Eur J Cardiothorac Surg 2007;32:186-187. doi:10.1016/j.ejcts.2007.03.029
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Detecting the Ademkiewicz artery: is it really necessary in everyday practice?
Narcis Hudorovi
*
Department of Endo and Vascular Surgery, University Hospital "Sestre Milosrdnice", Zagreb, Croatia
Received 24 February 2007;
accepted 19 March 2007.
* Corresponding author. Address: University Department of Surgery, University Hospital "Sestre Milosrdnice", Vinogradska 29, 10000 Zagreb, Croatia. Tel.: +385 1 46 40 774; fax: +385 1 38 62 292. (Email: narcis.hudorovic{at}zg.htnet.hr).
Key Words: Cost-effectiveness • Radiology and radiologists • Socioeconomic issues • Computed tomography • Angiography
In the article by Nojiri et al. [1], the authors study 13 patients with aneurysms and 14 patients with dissection of the descending thoracic or thoracolumbar aorta, who underwent sophisticated combined method of aortography and intra-arterial contrast injection angiography (IA-CTA) to depict the artery of Ademkiewicz (arteria radicularis magna (ARM)). Their results are similar with results obtained by the groups from Osaka, Iwate and Sapporo (Japan), and published a few years ago [2–4].
Concerning procedural safety and improving procedural results there is no statistically significant difference between IA-CTA and general selective angiography (GSA) in the preoperative assessment of ARM.
Moreover, as the authors stated, the incidence of complications by GSA is much lower than IA-CTA.
In this era of evidence-based care and limited resources any intervention by necessity must be both clinically effective and cost-effective [5]. Unfortunately, all above-mentioned articles are fraught with several major flaws for surgical ‘real-world’, as follows:
- 1. The authors did not point out the metrics for analysis of efficient cardiovascular imaging which include relative cost of the different modalities; the relative strength of test performance characteristics; comparative availability of evidence for the individual modality; risk from the procedure; variance in local availability and quality; consideration of patient preferences and comfort.
- 2. The authors did not compare the target values for DSA and the target values for IA-CTA. That would be attainable if EVAR is considered as the only treatment option. With the assumptions that IA-CTA involves minimal risk and could lead to incorrect recommendations for treatment, DSA would always be more cost-effective than IA-CTA, if both endovascular aneurysm repair (EVAR) and open surgical repair (OSR) are considered as treatment options.
- 3. If, however, we assume that IA-CTA involves no risks and has diagnostic accuracy that is comparable to that of DSA, then IA-CTA would be more cost-effective than DSA. In terms of developing new imaging modalities, it is important that the new modality has a fairly low cost and high sensitivity for the detection of cardiovascular pathology. There is no evidence of such data and statistical approaches to provide valid information of that topic.
- 4. The study does not consider international health care circumstances such as the expertise of the radiologists and the availability of equipment. For that reason the presented imaging modality is in the same range as MR angiography and DSA, or could only be experimental.
- 5. In the current study the cost-effectiveness of an imaging modality that fulfills the target criteria with the currently used modality in a pragmatic empirical setting is not determined. In such setting the costs incurred by performing the imaging examination must include the confidence of the physician in the examination result, and the patients and/or the physicians preferred imaging modalities.
- 6. A final limitation is that the authors failed to assume that the society's willingness to pay (i.e., amount of money society willing to pay for one additional QALY) could be defined.
Finally, the use of preoperative imaging modalities to depict the Ademkiewicz artery for the purposes of improving procedural safety is unnecessary in the era of thoracic endovascular aneurysm repair (TEVAR) and it is in controversy with published results by TEVAR trials, SVS Lifeline Registry and VA National Surgical Quality Improvement Programme.
References
- Nojiri J, Matsumoto K, Kato A, Takahiro M, Furokawa K, Ohtsubo S, Itoh T, Kudo S. The Ademkiewicz artery: demonstration by intra-arterial computed tomographic angiography. Eur J Cardiothorac Surg 2007;31:249-255.[Abstract/Free Full Text]
- Koshino T, Murakami G, Morishita K, Mawatari T, Abe T. Does the Ademkiewicz artery originate from the larger segmental arteries?. J Thorac Cardiovasc Surg 1999;117:898-905.[Abstract/Free Full Text]
- Yoshioka K, Niinuma H, Ohira A, Nasu K, Kawakami T, Sasaki M, Kawazoe K. MR angiography and CT angiography of Ademkiewicz: noninvasive preoperative assessment of thoracoabdominal aortic aneurysm. Radiographics 2003;23:1215-1225.[Abstract/Free Full Text]
- Yamada N, Okita Y, Minatoya K, Tagusari O, Ando M, Takamiya M, Kitamura S. Preoperative demonstration of the Ademkiewicz artery by magnetic resonance angiography in patients with descending or thoracoabdominal aortic aneurysms. Eur J Cardiothorac Surg 2000;18:104-111.[Abstract/Free Full Text]
- Patel MR, Spertus JA, Brindis RG, Hendel RC, Douglas PS, Peterson ED, Wolk MJ, Allen MJ, Rasin IE. ACCF proposed method for evaluating the appropriateness of cardiovascular imaging. JACC 2005;46:1606-1613.[Free Full Text]
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J. Nojiri, T. Itoh, and S. Kudo
Reply to Hudorovic
Eur. J. Cardiothorac. Surg.,
July 1, 2007;
32(1):
187 - 187.
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