Endovascular Versus Surgical Revascularization for Chronic Mesenteric Ischemia: Insights From the National Inpatient Sample Database.

OBJECTIVES: This study sought to compare in-hospital major adverse cardiac and cerebrovascular events (MACCE) following endovascular therapy with open surgery for chronic mesenteric ischemia (CMI). BACKGROUND: There are limited contemporary data on in-hospital cardiovascular outcomes among patients with CMI undergoing revascularization via endovascular therapy versus open surgery in the United States. METHODS: Patients with CMI undergoing endovascular or surgical (mesenteric bypass or endarterectomy) revascularization between 2007 and 2014 were identified from the National Inpatient Sample. Weighted national estimates were obtained. Primary and secondary endpoints were MACCE (death, myocardial infarction, stroke, cardiac post-operative complications) and composite in-hospital complications (MACCE + post-operative peripheral vascular complications, gastrointestinal hemorrhage, major bleeding, and bowel resection), respectively. Propensity score matching was used to obtain a balanced cohort of 880 unweighted patients in each group. RESULTS: Of 4,150 patients with CMI, 3,206 (77.2%) underwent endovascular therapy and 944 (22.8%) underwent surgery (weighted national estimates of 15,850 and 4,687, respectively). In the propensity-matched cohort, MACCE and composite in-hospital complications occurred significantly less often after endovascular therapy than surgery (8.6% vs. 15.9%; p < 0.001; and 15.3% vs. 20.3%; p < 0.006). Endovascular therapy was also associated with lower median hospital costs ($20,807.00 [interquartile range: $13,640.20 to $32.754.50] vs. $31,137.00 [interquartile range: $21,680.40 to $52,152.20]; p < 0.001, respectively) and shorter length of stay (5 [interquartile range: 2 to 10] vs. 10 [interquartile range: 7 to 17] days, respectively; p < 0.001) compared with open surgery. CONCLUSIONS: In a large, retrospective analysis of patients with CMI, endovascular therapy remained the dominant revascularization modality, and was associated with lower rates of MACCE, composite in-hospital complications, lower costs, and shorter length of stay compared with surgery.

Trends in settings for peripheral vascular intervention and the effect of changes in the outpatient prospective payment system.

BACKGROUND: Peripheral vascular intervention (PVI) is an effective treatment option for patients with peripheral artery disease (PAD). In 2008, Medicare modified reimbursement rates to encourage more efficient outpatient use of PVI in the United States. OBJECTIVES: The purpose of this study was to evaluate trends in the use and clinical settings of PVI and the effect of changes in reimbursement. METHODS: Using a 5% national sample of Medicare fee-for-service beneficiaries from 2006 to 2011, we examined age- and sex-adjusted rates of PVI by year, type of procedure, clinical setting, and physician specialty. RESULTS: A total of 39,339 Medicare beneficiaries underwent revascularization for PAD between 2006 and 2011. The annual rate of PVI increased slightly from 401.4 to 419.6 per 100,000 Medicare beneficiaries (p = 0.17), but the clinical setting shifted. The rate of PVI declined in inpatient settings from 209.7 to 151.6 (p < 0.001), whereas the rate expanded in outpatient hospitals (184.7 to 228.5; p = 0.01) and office-based clinics (6.0 to 37.8; p = 0.008). The use of atherectomy increased 2-fold in outpatient hospital settings and 50-fold in office-based clinics during the study period. Mean costs of inpatient procedures were similar across all types of PVI, whereas mean costs of atherectomy procedures in outpatient and office-based clinics exceeded those of stenting and angioplasty procedures. CONCLUSIONS: From 2006 to 2011, overall rates of PVI increased minimally. However, after changes in reimbursement, PVI and atherectomy in outpatient facilities and office-based clinics increased dramatically, neutralizing cost savings to Medicare and highlighting the possible unintended consequences of coverage decisions.

Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST).

