Pseudoendoleak: A post-endovascular aortic repair ultrasound surveillance pitfall - Single institution case series.

INTRODUCTION: In the context of increasingly common endovascular treatment for abdominal aortic aneurysms, endoleak is a relatively common complication of (abdominal) EVAR, and ongoing multimodality surveillance programs are recommended by expert bodies including the Society for Vascular Surgery (SVS). We describe the colour doppler ultrasound (CDUS) finding defined as pseudoendoleak that may be misinterpreted as significant endoleak and may be resolved through the use of contrast-enhanced ultrasound (CEUS). METHODS: Retrospective review of cases at our institution identified five cases where apparent endoleak on CDUS was not evident on CEUS, performed immediately following CDUS. RESULTS: Each of these five cases demonstrated interval increase in sac size at varying intervals post-EVAR, and in 4 out of 5 cases, no endoleak was demonstrated on multiple other modalities, at multiple time points. One case demonstrated an isolated type 2 endoleak at one time point, a finding that could not be reproduced. In each case, index-positive CDUS is thought to represent agitated fluid within the excluded sac that is not in continuity with the arterial blood pool as evidenced by the absence of CEUS enhancement. CONCLUSIONS: In cases of positive post-EVAR CDUS, CEUS is an effective tool to exclude the presence of pseudoendoleak and thus avoid further and potentially invasive diagnostic modalities in an elderly and comorbid cohort.

A retrospective cost analysis of angioplasty compared to bypass surgery for lower limb arterial disease in an Australian tertiary health service.

INTRODUCTION: Percutaneous transluminal angioplasty (PTA) and surgical bypass (BYP) are treatment options for symptomatic peripheral arterial disease (PAD). PTA and BYP have different clinical outcomes and cost implications. This paper aims to compare hospital-related costs of PTA and BYP for PAD of the lower limbs in an Australian health service. METHODS: A retrospective cost analysis using clinical and financial data from an urban, tertiary hospital was performed. Patient cohorts were matched to existing published studies and 3-year findings were calculated. Outcomes measured were mean initial admission cost; mean bed stay; mean complication rate; mean cost of re-intervention at 12 months and extrapolated mean cost at 3 years. RESULTS: The mean total admission costs for PTA compared to BYP were $8758 vs. $27,849 (P < 0.001). Patients undergoing BYP were admitted for 10.25 vs. 3.77 nights (P < 0.001). The complication rate was greater in the BYP group for infection only. Re-intervention was required by 13% of the PTA group and 16% of the BYP group, at a mean cost of $11,798 and $14,728, respectively (P = 0.453). The extrapolated total mean cost at 3 years was higher in the BYP group for patients with both intermittent claudication ($26,764 vs. $11,402) and critical limb ischaemia ($27,719 vs. $12,655). CONCLUSIONS: In this cohort, PTA is a favourable alternative to BYP for PAD of the lower limbs as it is less costly, does not result in a greater re-intervention rate at 1 year and has been previously demonstrated to have comparable clinical outcomes. Given the limitations of this retrospective analysis, a prospective cost-effectiveness analysis is recommended.

Review of knee arthroscopic practice and coding at a major metropolitan centre.

BACKGROUND: Arthroscopic knee surgery has been a topic of significant controversy in recent orthopaedic literature. Multiple studies have used administrative (Victorian Admitted Episodes Dataset and Centre for Health Record Linkage) data to identify trends in practice. This study explored the usage and reporting of arthroscopic knee surgery by conducting a detailed audit at a major Victorian public hospital. METHODS: A database of orthopaedic procedures at St Vincent's Hospital Melbourne was used to retrospectively identify cases of knee arthroscopy from 1 December 2011 to 1 April 2014. Procedures were categorized as diagnostic or interventional, and native and prosthetic joints were analysed separately. Procedure codes were reviewed by comparing a registrar, auditor and hospital coders for agreement. RESULTS: Of the 401 cases for analysis, 375 were conducted in native knees and 26 in prosthetic joints. Of native knees, 369 (98.4%) were considered interventional. The majority of these were conducted for meniscal pathology (n = 263, 70.1%), osteoarthritis (OA) (n = 25, 6.7%) and infection (n = 28, 7.6%). Comparison of codes assigned by different parties were found to be between 57% (k = 0.324) and 70% (k = 0.572) agreement, but not statistically significant. CONCLUSIONS: In this study, the most common indication for arthroscopy was meniscal pathology. Arthroscopy was rarely performed for OA in the absence of meniscal pathology. Diagnostic arthroscopy was rarely performed in the native knee, and fair to moderate agreement existed between parties in assigning Medicare Benefits Schedule procedure codes.

Prospective analysis of rural-urban differences in demographic patterns and outcomes following total joint replacement.

OBJECTIVE: Little is known about whether rural-urban differences exist in patients after hip and knee joint replacement surgery. We compared patient characteristics, pain and functional outcomes of rural and urban patients undergoing joint replacement surgery in a single high-volume metropolitan centre. DESIGN: Prospective cohort study conducted in patients who underwent primary elective hip (THJR) or knee replacement (TKJR) between 1 January 2006 and 31 December 2009. SETTING: A university-affiliated tertiary referral centre situated in the central metropolitan region of Melbourne, Australia. PARTICIPANTS: One thousand nine hundred fifty-five consecutive patients undergoing primary total joint replacement. MAIN OUTCOME MEASURE: Pain and function were assessed preoperatively and 12 and 24 months postoperatively. The main independent variable was geographic location specifically comparing patients residing in rural/regional compared with urban communities. RESULTS: A total of 2193 primary joint replacements were performed (981 THJR and 1212 TKJR) in 1955 patients. Rural patients presented at a younger age and with earlier radiographic disease than their urban counterparts. There was a higher rate of rheumatoid arthritis among rural patients presenting for TKJR. There was no difference in pain and function scores between groups at 12 and 24 months post-surgery. CONCLUSION: In our series of 1955 patients undergoing total hip and knee joint replacement surgery, rural patients presented at a younger age and an earlier stage of disease progression. At 24 months, rural patients had pain and functional outcomes as good as their urban counterparts. More research is required to determine which factors lead to the early presentation of rural patients.