Impact on physician workload and revenue following the creation of a specialty vein clinic within an academic vascular practice.

OBJECTIVE: To evaluate the impact of creating a new specialty vein clinic within an academic-based vascular practice on clinical volume, physician workload and financial parameters. METHODS: All patients evaluated and treated for varicose vein related problems within an academic vascular surgery practice were identified from institutional billing databases. Data were stratified according to the time period prior to establishing a vein clinic (PRE-VC) (1999-2001) and after creation of a vein clinic (POST-VC) (2002-2004). Clinical volume, physician workload and financial parameters were evaluated. Comparisons were made between vein (VEIN) and overall vascular (VASC) practice trends. RESULTS: Comparison of clinical volume, physician workload and financial parameters in both the clinic and operative settings showed larger and more rapid expansion of the VEIN practice than VASC practice between PRE-VC and POST-VC time periods (VEIN vs.VASC growth, respectively: new patient clinic volume +162 vs. +18%; clinic relative value units (RVUs) +131 vs. +1%, clinic revenue +201 vs. +44%; procedure volume +348 vs. +19%; procedure RVUs +129 vs. +11%; procedure revenue +93 vs. +10%). Comparing the beginning of PRE-VC to the end of POST-VC time periods, an increasing trend was also present for the percentage of VEIN practice accounting for the total VASC practice (%VEIN PRE-VC to POST-VC, respectively: new patient clinic volume 11.6-30.2%; clinic RVUs 3.2-48.2%; clinic revenue 17.6-31.2%; procedure volume 3.1-14.3%; procedure RVUs 2.8-9.8%; procedure revenue 3.3-11.7%). CONCLUSION: Establishing a specialty vein clinic within an academic vascular practice can lead to a rapid expansion of clinical volume with associated increase in physician workload and reimbursement at a rate greater than that for the overall vascular practice.

Impact of Medicare denials on noninvasive vascular diagnostic testing.

PURPOSE: The purpose of this study was to evaluate the impact of Medicare coverage limitations and claim denials on noninvasive vascular diagnostic testing. METHODS: All Medicare claims for noninvasive vascular diagnostic studies from January 1, 1999, to December 31, 1999, were identified from the hospital billing database according to Current Procedural Terminology codes for carotid artery duplex ultrasound scan, venous duplex ultrasound scan, and lower-extremity arterial Doppler scan. Reasons for Medicare denial of payment for these tests were reviewed and a cost analysis was performed. RESULTS: During the 1-year period, there were 1096 noninvasive vascular diagnostic studies performed on Medicare patients. Of these 1096 tests, 176 (16.1%) were denied by Medicare (19.6% of 408 carotid duplex ultrasound scans, 16.8% of 345 venous duplex ultrasound scans, and 11.1% of 343 lower-extremity arterial Doppler scans). Of the noninvasive vascular tests denied by Medicare, an abnormal result was present in 72.5% of carotid duplex ultrasound scans, 32.8% of venous duplex ultrasound scans, and 78.9% of lower-extremity arterial Doppler scans. Overall, 88.1% of all initially denied claims (N = 176) were ultimately reimbursed by Medicare after resubmission, including 77.1% of the 118 claims denied based on compliance rules for "medical necessity." CONCLUSION: Because of coverage limitations, Medicare denials of noninvasive vascular diagnostic tests can lead to potential uncompensated physician and hospital technical fees if denied claims are unrecognized. Vascular laboratories performing these tests need to review compliance with Medicare guidelines. Improvements may need to be made at both the provider and Medicare carrier levels in obtaining reimbursement for appropriately ordered noninvasive vascular diagnostic studies.

Durability of percutaneous angioplasty and stent implantation for the treatment of abdominal aortic coarctation: a case report.

Abdominal aortic coarctation (AAC) is an uncommon vascular lesion with serious sequelae related to uncontrolled hypertension. Balloon-expandable stents have recently been utilized in the treatment of AAC as an alternative to surgical intervention. A 17-year-old female presented with hypertension uncontrolled by beta blockade. She underwent angiography, which revealed an isolated supraceliac aortic coarctation without visceral or renal artery involvement. Balloon angioplasty with stent placement was performed. At 2-year follow-up, a restenosis was identified and was treated with repeat balloon-expandable stent placement. Implantation of balloon-expandable stents is a safe and technically feasible treatment modality for abdominal aortic coarctation not involving the renal and mesenteric arteries. However, it is currently unknown whether the long-term durability of this approach may limit its effectiveness when compared to traditional surgical interventions.