BACKGROUND AND PURPOSE: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated similar rates of the primary composite end point between carotid artery stenting (CAS) and carotid endarterectomy (CEA), although the risk of stroke was higher with CAS, and the risk of myocardial infarction was higher with CEA. Given the large number of patients who are candidates for these procedures, an understanding of their relative cost and cost-effectiveness may have important implications for health care policy and treatment guidelines. METHODS: We performed a formal economic evaluation alongside the CREST trial. Costs were estimated from all trial participants over the first year of follow-up using a combination of resource use data and hospital billing data. Patient-level health use scores were obtained using data from the SF-36. We then used a Markov disease-simulation model calibrated to the CREST results to project 10-year costs and quality-adjusted life expectancy for the 2 treatment groups. RESULTS: Although initial procedural costs were $1025/patient higher with CAS, postprocedure costs and physician costs were lower such that total costs for the index hospitalization were similar for the CAS and CEA groups ($15 055 versus $14 816; mean difference, $239/patient; 95% CI for difference, -$297 to $775). Neither follow-up costs after discharge nor total 1-year costs differed significantly. For the CREST population, model-based projections over a 10-year time horizon demonstrated that CAS would result in a mean incremental cost of $524/patient and a reduction in quality-adjusted life expectancy of 0.008 years compared with CEA. Probabilistic sensitivity analysis demonstrated that CEA was economically attractive at an incremental cost-effectiveness threshold of $50 000/quality-adjusted life-year gained in 54% of samples, whereas CAS was economically attractive in 46%. CONCLUSIONS: Despite slightly lower in-trial costs and lower rates of stroke with CEA compared with CAS, projected 10-year outcomes from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00004732.

Cost of treating high-risk symptomatic carotid artery stenosis: stent insertion and angioplasty compared with endarterectomy.

OBJECT: Definitive data characterizing the safety and efficacy of carotid angioplasty with stent placement (CAS) for symptomatic, occlusive carotid artery (CA) disease require further refinements and standardization of techniques as well as large prospective studies on a par with the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Despite the absence of such data, many surgeons have performed angioplasty and stent placement in patients with clinical or anatomical features known to add significant perioperative risk and capable of disqualifying the patients from participation in NASCET: There exists no cost analysis comparing high-risk endarterectomy with percutaneous angioplasty and stent insertion. METHODS: Forty-five patients (29 men and 16 women) with high-risk, symptomatic CA stenosis have been treated with CAS at the authors' institution since 1996. Indications for this procedure included symptomatic recurrent stenosis following CA endarterectomy (CEA), active coronary disease, high CA bifurcation, and severe medical comorbidities. A longstanding CEA computer database was screened for control patients with similar risk factors; 391 patients (276 men and 115 women) were identified. Actual cost data, duration of hospital stay, and relevant clinical data from the time of treatment until hospital discharge were collected in each patient. The median total cost of CAS was dollar 10,628, whereas that for CEA was dollar 10,148 (p = 0.495). CONCLUSIONS: In patients with high-risk, NASCET-ineligible CA stenosis there was no overall statistically significant cost difference between CEA and CAS. Given that there may not be a cost advantage for either procedure, procedural risk, efficacy, and durability should be key factors in determining the optimal treatment strategy.

Is carotid angioplasty and stenting more cost effective than carotid endarterectomy?

OBJECTIVE: Carotid angioplasty and stenting (CAS) has been advocated as a minimally invasive and inexpensive alternative to carotid endarterectomy (CEA). However, a precise comparative analysis of the immediate and long-term costs associated with these two procedures has not been performed. To accomplish this, a Markov decision analysis model was created to evaluate the relative cost effectiveness of these two interventions. METHODS: Procedural morbidity/mortality rate for CEA and costs (not charges) were derived from a retrospective review of consecutive patients treated at New York Presbyterian Hospital/Cornell (n = 447). Data for CAS were obtained from the literature. We incorporated into this model both the immediate procedural costs and the long-term cost of morbidities, such as stroke (major stroke in the first year = $52,019; in subsequent years = $27,336/y; minor stroke = $9419). We determined long-term survival rate in quality-adjusted life years and lifetime costs for a hypothetic cohort of 70-year-old patients undergoing either CEA or CAS. Our measure of outcome was the cost-effectiveness ratio. RESULTS: The immediate procedural costs of CEA and CAS were $7871 and $10,133 respectively. We assumed major plus minor stroke rates for CEA and CAS of 0.9% and 5%, respectively. We assumed a 30-day mortality rate of 0% for CEA and 1.2% for CAS. In our base case analysis, CEA was cost saving (lifetime savings = $7017/patient; increase in quality-adjusted life years saved = 0.16). Sensitivity analysis revealed major stroke and death rates as the major contributors to this differential in cost effectiveness. Procedural costs were less important, and minor stroke rates were least important. CAS became cost effective only if its major stroke and mortality rates were made equivalent to those of CEA. CONCLUSION: CEA is cost saving compared with CAS. This is related to the higher rate of stroke with CAS and the high cost of stents and protection devices. To be economically competitive, the mortality and major stroke rates of CAS must be at least equivalent if not less than those of CEA.

