular Procedures: Specialty Endovascular Procedures: Specialty

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SLIDE 2

4/14/2016 2

JACC, 2016 JACC, 2016

Admissions: 642,433 Years: 2003 - 2011

M

  • n

t h s

Open Open Endo Endo

Lipsitz, VEITH 2008 Lipsitz, VEITH 2008

DURATION OF FOLLOW-UP DURATION OF FOLLOW-UP Published Outcomes: OPEN vs ENDO 103 Reports: 1976 - 2006 Published Outcomes: OPEN vs ENDO 103 Reports: 1976 - 2006 TASC II TASC II

J Vasc Surg, 2007 J Vasc Surg, 2007

How Far Should We Go with the Endovascular Treatment of Advanced PAD?

Femoro-Popliteal Revascularization Femoro-Popliteal Revascularization Bypass Surgery Endovascular Therapy

PTA PTA +/- Stent Stent

  • Balloons
  • Cutting Balloons
  • Drug-Coated Balloons
  • Balloon Expandable Stents
  • Self-Expanding Stents
  • Drug-Eluting Stents
  • Covered Stents
  • Bioabsorbable Stents
  • Cryoplasty
  • Brachytherapy
  • Laser
  • Atherectomy
  • Percutaneous Bypass
  • Vein
  • Prosthetic
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SLIDE 3

4/14/2016 3

AFFORDABLE CARE ACT AFFORDABLE CARE ACT

Health Care Coverage for the Uninsured Increase Regulation of Private Health Insurers Reduce Healthcare Spending (“bend the curve”) Health Care Coverage for the Uninsured Increase Regulation of Private Health Insurers Reduce Healthcare Spending (“bend the curve”)

  • 3 Goals -
  • 3 Goals -

Source: Kaiser Family Foundation Source: Kaiser Family Foundation

Impact of ACA on Medicare Spending Impact of ACA on Medicare Spending

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SLIDE 4

4/14/2016 4

HEALTH CARE REFORM: Medicare Spending HEALTH CARE REFORM: Medicare Spending

Value-Based Purchasing:

  • Rewards for Quality Outcomes
  • Penalties for Readmission

Reductions in Annual Updates for Hospitals Bundled Payments Over a Longer Episode of Care Accountable Care Organizations

  • Shared Savings Programs

Independent Payment Advisory Board (IPAB)

“ Today health care is moving away from the old-fashioned, volume-driven, fee-for-service, fragmented health care approach towards a value-based, health-based system ”

Ronald R. Peterson, President The Johns Hopkins Hospital & Health System

“ Today health care is moving away from the old-fashioned, volume-driven, fee-for-service, fragmented health care approach towards a value-based, health-based system ”

Ronald R. Peterson, President The Johns Hopkins Hospital & Health System

TASC II TASC II

J Vasc Surg, 2007 J Vasc Surg, 2007

How Far Should We Go with the Endovascular Treatment of Advanced PAD?

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SLIDE 5

4/14/2016 5

World J Surg, 2011 World J Surg, 2011

University Hospital, Basel University Hospital, Basel

Patients: 110 Bypass Grafts: 124

  • AK (32%)
  • BK (50%)
  • Tibial (18%)

30-Day Mortality: 0.8% Follow-Up (mean): 77 mos 63% 87% 87% 90% 90% 70%

Ann Vasc Surg, 2011 Ann Vasc Surg, 2011

Patients: 427 Lesions: 499 TASC

A: 26 (5.2%) B: 140 (28.1%) C: 168 (33.7%) D: 165 (33.1%)

Patients: 427 Lesions: 499 TASC

A: 26 (5.2%) B: 140 (28.1%) C: 168 (33.7%) D: 165 (33.1%)

  • Mt. Sinai Hospital, New York
  • Mt. Sinai Hospital, New York

Fem-Pop Bypass Grafts

J V asc Surg, 1986

Huntington Memorial Hosp. U Southern California Huntington Memorial Hosp. U Southern California

Patients: 192 PTA / Stent Procedures: 239

J Vasc Surg, 2011 J Vasc Surg, 2011

P< .001 55% 22% Primary Patency

Patency: Vein Diameter Patency: Vein Diameter

J Vasc Surg, 2007 J Vasc Surg, 2007

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SLIDE 6

4/14/2016 6

SUNY, Buffalo SUNY, Buffalo

J Vasc Surg, 2008 J Vasc Surg, 2008

Patients: 127 Limbs: 139

PTFE Fem-Pop: 46 PTA / S: 93

Patients: 127 Limbs: 139

PTFE Fem-Pop: 46 PTA / S: 93

Primary Patency Primary Patency

Procedures: 506 Patients: 472

Claudication: 37%

Mortality: 0.8% F/U: 0-48 (median, 12.4) mos. Procedures: 506 Patients: 472

Claudication: 37%

Mortality: 0.8% F/U: 0-48 (median, 12.4) mos.