The value of air plethysmography in predicting clinical outcome after surgical treatment of chronic venous insufficiency.

PURPOSE: The role of air plethysmography (APG) as a predictor of clinical outcome after surgery in venous disease is yet to be defined. The purpose of this study was to investigate the value of APG in predicting clinical outcome after venous surgery for chronic venous insufficiency (CVI). METHODS: Seventy-three extremities in 71 patients with Class 3 through 6 CVI were assessed preoperatively with CEAP (c linical, e tiologic, a natomic, p athophysiologic) criteria, standing reflux duplex ultrasound scan, and APG with measurements of preoperative venous filling index (VFI), venous volumes, ejection fraction, and residual volume fraction. After surgical treatment of the affected limbs, repeat APG studies were obtained within 6 weeks. Established venous reporting standards were used for follow-up to calculate clinical symptom scores (CSSs) in each patient. RESULTS: Superficial venous reflux occurred alone in 24 limbs or in conjunction with perforator incompetence in 26 limbs. Deep and superficial reflux, with or without perforator incompetence, was found in 16 limbs, and seven limbs had isolated deep insufficiency. Follow-up was available in 60 of 71 patients (mean period, 44.3 months). Postoperative APG demonstrated significant hemodynamic changes after surgery as measured with VFI, venous volumes, ejection fraction, and residual volume fraction. Mean CSSs decreased from 7.35 +/- 0.56 preoperatively to 1.79 +/- 0.32 at late follow-up after surgery (P <.001). With the use of logistic regression, the parameter correlating most closely with clinical outcome was the VFI. A normal postoperative VFI (

Prospective screening for postoperative deep venous thrombosis in patients undergoing infrainguinal revascularization.

PURPOSE: The incidence of deep venous thrombosis (DVT) in patients undergoing infrainguinal bypass graft procedures has not been well documented, and the need for routine prophylaxis remains controversial. The purpose of this study was to prospectively evaluate the risk of postoperative DVT complicating infrainguinal revascularization. METHODS: Seventy-four patients undergoing infrainguinal bypass graft procedures during a 12-month period were prospectively screened for DVT. Bilateral lower extremity venous duplex scan imaging was performed preoperatively and within 1 week and 6 weeks, postoperatively. Routine DVT prophylaxis was not used, with anticoagulation reserved for specific indications. RESULTS: Of the 74 patients screened, three patients (4.1%) had DVT identified on preoperative venous duplex scan imaging and were excluded from the study. Of the remaining 71 patients enrolled, only two patients (2.8%) had postoperative DVT. Postoperative DVT was ipsilateral to the bypass graft extremity in both patients, with involvement of the peroneal vein in one patient and the femoral vein in the other. Although routine prophylaxis was not used, 18 of these patients (25%) were anticoagulated for other indications, with DVT occurring in one patient (5.6%). Of the remaining 53 patients who did not receive postoperative anticoagulation, only one patient (1.8%) had DVT. CONCLUSIONS: According to this prospective study, the risk of postoperative DVT in patients undergoing infrainguinal revascularization is low. Routine prophylaxis is not recommended, with postoperative anticoagulation reserved for specific indications.

Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency.

OBJECTIVE: Although newer techniques to promote the healing of leg ulcers associated with chronic venous insufficiency are promising, improved healing rates and cost effectiveness are unproven. We prospectively followed a series of patients who underwent treatment with outpatient compression for venous stasis ulcers without adjuvant techniques to determine healing rates and costs of treatment. METHODS: Two hundred fifty-two patients with clinical or duplex scan evidence of chronic venous insufficiency and active leg ulcers underwent treatment with ambulatory compression techniques. The patients were prospectively followed with wound measurements at 1-week to 2-week intervals, and the factors that were associated with delayed healing were determined. RESULTS: Of all the ulcers, 57% were healed at 10 weeks of treatment and 75% were healed at 16 weeks. Ultimately, 96% of the ulcers healed, and only 1 major amputation was necessitated (0.4%). Initial ulcer size and moderate arterial insufficiency (ankle brachial index, 0.5 to 0.8; n = 34) were factors that were independently associated with delayed healing (P <.01). Patient age, ulcer duration before treatment, and morbid obesity did not significantly affect healing times. The cost of 10 weeks of outpatient treatment with compression techniques ranged from $1444 to $2711. CONCLUSION: The treatment of venous stasis ulcers with compression techniques results in reliable, cost-effective healing in most patients. Current adjuvant techniques may prove to be useful but are likely to be cost effective only in a minority of cases, particularly in patients with large initial ulcer size or arterial insufficiency.