Maintenance of patency following remote superficial femoral artery endarterectomy.

BACKGROUND: Remote superficial femoral artery endarterectomy (RSFE) is a minimally invasive means of superficial femoral artery revascularisation. It comprises a single groin incision and securing of the distal cut end of atheroma with an intraluminal stent. AIM: To determine medium-term results of RSFE, with particular reference to costs of maintaining patency. METHODS: Stenosis development, and patency of 25 RSFE were compared with 25 randomly selected in situ vein bypasses with similar follow-up (18-33 months). RESULTS: Following RSFE 17 stenoses were identified by duplex surveillance. Half of those arteries patent at 1 yr had stenoses. Angioplasty (PTA) was carried out for 11 stenoses. Four stenoses developed more than 12 months following RSFE. One patient died and nine arteries occluded during follow-up. Primary and primary- assisted patency at 18 months were 31 and 63% respectively. By contrast six stenoses were identified in 25 in situ grafts, all within one year. Four PTAs were carried out. Three grafts occluded. Excluding cost of three monthly duplex surveillance the cost of maintaining RSFE patency was approximately five times that of maintaining in situ bypass patency. CONCLUSION: The initial cost advantage of RSFE is offset by the increased costs of maintaining patency. Duplex surveillance probably needs to be continued indefinitely.

A systematic review of cost-effectiveness research of stroke evaluation and treatment.

BACKGROUND AND PURPOSE: This work was undertaken to review research addressing the cost-effectiveness of stroke-related diagnostic, preventive, or therapeutic interventions. METHODS: We performed searches of MEDLINE, Excerpta Medica online, HealthSTAR, and Sciences Citation Index Expanded and examined the reference lists of the studies and reviews obtained. From these, we selected studies that reported an incremental analysis of cost per effect, in which the effect measure was life-years or quality-adjusted life-years. We abstracted data from each study using a standardized reporting form. Twenty-six articles met the eligibility criteria and were included in the review. RESULTS: The methodological quality of the articles reviewed has improved compared with previously reported. Many stroke evaluation and treatment policies may result in benefits to health that are considered worth their cost. Some interventions were considered cost-ineffective (anticoagulation in low-risk nonvalvular atrial fibrillation and surveillance with duplex ultrasound after endarterectomy). Different studies addressing the cost-effectiveness of screening asymptomatic carotid stenosis resulted in strikingly divergent conclusions, from being cost-effective to being detrimental. Other studies omitted important costs that, if included, would likely have had profound impact on their cost-effectiveness estimates. CONCLUSIONS: Given the divergent conclusions drawn from studies addressing similar questions, it may be premature to use the results of cost-effectiveness research in developing stroke policy and practice guidelines. Successful implementation of such evaluations in the care of patients with stroke will depend on further standardization of methodology and critical appraisal of reported findings.

Changing practice and costs of carotid endarterectomy in Toronto, Canada.

BACKGROUND AND PURPOSE: During our annual audits of carotid endarterectomy (CEA) in Toronto metropolitan hospitals, we have been aware of major changes in the practice of this operation in recent years. To evaluate the effect of changing practice on costs of carotid endarterectomy, we have therefore compared the effects of changes in length of stay, complication rates, and other variables on cost during the last 3 years for which we have complete data. METHODS: We evaluated 757 consecutive patients, of whom 600 had CEA procedures in 3 teaching hospitals, and 190 procedures in 2 community hospitals in metropolitan Toronto. We estimated costs using a specially designed computer program, Transitional System Incorporated, including surgical complications, in patients admitted between January 1994 and December 1996. RESULTS: There was a significant decrease in length of stay in both groups of hospitals, mainly due to preoperative outpatient evaluation but also due to lower complication rates, which probably reflect an increase in asymptomatic surgery in both hospital groups. Costs fell from approximately $8000 per procedure to $5000 in asymptomatic patients and from approximately $10,000 to $7000 in symptomatic patients (Can $). CONCLUSIONS: Major changes in the management of patients undergoing CEA have resulted in a significant decrease in both length of hospital stay and utilization of postoperative intensive care. At the same time, complication rates have significantly fallen, although our mortality and morbidity figures remain slightly higher than those from published multicenter trials. Future changes in surgical practice in Canada, including noninvasive carotid imaging, should produce even lower costs within the next few years.