J Vasc Surg, 2008 J Vasc Surg, 2008

25% Pancreatic Cancer Pancreatic Cancer

Ann J Radiol, 2007 Ann J Radiol, 2007

Survival Survival

Subintimal Angioplasty

J Vasc Surg, 2010 J Vasc Surg, 2010

Procedures: 495 Patients: 482 F/U: 0-34 (mean, 8.6) mos. Procedures: 495 Patients: 482 F/U: 0-34 (mean, 8.6) mos.

33%

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SLIDE 7

4/14/2016 7 Recurrent Glioblastoma Recurrent Glioblastoma

BMJ, 2004 BMJ, 2004

Survival Survival

33%

Patients: 63

Claudication: 65% TASC C / D: 89%

Ann Vasc Surg, 2011 Ann Vasc Surg, 2011 25.9% 24.2%

p= .392

J Vasc Surg, 2013 J Vasc Surg, 2013

Primary Patency

Patients (C/D): 148 VIABAHN: 76 Stent: 72 Lesion Length (mean): 18 cm. Patients (C/D): 148 VIABAHN: 76 Stent: 72 Lesion Length (mean): 18 cm.

Assisted Primary Patency Assisted Primary Patency Secondary Patency Secondary Patency

89% 70%

p= .04

89% 80%

p= .304

Covered Stents Patients: 86 Limbs: 100

TASC: A: 18 B: 56 C: 11 D: 15

Patients: 86 Limbs: 100

TASC: A: 18 B: 56 C: 11 D: 15

Primary Patency Primary Patency Secondary Patency Secondary Patency

J Vasc Surg, 2009 J Vasc Surg, 2009

Baylor University Medical Center Baylor University Medical Center

TASC C & D Covered Stents Covered Stents

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4/14/2016 8

Heparin-Bonded Covered Stents Heparin-Bonded Covered Stents

Patients: Viabahn 72 (19 cm) BMS 69 (17 cm)

JACC, 2015 JACC, 2015

Patients: 474

DES: 236 PTA: 238

PTA Failure: 100

DES: 61 BMS: 59

Patients: 474

DES: 236 PTA: 238

PTA Failure: 100

DES: 61 BMS: 59

J Am Coll Cardiol, 2013 J Am Coll Cardiol, 2013 Fem-Pop Bypass Grafts

J V asc Surg, 1986

(Length: 66 mm) (Length: 63 mm) (Length: 66 mm) (Length: 63 mm)

Drug Eluting Stents Drug Eluting Stents

Circulation, 2016 Circulation, 2016

DES: 236 PTA: 238

(Length: 66 mm) (Length: 63 mm) (Length: 66 mm) (Length: 63 mm)

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SLIDE 9

4/14/2016 9

  • Patients: 476
  • Claudication: 92%
  • Lesion Length: < 15 cm
  • Patients: 476
  • Claudication: 92%
  • Lesion Length: < 15 cm

LEVANT 2 LEVANT 2 65.2% 52.6%

N Engl J Med, 2015

Drug Coated Balloons Drug Coated Balloons

63% 87% 87% 90% 90% 70%

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4/14/2016 10

  • Patients: 331
  • Stenosis Length: < 18 cm
  • Occlusion Length: < 10 cm
  • Mean Lesion Length
  • Patients: 331
  • Stenosis Length: < 18 cm
  • Occlusion Length: < 10 cm
  • Mean Lesion Length

