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OBJECTIVES: The acutely symptomatic, thrombosed filter-bearing IVC has been shown to respond well to multimodality endovascular therapy (MMET). In this report, we define the clinical efficacy, physician work effort, utilization of institutional resources and costs associated with this practice.
METHODS: Hospital clinical and financial records of six consecutive patients (4 males, 2 females; age range 45 - 67 years), managed by a single endovascular surgeon at a single institution over a period of 30 months who were treated by MMET for IVC recanalization in the presence of an IVC filter were reviewed. Modalities used for treatment, number of trips to the interventional suite, clinical outcome, ratio of institutional treatment cost/ total cost of care, and physician time and physician wRVUs associated with management were recorded. RVUs were tabulated based upon the 2012 National Physician Fee Schedule Value File, July 2012 release.
RESULTS:
Clinical success was achieved in 5 of 6 patients overall but in 100% of those who completed therapy. Grade III (complete lysis) patency was achieved in 4 patients, 2 procedures each in 2 patients and 3 procedures each in 2 patients. Grade II (50-90%) lysis was achieved in 1 patient having 2 procedures. One patient with metastatic carcinoma and advanced phlegmasia opted for withdrawal of support and hospice without completing therapy. Modalities included catheter-directed, ultrasound-assisted thrombolysis in 6 patients, mechanical thrombectomy and aspiration in 4, balloon venoplasty in 3, trans-filter stent placement in 1, and filter retrieval/replacement in 2. Mean total of all procedural (in-room) time per patient was 240 minutes (range:130 to 334) and mean total procedural wRVUs accumulated for the care rendered was 32.55/patient (range:24.65 to 47.95). Estimated mean total consultative/rounding time was 222 minutes per patient (range: 160 to 290) and accounted for 9.57 wRVUs/patient (range:6.88 to 11.47). Institutional costs per case are shown in the table below. The ratio of mean costs directly related to IVC recanalization/total mean costs was 0.33 (range: 0.19 to 0.61).Contribution to margin was negative in 4 of 6 cases.
CONCLUSIONS: MMET represents highly-efficacious first-line therapy for catastrophic venous disorders; however, as demonstrated in the present focused experience with thrombosis of the filter-bearing IVC, the practice is resource intensive and undervalued.