title: Clinical and economic outcomes of embolic complications and strategies for distal embolic protection during percutaneous coronary intervention in saphenous vein grafts.
abstract: BACKGROUND
  Although distal embolic protection (DEP) is increasingly utilized in saphenous vein graft percutaneous coronary intervention (SVG PCI), the clinical and economic outcomes of different DEP strategies are unknown.
  
  
  METHODS
  We compared 3 DEP strategies (no DEP, routine DEP, selective DEP in high-risk cases) in 126 consecutive cases of SVG PCI performed without DEP in a single catheterization laboratory over a 4-year period. No SVG PCI was excluded. High risk was defined using 2 multivariate predictors of embolic complication previously validated by NCDR (graft age greater than or equal to 8 years and or friable appearance with thrombus). Costs were determined by a ratio of cost-to-charges methodology and average cost of the two FDA-approved DEP devices ($1,350) with similar efficacy.
  
  
  RESULTS
  Without DEP, the incidence of embolic complications was 17% (22/126), resulting in major adverse coronary events (MACE) in 3.2% (4/126) of all cases: 2 deaths, 1 myocardial infarction, and 1 emergency coronary artery bypass. Embolic complications significantly increased both procedure costs by $2,725 (p < .001) and total hospital costs approximately $2,800 (p < 0.05). Risk adjustment for selective DEP use correctly predicted 86% (19/22) of embolic complications, including all MACE, at an incremental cost of $684 per patient for selective DEP versus $1,150 per patient for routine DEP. Selective DEP would cost $43,127 per death prevented versus $72,461 using routine DEP during the index hospitalization.
  
  
  CONCLUSIONS
  Embolic complications increase cost in excess of the cost of a DEP device. This risk adjustment model correctly predicted the majority of cases of embolic complication and all MACE, suggesting that selective DEP use may help reduce utilization of DEP by an almost 50% cost reduction compared to routine use.
authors.affiliation: Section of Cardiology, Rush University Medical Center, Chicago, Illinois, USA.
authors.forename: Shaun R
authors.initials: SR
authors.lastname: Senter
authors.forename: Sandeep
authors.initials: S
authors.lastname: Nathan
authors.forename: Akshay
authors.initials: A
authors.lastname: Gupta
authors.forename: Lloyd W
authors.initials: LW
authors.lastname: Klein
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects*; D015331:Cohort Studies; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D003365:Costs and Cost Analysis; D004617:Embolism / Q000191:economics* / Q000209:etiology* / Q000517:prevention & control; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000628:therapy*; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D011315:Preventive Medicine / Q000379:methods; D012189:Retrospective Studies; D012501:Saphenous Vein / Q000637:transplantation*; D016896:Treatment Outcome