IN.PACT SFA IN.PACT SFA

Drug Coated Balloons Drug Coated Balloons

8.94 vs 8.81 cm

JACC, 2015 JACC, 2015

Helsinki University General Hospital Helsinki University General Hospital

Eur J Vasc Endovasc Surg, 2010 Eur J Vasc Endovasc Surg, 2010

Patients: 858

PTA: 517 (60%) Bypass: 341 (40%) Years: 2000 - 2007

Patients: 858

PTA: 517 (60%) Bypass: 341 (40%) Years: 2000 - 2007

LIMB SALVAGE LIMB SALVAGE Pp< .0001

“ The definition of insanity is doing the same thing over and

  • ver and expecting a different
  • result. ”

“ The definition of insanity is doing the same thing over and

  • ver and expecting a different
  • result. ”

Albert Einstein Albert Einstein

Huntington Memorial Hosp. U Southern California Huntington Memorial Hosp. U Southern California

Patients: 192 PTA / Stent Procedures: 239

J Vasc Surg, 2011 J Vasc Surg, 2011

P< .001 55% 22% Primary Patency

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SLIDE 11

4/14/2016 11

Huntington Memorial Hosp. U So. Cal Huntington Memorial Hosp. U So. Cal

Patients: 192 PTA/Stent Procedures: 239

J Vasc Surg, 2011 J Vasc Surg, 2011

Consequences of Stent Failure Consequences of Stent Failure

Patients: BMS: 71 (TASC D 12%)

(Claud. 48%)

SG: 63 (TASC D 40%)

(Claud. 63%) J Vasc Surg, 2013 J Vasc Surg, 2013 J Vasc Surg, 2010 J Vasc Surg, 2010

Patients: 452 Bypass vs Endovascular Patients: 452 Bypass vs Endovascular

Amputation-Free Survival Amputation-Free Survival BASIL TRIAL BASIL TRIAL

One Year: Graft Occlusion Rate Amputation Rate One Year: Graft Occlusion Rate Amputation Rate

J Vasc Surg, 2011 J Vasc Surg, 2011

Patients: 1,880 LEBs Prior PVI: 603 (32%) Years: 2003 - 2009 Patients: 1,880 LEBs Prior PVI: 603 (32%) Years: 2003 - 2009

VSGNE VSGNE

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SLIDE 12

4/14/2016 12 Deductibles Deductibles Copayments Copayments

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4/14/2016 13

J Vasc Surg, 2008 J Vasc Surg, 2008

East Carolina Brody School of Medicine East Carolina Brody School of Medicine

Open Endo. (n= 183) (n= 198) p Open Endo. (n= 183) (n= 198) p 10 Patency (12 mos) 77% 65% < .01 10 Assisted Patency (12 mos) 93% 80% < .01 Hospital Costs $12, 389 $6,739 < .001 10 Patency (12 mos) 77% 65% < .01 10 Assisted Patency (12 mos) 93% 80% < .01 Hospital Costs $12, 389 $6,739 < .001

Femoral-Popliteal Disease Femoral-Popliteal Disease

J Vasc Surg, 2008 J Vasc Surg, 2008

East Carolina Brody School of Medicine East Carolina Brody School of Medicine

COSTS: Per Day of Patency COSTS: Per Day of Patency

Claudicants Limb Salvage Claudicants Limb Salvage

Per day patency Per day patency

J Vasc Surg, 2011 J Vasc Surg, 2011

National Inpatient Sample Patients: 563,143 National Inpatient Sample Patients: 563,143

COST INCREASE (%): 2001 - 2007 PTA 60% BYPASS SURGERY 38% COST INCREASE (%): 2001 - 2007 PTA 60% BYPASS SURGERY 38%

“ I shall not today attempt further to define ………. hard-core pornography. But I know it when I see it. ” “ I shall not today attempt further to define ………. hard-core pornography. But I know it when I see it. ”

Jacobellis v. Ohio, 1964 Jacobellis v. Ohio, 1964 Justice Potter Stewart Justice Potter Stewart

Pornography Pornography

  • You know when you see a patient

who is best served by a bypass graft.

  • Patients with TASC D and most

patients with TASC C lesions should undergo a bypass graft.

  • Patients after multiple failed

endovascular procedures should undergo a bypass graft.

  • You know when you see a patient

who is best served by a bypass graft.

  • Patients with TASC D and most

patients with TASC C lesions should undergo a bypass graft.

  • Patients after multiple failed

endovascular procedures should undergo a bypass graft.

…..and there’s nothing wrong

with doing a bypass graft in the endovascular era!

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