Descending thoracic aorta to iliofemoral artery bypass grafting: a role for primary revascularization for aortoiliac occlusive disease?

PURPOSE: Bypass grafts that originate from the descending thoracic aorta to the iliac or femoral arteries are well described but are not commonly used as primary procedures, and the long-term results remain unknown. A 15-year experience with 50 descending thoracic aorta to iliofemoral artery bypass grafts for aortoiliac occlusive disease is the basis of this report. METHODS: From January 1983 to December 1997, patients who underwent bypass grafting procedures from the descending thoracic aorta to the iliac or femoral arteries were identified. Surgical indications, morbidity and mortality rates, primary and secondary patency rates, limb salvage rates, and survival rates were determined. RESULTS: Fifty descending thoracic aorta to iliofemoral artery bypass grafting procedures were performed 24 (48%) for severe claudication, 22 (44%) for rest pain, and 4 (8%) for ischemic ulceration. A primary procedure was performed in 31 patients (62%) for complete occlusion (21 patients) and severe atherosclerotic disease (10 patients) of the infrarenal aorta. The indications for 19 secondary revascularizations (38%) were prior aortic or extra-anatomic graft failure in 17 cases and aortic graft infection in 2 cases. The follow-up periods ranged from 1 to 150 months (mean, 39 months). The cumulative life-table 5-year primary patency, secondary patency, limb salvage, and survival rates were 79%, 84%, 93%, and 67%, respectively. An improved patency trend was observed for patients who underwent operation for severe claudication as compared with limb-threatening ischemia (92% and 69%; P =.07). However, there was no difference between primary and secondary operations in primary patency rates (81% and 79%; P = NS) or survival rates (72% and 62%; P = NS). CONCLUSION: Descending thoracic aorta to iliofemoral artery bypass grafting has excellent overall long-term results. These results support its more liberal use for primary revascularization, especially for patients with severe atherosclerotic disease or complete occlusion of the infrarenal aorta.

Efficacy of color flow duplex imaging for proximal upper extremity venous outflow obstruction in hemodialysis patients.

PURPOSE: The efficacy of color flow duplex imaging (CFDI) in detecting proximal upper extremity venous outflow obstruction in hemodialysis patients was compared with that of traditional contrast venography. METHODS: From 1993 through 1997, all hemodialysis patients who were evaluated for upper extremity venous outflow obstruction of the axillary, subclavian, or brachiocephalic veins with both CFDI and venography were identified. Medical history, hemodialysis access procedures, and indications for imaging were reviewed. The diagnostic accuracy of CFDI was compared with that of venography for proximal venous outflow obstruction, including focal stricture, partial obstruction, or complete occlusion. RESULTS: Sixty upper extremities in 42 hemodialysis patients were imaged with both CFDI and venography. Previous ipsilateral intravenous dialysis catheters had been present in 33 (55%) of the extremities imaged; current catheters were present in 16 (27%) of the extremities imaged; and 28 (67%) of the extremities imaged had a current ipsilateral arteriovenous (AV) shunt. Five (8%) of the 60 duplex scans were nondiagnostic because of artifact from intravenous dialysis catheters (3) or incomplete visualization of the subclavian or brachiocephalic veins (2) and were excluded from further analysis. In the remaining 55 duplex scans, proximal venous outflow obstruction was found in 18 (33%), compared with 21 (38%) identified by means of venography (P = not significant [NS]). Overall sensitivity, specificity, positive predictive value, and negative predictive value for CFDI were 81%, 97%, 94%, and 89%, respectively. CONCLUSION: CFDI is a reliable means of detecting proximal upper extremity venous outflow obstruction and should replace contrast venography as the initial imaging study in hemodialysis patients.

Late clinical and hemodynamic sequelae of isolated calf vein thrombosis.