The effect of a drug and supply cost feedback system on the use of intraoperative resources by anesthesiologists.

UNLABELLED: We performed a randomized, prospective study to evaluate the use of a written feedback system in reducing the intraoperative costs of drugs and supplies used by anesthesiologists. Over 6 mo, 27 anesthesiology residents were randomized to feedback and control groups for their rotations in neurosurgical anesthesia. We recorded the cost of drugs and supplies for three procedures: carotid endarterectomy, lumbar decompression, and cervical decompression. For each study case, members of the feedback group received a written cost analysis showing their performance relative to the departmental average. Members of the feedback group had significantly lower costs for carotid endarterectomies ($79.98 +/- $15.20 vs $97.59 +/- $21.53) and for lumbar decompressions ($56.72 +/- $16.49 vs $76.05 +/- $20.11). The source of savings included lower use rates for propofol and etomidate and for patient warming devices. Analysis of data from recovery areas revealed a trend toward lower patient temperature in lumbar procedures performed by the feedback group. Three months after the feedback period, we collected a follow-up data set in the absence of feedback. This revealed a significant rebound in overall cost by the feedback group for both carotid endarterectomies and lumbar surgery. IMPLICATIONS: This is the first randomized, prospective evaluation of a cost management system in anesthesia. Using resident anesthesiologists, we showed that the written feedback of individualized performance data can be used to lower the overall cost of intraoperative drugs and supplies used for an anesthetic in the absence of mandated clinical guidelines.

Cost-effectiveness of carotid endarterectomy.

Carotid endarterectomy (CEA) reduces the risk of stroke in symptomatic patients with high-grade carotid stenosis. In this study, we evaluated the long-term, societal cost-benefit ratio of endarterectomy using a decision analysis model. We reviewed the results of 150 CEAs performed at an academic center and established a Markov model comparing cohorts of patients who experienced transient ischemic attacks and then underwent observation, aspirin therapy, or CEA. The cost-effectiveness of CEA was estimated using perioperative complication rates from our review and from the North American Symptomatic Carotid Endarterectomy Trial. Stroke and mortality rates were estimated from the literature. Cost estimates were based on medicare reimbursement data. Among the 150 CEAs reviewed, complications included major stroke (0.67%), minor stroke (1.33%), myocardial infarction (1.33%), pulmonary edema (0.67%), and wound hematoma (3.33%). There were no deaths or intracerebral hemorrhages. Using complication rates from our review, CEA produced cost savings of $5730.62 over the cost of observation and $3264.66 over the cost of aspirin treatment. CEA extended the average quality-adjusted life expectancy 15.8 months over that of observation and 13.2 months over that of aspirin. Substituting the North American Symptomatic Carotid Endarterectomy Trial results, CEA yielded savings of $2997.50 over the cost of observation and $531.54 over the cost of aspirin. Quality-adjusted life expectancy was extended 13.8 months compared with observation and 11.2 months compared with aspirin therapy. This analysis demonstrates that when performed with low perioperative morbidity and mortality rates, CEA is a highly cost-effective therapy for symptomatic carotid stenosis and results in substantial societal cost and life savings.

The cost-effectiveness of treatment of short occlusive lesions in the femoropopliteal artery: balloon angioplasty versus endarterectomy.

