Cardiac-CT and Cardiac-MR examinations cost analysis, based on data of four Italian Centers.

PURPOSE: To establish the appropriate number of Cardiac-CT and Cardio-MR examinations, to determine an economically justified and sustainable investment in these two technologies, for an exclusive cardiologic use. MATERIALS AND METHODS: From July 2013 to July 2014, through a survey in four different Italian Departments of Radiology, data on the costs of Cardiac-CT and Cardiac-MR examinations were collected. For the evaluation of the costs of examinations, it was used an analytical accounting system, considering only the direct costs (consumables, health personnel work time, equipment amortization/maintenance) and other costs (utilities, services, etc.). Indirect costs (general costs) were not assessed. It was made a simulation, assuming an exclusive use of the CT and MR equipments for Cardiac-CT and Cardiac-MR examinations, calculating the annual number necessary to arrive at the Break Even Point (BEP: the point at which cost or expenses and revenue are equal). RESULTS: On the basis of the CT costs, in order to reach the BEP, performing only Cardiac-CT examinations, an average of 2641-2752 examinations/year is needed. The annual time commitment of the Medical Professional to ensure the number of examinations to reach the BEP is 2625-2750 h/year, equivalent to two Medical Doctors in a Cardiology Department. The recent Cardiac-CT Italian Registry, in the period January-June 2011, reports a number of examinations of 3455 patients in 47 different Centers, distributed throughout the whole national territory. With regard to MR, in order to reach the BEP, performing only Cardiac-MR examinations, an average of 2435-3123 examinations/year is needed. The annual time commitment of the Medical Professional to ensure the number of examinations to reach the BEP is 2437-3125 h/year, equivalent to two Medical Doctors in a Cardiology Department. The recent Cardiac-MR Italian Registry reports a number of examinations of 3776 patients in 40 Centers, distributed throughout the whole national territory. CONCLUSION: This research has shown that, only on the basis of costs, currently in Italy is anti-economic an exclusive use of CT or MR equipment for cardiac exams, unless it's not decided, regardless of the recent guidelines and clinical indications, to submit all patients with cardiac diseases (diseases of the coronary arteries and cardiomyopathies) to Cardiac-CT and Cardiac-MR examinations. This might likely to increase both the inappropriate examinations and either health spending and in the case of CT with important repercussions, in terms of radio-exposure, subject to forensic procedures.

Venae comitantes as a potential vascular resource to create native arteriovenous fistulae.

PURPOSE: The arteriovenous fistula (AVF) represents the gold standard for hemodialysis (HD) vascular access. In some critical cases, use of the deep venous circle may represent an alternative approach and venae comitantes could be employed for this purpose. METHODS: Sixty patients with chronic renal failure in which the deep venous circle was used to create an AVF were identified; of the 48 who had a direct anastomosis between the brachial artery and vena comitans, 42 had a long-term follow-up (mean follow-up 59 weeks), while six were lost to follow-up. RESULTS: Immediate success (patency and palpable thrill) was achieved in 88% of cases (primary and early failure 12%). Primary accessibility rate was 62%, while 11 patients required a second surgical approach to make the vein accessible to needling. Secondary accessibility rate of 71% was due to surgical revisions. In the 80-week observation period, the complication rate was 10% with irreversible loss of the AVF in all these cases. Cumulative patency was 71% at the 80th week. Including all 42 patients, technical and functional success rate, defined as vein accessibility to needling and chance of an adequate HD treatment, was 62%. CONCLUSIONS: AVF employing venae comitantes may represent a suitable alternative in the absence of other vascular accesses for HD.

[Multislice computed tomographic angiography in the assessment of central veins for endovascular treatment planning: comparison with phlebography]. / Angio-TC MS nello studio dei vasi venosi centrali per la pianificazione del trattamento endovascolare: studio comparativo con la flebografia.

The dysfunction of a vascular access for hemodialysis and its loss may depend on drainage difficulties of the superficial or deep venation due to hemodynamically significant stenosis or obstruction of a central vein, which generally involve the innominate-subclavian veins or superior vena cava. These alterations are often neglected due to their central and deep location; when there is hemodynamic compensation, they may remain asymptomatic. For these reasons every suspect clinical sign for central vein stenosis (gross arm syndrome or venous hypertension in an arteriovenous fistula) must not be ignored, as timely intervention is essential for functional recovery of the vessel and for the protection of the arteriovenous fistula. The modern imaging techniques ensure thorough diagnostic assessment, while the possibilities of endovascular treatment with interventional radiology allow, in a large proportion of cases, optimal minimally invasive treatment, but above all the recovery of venation in a hemodialyzed patient. We report our experience with multislice computed tomographic angiography (MS-CTA) and reconstruction software for treatment planning of central vein stenosis or obstruction. Forty-nine patients were studied with MS-CTA (GE 16). Images were acquired in the venous phase (120-180 seconds after contrast medium injection) followed by digital vascular reconstruction (AutoBone for bone removal, vessel analysis for caliber and length measurements, thin and curved MIP, MPR). Within a week control phlebography was performed. The venous tree was divided into seven segments and analyzed in a double-blind fashion with a distinction between patent segments, 50-70% stenosis, >70% stenosis, occlusion, and collateral vascular beds. There was excellent correspondence in all the examined segments for patency, >70% stenosis, and occlusion, with high sensitivity (98%), specificity (99.3%), and diagnostic accuracy (99.1%). The binomial test demonstrated a highly significant concordance (alpha=0.99) for all patients and in all vascular segments with the exception of 70% stenoses, in which MS-CTA gave a slight overestimate. In the central venous district, color Doppler ultrasonography may not be as effective as for the peripheral study of arteriovenous fistulae, and second-level imaging techniques such as MS-CTA are more useful. We suggest that endovascular treatment must be preceded by MS-CTA. This examination shows the lesions that may benefit from endovascular treatment and recognizes ''uncrossable'' lesions, ie, the ones that will not benefit from treatment. Moreover, it allows accurate planning of endovascular treatment by showing the lesion type (stenosis or obstruction), the position and extension of the involved vessels, the vessel caliber above and below the lesion, and the possible presence of a collateral vascular bed. MS-CTA with dedicated reconstruction software, if correctly performed and accurately reconstructed, is a precious tool for diagnosis and treatment planning.