PURPOSE: Despite the frequent occurrence of isolated calf vein thrombosis (ICVT), little is known about the long-term clinical and hemodynamic sequelae of this condition. This study was conducted to determine late clinical symptoms and vascular laboratory abnormalities in patients after ICVT. METHODS: Of 146 patients in whom ICVT was documented by color flow duplex scanning between 1989 and 1994, 37 were reexamined. Data included history, physical examination, venous recovery time (VRT), and duplex valve closure time (DVCT). A control group with no history of venous disease also underwent identical clinical and hemodynamic testing. RESULTS: Thirty-seven patients (18 male and 19 female) with a median age of 56 years (range, 22 to 76 years) were examined at a mean follow-up of 3.4 years (range, 2.2 to 5.8 years) after the diagnosis of ICVT in 39 extremities. Seventeen subjects (34 extremities) were recruited as normal controls. Presenting symptoms at the time of ICVT included calf pain in 17 patients, calf swelling in seven, pain and swelling in seven, pulmonary symptoms in four, pulmonary symptoms and calf pain in one, and no symptoms in one. In the patients with ICVT, VRT was abnormal in 23% of extremities with ICVT and in 9% of extremities without ICVT. None of the extremities in the control group had an abnormal VRT (p < 0.05). DVCT was abnormal in one or more venous segments in 26% of extremities diagnosed with ICVT and in 6% of control extremities (p < 0.05). Follow-up clinical examination in patients with ICVT revealed 13 (35%) with reticular veins, 10 (27%) with varicose veins, two (5.4%) with edema, one (2.7%) with pigmentation and ulcer (contralateral extremity to ICVT with a previous history of proximal deep venous thrombosis), 13 (35%) with mild discomfort, and one (2.7%) with severe pain. All symptoms attributable to ICVT were mild in nature except in one patient who had severe pain and no physical or hemodynamic vascular laboratory abnormalities at follow-up. CONCLUSION: At an average of 3.4 years after ICVT, approximately one third of patients showed evidence of mild to moderate venous valvular insufficiency, but mostly in segments not involved with ICVT, and few had significant clinical symptoms attributable to venous disease.

Pulmonary embolism is associated with the combination of isolated calf vein thrombosis and respiratory symptoms.

PURPOSE: Overall prevalence of pulmonary embolism (PE) in patients with deep venous thrombosis (DVT) isolated to calf veins is low. However, the prevalence of PE in the subgroup of patients with respiratory symptoms and isolated calf vein thrombosis (CVT) is unknown. Such information is important in determining whether patients with CVT only and respiratory symptoms should undergo evaluation for PE. The purpose of this study was to determine the prevalence of PE in patients with respiratory symptoms and isolated CVT. METHODS: From 1992 through 1994, all patients assessed by duplex scanning for lower extremity DVT were reviewed, and those found to have isolated CVT and lower extremity or respiratory symptoms were identified. Patients who had respiratory symptoms or later developed respiratory symptoms in addition to lower extremity symptoms underwent pulmonary angiography or ventilation/perfusion (V/Q) scanning. Positive results on pulmonary arteriograms or "high probability" V/Q scans were considered diagnostic of PE. RESULTS: There were 105 patients with isolated CVT and symptoms. Twenty-six patients had respiratory symptoms; nine (35%) had PE and two died. Seventy-nine patients had only lower extremity complaints; five later developed respiratory symptoms. All five had PE and none had progression of CVT on repeat duplex scanning. Neither age, gender, prior DVT/PE, obesity, pregnancy, medication, known malignancy, smoking, recent surgery, or trauma predicted PE. CONCLUSIONS: Patients with respiratory symptoms and duplex diagnosed isolated CVT have a high prevalence of PE and require pulmonary angiographic or V/Q scanning to rule out PE.

Synchronous colon primaries have the same prognosis as solitary colon cancers.

PURPOSE: This study was designed to determine the prognosis of patients with synchronous colon primary tumors. METHODS: An 18-year, multi-institutional database of 4,878 colon cancer patients was reviewed, and patients with synchronous tumors were identified. Survival for each group was calculated by the Kaplan-Meier method and compared using log-rank analysis. RESULTS: There were 160 patients (3.3 percent) with 339 synchronous tumors. Eight percent of these patients had more than two tumors at the time of diagnosis. TNM staging of all synchronous tumors was 12 percent Stage 0, 41 percent Stage I, 21 percent Stage II, 16 percent Stage III, and 7 percent Stage IV. Based on highest stage lesion, 1 percent of patients were at Stage 0, 28 percent Stage I, 33 percent Stage II, 25 percent Stage III, and 11 percent Stage IV. Disease-specific five-year survival by highest stage was 87 percent for Stage 0 or I, 69 percent for Stage II, 50 percent for Stage III, and 14 percent for Stage IV (all differences significant by log-rank test). These "highest stage" survivals for patients with synchronous tumors were not significantly different from survival of patients with the same stage solitary tumors in our database or from survival of patients with solitary colon cancer in national tumor databases. CONCLUSION: For patients with synchronous colon cancers, survival is the same as for patients with solitary colon tumors on a stage-for-stage basis, when highest stage synchronous tumor is considered.

Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease.

PURPOSE: A comparison of aortofemoral bypass grafting (AOFBG) and axillofemoral bypass grafting (AXFBG) for occlusive disease performed by the same surgeons during a defined interval forms the basis for this report. METHODS: Data regarding all patients who underwent AOFBG of AXFBG for lower-extremity ischemia caused by aortoiliac occlusive disease were prospectively entered into a computerized vascular registry. The decision to perform AOFBG rather than AXFBG was based on assessment of surgical risk and the surgeon's preference. This report describes results for surgical morbidity, mortality, patency, limb salvage, and patient survival for procedures performed from January 1988 through December 1993. RESULTS: We performed 108 AXFBGs and 139 AOFBGs. AXFBG patients were older (mean age, 68 years compared with 58 years for AOFBG, p<0.001), more often had heart disease (84% compared with 38%, p<0.001), more often underwent surgery for limb-salvage indications (80% compared with 42%, p<0.001). No significant differences were found in operative mortality (AXFBG, 3.4%; AOFBG, <1.0%, p=NS), but major postoperative complications occurred more frequently after AOFBG (AXFBG, 9.2%; AOFBG, 19.4%; p<0.05). Follow-up ranged from 1 to 83 months (mean, 27 months). Five-year life-table primary patency, limb salvage, and survival rates were 74%, 89%, and 45% for AXFBG and 80%, 79%, and 72% for AOFBG, respectively. Although the patient survival rate was statistically lower with AXFBG, primary patency and limb salvage rates did not differ when compared with AOFBG. CONCLUSION: When reserved for high-risk patients with limited life expectancy, the patency and limb salvage results of AXFBG are equivalent to those of AOFBG.

Do normal early color-flow duplex surveillance examination results of infrainguinal vein grafts preclude the need for late graft revision?

PURPOSE: Optimal duration of postoperative duplex surveillance of infrainguinal vein grafts is not known. Previous reports have suggested nearly all vein graft stenoses are present within the first postoperative year, and normal duplex examination results during this time eliminate the need for ongoing graft surveillance. To determine whether surveillance may be safely discontinued in patients with normal early postoperative surveillance studies, we reviewed the color-flow surveillance examinations in our patients who underwent infrainguinal reverse vein graft revisions during a 4 1/2 year period. METHODS: Clinical and vascular laboratory records were reviewed of all patients who underwent infrainguinal reverse vein bypass grafting followed by subsequent graft revision for a duplex scanning-detected abnormality at our institution between January 1990 and July 1994. RESULTS: Of 447 infrainguinal reverse vein bypasses performed, 36 (8.1%) underwent surgical revision as a result of an abnormal finding during routine duplex surveillance. The initial postoperative duplex examination was obtained within 2 weeks of graft implantation in 23 (64%) patients, between 2 weeks and 3 months in 10 (28%) patients, and between 3 and 6 months in three (8%) patients. Duplex abnormalities prompting revision included 11 (31%) grafts with a mid-graft peak systolic velocity (PSV) < or = 45 cm/sec, 23 (64%) grafts with a focal PSV > or = 200 cm/sec, one graft with a PSV > or = 150 cm/sec but < 200 cm/sec, and one thought to be occluded by duplex but found to be patent by angiography. Abnormal duplex findings were initially detected within 2 weeks of graft implantation in five (14%) patients, between 2 weeks and 3 months in eight (22%) patients, from 3 to 6 months in 12 (33%) patients, from 6 to 12 months in six (17%) patients, and > 1 year in five (14%) patients. In only 25% of cases were mid-graft PSVs < or = 45 cm/sec or focal velocities > or = 200 cm/sec identified on the initial examination; 75% were found during subsequent surveillance. CONCLUSIONS: Although most reverse vein graft abnormalities detected by duplex surveillance and prompting graft revision appear within the first postoperative year, many are not detected on the initial examination. In our recent experience 31% of duplex abnormalities leading to vein graft revision were first detected more than 6 months after operation. Discontinuation of graft surveillance based on normal early findings will result in thrombosis of some vein grafts that may otherwise be salvaged.