OBJECTIVE: To compare the short- and long-term outcome and the costs involved in balloon angioplasty (BA) and thromboendarterectomy (EA) of short femoropopliteal occlusions. DESIGN: Retrospective study. PATIENTS AND METHODS: Forty-one lower limbs underwent EA from 1980 until 1988 and BA was performed in 62 limbs between 1988 and 1993. The two groups of patients were well matched for age, gender, cardiovascular risk-factors and the length of the femoropopliteal occlusions. In addition to clinical follow-up colour-Duplex scanning and intraarterial DSA were performed. Complete occlusions or significant restenoses were considered failure of the reconstruction. Actual costs were calculated by the hospital economic administration. RESULTS: The 3-year primary patency in EA patients was 87% and in the BA group 44% (p = 0.0002). Redo procedures were required in seven (17%) patients with EA and in 24 (39%) with BA. Patency after redo procedures, i.e. tertiary patency, was 94% and 74% after 3 years in the EA and BA group respectively (p = 0.14). The mean cost of the primary treatment was higher in EA than in BA patients (p < 0.0001). Mean total treatment costs including the expenses involved with redo procedures were also higher in the group with EA than with BA (p < 0.001). However, the cost-effectiveness expressed as the total costs per month tertiary patency, was not significantly different for the two treatment groups; in patients with EA the ratio of total treatment costs and tertiary patency was NFl 309, and in patients with BA NFl 287. CONCLUSION: Contrary to the general view the expenses associated with surgical treatment are comparable with those of an endovascular procedure, if the costs are expressed as a cost-to-patency ratio.

Evaluating quality, cost-effective health care. Vascular database predicated on hospital discharge abstracts.

This population-based study examines all carotid endarterectomies (CE) performed by all surgeons in a single state over a 10-year period. The methodology is designed to determine morbidity rate, mortality rate, cost, and length of stay, as well as to understand the effect of pre-existing chronic disease, physician, and hospital volume on these outcome variables. The data source consisted of hospital discharge abstract data uniformly collected on all admissions (N = 5.9 million) to acute care hospitals in the state. In the decade 1979 to 1988, 11,199 patients underwent CE. Mortality rate from CE was 2.1%, and the postoperative stroke rate was 3.7% over this period. High physician volume decreased the mortality rate (p less than 0.05) and stroke rate (p less than 0.01) by 50% and significantly (p less than 0.001) reduced hospital cost and length of stay independent of patient complexity. Examination of cost data, adjusted for inflation, showed a decrease in mean cost for CE over the decade. Thus physicians are providing better care for less hospital dollars. Both patient and payor outcome is improved by concentrating CE patients in the hands of high-volume surgeons. Although the data suggests this trend is already evolving, the pace of this evolution can be expected to increase as payors recognize that regionalization of this procedure lowers costs.

Carotid endarterectomy: a ten-year analysis of outcome and cost of treatment.

Between 1978 and 1988, 215 patients with an average age of 67 years, underwent 246 carotid endarterectomies. Two hundred ten (85.4%) patients were symptomatic, and 36 (14.6%) were asymptomatic. Six patients (2.4%) had a postoperative stroke, and all had immediate reoperation. One of these patients died (30 day mortality rate, 0.4% for the series), and two (0.8%) recovered completely, whereas three (1.2%) had a mild permanent neurologic deficit. Two patients (0.8%) had nonfatal myocardial infarction. Mean follow-up of 42.2 months (range, 1 to 126 months) was achieved. At 5 and 8 years actuarial survival rates of 82% and 66% and stroke-free survival rates of 67% and 37% were observed. Actuarial stroke free rates of 90% at 5 and 8 years were noted. By introducing and observing guidelines that required preoperative study of most clearly defined classes of patients before admission for surgical treatment, the average length of stay for carotid endarterectomy was lowered from 9.5 days in the first 5 years of the study to 5.8 days in the second 5 years (p = 0.001). Average hospital charges, expressed in constant dollars, decreased from $3113 in the first 5 years to $2620 in the second 5 years (p = 0.02) despite an 88% inflationary increase in medical consumer price index. This experience shows that the length of hospitalization of patients with carotid endarterectomy can be reduced and the cost of admission lowered without untoward effect on perioperative morbidity and mortality rates.

Cost effectiveness of regional anesthesia in carotid endarterectomy.

