Safety and cost savings of endovascular procedures: are outpatient interventions feasible when combined with open surgery?

As increasing experience and comfort with endovascular interventions performed in an outpatient setting has occurred, the safety and cost effectiveness of performing these procedures without an overnight stay were analyzed, especially when endovascular procedures were combined with open vascular operations requiring an arteriotomy and surgical closure. Ninety patients underwent endovascular procedures alone or concomitantly with open, minor vascular operations to salvage a failing graft between February 1994 and June 1999. Patients undergoing endovascular interventions during primary lower extremity bypass or other major surgical procedures were not included in this review because they were not candidates for outpatient procedures. Balloon angioplasty alone (79) or angioplasty with stent placement (11) was performed to treat stenoses in 50 failing grafts, 16 iliac, 14 femoral, 5 tibial, and 5 axilla/subclavian arteries. A significant increase in outpatient procedures was accomplished as more experience was garnered with these techniques: 19% (8/42) between 1994 and 1996 vs 57% (28/48) between 1997 and 1999 (p = 0.001). Age and comorbidity did not play a role in determining the need for admission because there were no significant differences in patients with diabetes mellitus, hypertension, smoking, or hyperlipidemia and those admitted or discharged the same day (p > 0.05). Patients admitted for overnight observation tended to have longer mean operative times and more complex revascularizations than outpatients (110 vs 69 min, respectively; p < 0.0001). Twenty-seven patients underwent surgical exposure of the access vessel: 63% (17) were admitted and 37% (10) were discharged the same day. Sixty-three patients underwent a percutaneous procedure: 42% (27) were admitted and 58% (37) were discharged the same day. Outpatients were more likely to receive only local anesthesia (83%; 30/35) compared to patients admitted overnight (67%; 36/53); the remaining patients received spinal or epidural anesthesia. Complications included graft thrombosis within 30 days in 6% (5/90) of patients and arterial graft infection in 2% (2). No patient required surgery for bleeding. The average charges for outpatient interventions were $1980 compared to $10,026 for patients who stayed overnight (p < 0.0001). As vascular surgeons become more experienced and comfortable with outpatient endovascular procedures, especially when performed in combination with open minor vascular surgery, significant cost savings can be realized without sacrificing patient safety. Even when open surgical exposure is planned, patients should be instructed preoperatively to anticipate discharge the day of their procedure to minimize resistance to this strategy.