The purpose of this prospective study was to assess safety, efficacy, and hospital costs (excluding medications) and laboratory tests related to general (GA) and regional anesthesia (RA) for carotid endarterectomy (CEA). One hundred patients underwent CEA; 50 received GA and 50 received RA. Thirty-eight men (eight diabetic) and 12 women (two diabetic), with an average age of 62.4 (47 to 79) years comprised the GA group; 35 men (six diabetic) and 15 women (one diabetic), with an average age of 64.1 (51 to 74) years comprised the RA group. Twenty-one patients (17 men, 4 women) in the GA and 24 patients (19 men, 5 women) in the RA group had hypertension. Every patient had some stigmata of cardiac disease. Patients receiving GA for CEA spent an average of 1.2 days in the surgical Intensive Care Unit (ICU) and 6.1 days in a regular hospital bed, for an average cost of $4547. The patients who underwent CEA under RA had an average of 0.1 ICU days and 4.1 regular hospital days, for a cost of $2067. RA saved $2480 per patient and $124,000 in our study group, with no increase in mortality or morbidity rates (P less than 0.001). RA is superior to GA in cost-effectiveness for patients undergoing CEA.

Optimal resources for carotid endarterectomy.

This review compares the results and costs of carotid endarterectomy (CE) done by a single surgeon over a 1-year period working at both a university hospital (UH) and a community hospital (CH). Hospital and financial records of 157 patients were reviewed, 78 at UH and 79 at CH. The patient populations were matched for age, associated illnesses, and presenting symptoms. The principles of patient management were identical at both hospitals except that shunting requirements were determined by electroencephalographic monitoring at UH. There were no differences in the complication rates, and the combined stroke/mortality rate was 0.6%. The cost of CE was 56% greater on a per patient basis at UH ($3918 versus $6126, p less than 0.001) and 23% greater on a per diem basis at UH ($611 versus $755, p less than 0.001). Patients stayed longer at UH (8.2 days versus 6.6 days at CH, p less than 0.03). These differences are largely explained by three types of delays at UH. First, patients with cardiovascular accidents at UH were kept in the hospital before surgery until maximum improvement occurred whereas patients at CH were allowed to convalesce at home before CE. Patients operated on after a cardiovascular accident spent an average of 17.6 days in UH while a similar group spent only 7.3 days in hospital at CH (p less than 0.03). Second, delays in obtaining angiograms of greater than 2 hospital days occurred in 28% of patients at UH compared with only 10% at CH (p less than 0.05). Third, delays in scheduling operating room time of greater than 2 hospital days occurred in 17% of patients at UH and in only 7% of patients at CH (p less than 0.05). When there were no delays, the cost of treating patients at each hospital was identical, $3483 at CH and $3520 at UH. UH must accept the fact that equally good results can be obtained at CH, and although the potential exists for equal costs at both types of hospitals, the CH provides the service at a lower cost. UH administrators must address these inefficiences if the UH is to compete effectively in the current marketplace.

A proposed method for using a reimbursement moratorium to encourage recruitment for a randomized study of carotid endarterectomy.

As indicated by Barnett, Plum and Walton, a definitive clinical trial to resolve the issue of the effectiveness of carotid endarterectomy is clearly needed. A proposal to foster such a trial, through a moratorium on third-party reimbursement other than for randomized patients, has herein been presented.

Advocates in vascular controversies.

The cardiovascular surgeon may find bibliographic support for his or her particular therapeutic bias for almost any controversial clinical problem. Such management dilemmas are not unique to vascular surgery in particular or surgery in general but reflect much of the field of medicine. Therapeutic controversies usually represent our ignorance of the natural history of disease or the deficiencies in our knowledge of the efficacy of medical or surgical therapy. While prospective epidemiologic studies or randomized blind clinical trials should be the optimal basis for our therapeutic decisions, how much of medical practice can lay claim to such a foundation? This panel debate represents a programmatic attempt to accomplish what each of us should, but often fails to, do in reaching a clinical therapeutic decision in the face of controversial alternatives: namely, objectively search one's experience and the available literature, pro and con. This approach proved very popular to those attending the meeting of the Southern Association for Vascular Surgery. The audience was greeted with the fruits of labor of the panelists who had taken their charge seriously. As advocates of their particular position in the therapeutic arguments, each panelist had carefully reviewed the pertinent literature, much of which is subject to the deficiencies and bias that are reflected in our clinical approach to these problems. Indeed, some of the advocates used the same literature references to support their opposing sides of the argument. Nevertheless, the eloquence and intensity of each presentation heightened the interest and understanding of the audience to these controversies. The annotated bibliography left a tangible document of the effort that had been expended in this debate. One hopes that out of our increased recognition of the fallibility of some of our therapeutic approaches to vascular controversies will come future efforts to base our clinical decisions on the results of epidemiologic studies or properly designed clinical trials.