Hasan H Dosluoglu1, Purandath Lall2, Raphael Blochle3, Linda M Harris3, Maciej L Dryjski3. 1. Division of Vascular Surgery, Veterans Affairs Western New York Healthcare System, Buffalo, NY; Division of Vascular Surgery, Department of Surgery, State University of New York at Buffalo, Buffalo, NY. Electronic address: dosluoglu@yahoo.com. 2. Division of Vascular Surgery, Veterans Affairs Western New York Healthcare System, Buffalo, NY; Division of Vascular Surgery, South West Regional Health Authority, San Fernando, Trinidad and Tobago. 3. Division of Vascular Surgery, Department of Surgery, State University of New York at Buffalo, Buffalo, NY.
Abstract
OBJECTIVE: Percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) has been associated with fewer groin wound complications and shorter operative times, but same-day discharge (SDD) has not been reported. The goal of our article is to assess the feasibility and safety of ambulatory PEVAR and identify patient characteristics that are eligible for this approach. METHODS: Consecutive patients who underwent elective endovascular abdominal aortic aneurysm repair (EVAR) between March 2011 and December 2012 were reviewed. SDD was discussed during the preoperative visit with patients who were functionally independent, without significant comorbidities, and had favorable anatomy. These patients were given the option to be discharged in the evening of the PEVAR after 6 hours of bed rest if the procedure was uneventful. Causes for discharge delay and early outcomes were analyzed. RESULTS: During the study period, 79 patients underwent abdominal aortic aneurysm (AAA) repair, 64 of whom (mean age, 70.2 ± 9.9; range, 59-97) had elective EVAR (3 ruptures, 5 acute presentations, 3 fenestrated EVARs, 4 elective open AAA repairs were excluded). Fifty-three patients (83%) had bilateral percutaneous access, seven had unilateral percutaneous (11%) access, and the remaining four (6%) had bilateral femoral endarterectomies. The percutaneous closure success rate was 96% in 113 attempts (three conversions for inadequate hemostasis, one for inability to deploy device). Mean length of stay was 1.3 ± 1.4 days (median, 1 day) with no 30-day mortality. Twenty-one patients (33%) were discharged the same day (SDD group), 24 (37%) on postoperative day (POD) 1, 16 (25%) on POD 2/3, and 3 (5%) stayed ≥ 4 days. One patient in the SDD group was readmitted on POD 3 after EVAR for severe postimplantation syndrome. Of the 23 patients who were discharged on POD 1, 10 were kept overnight due to severe chronic obstructive pulmonary disease, coronary artery disease, or advanced age, three transportation issues, two inability to void, two patient preference, two for renal protection, and four due to unplanned femoral cutdown. Patients in the SDD group were significantly younger (66.5 ± 5.4 years vs 72.0 ± 10.6 years; P = .029), had smaller AAAs (5.3 ± 0.5 cm vs 5.9 ± 1.0 cm; P = .013), less blood loss (115 ± 90 mL vs 232 ± 198 mL; P = .012), and shorter operating time (79 ± 24 minutes vs 121 ± 73 minutes; P = .013). There were fewer American Society of Anesthesiologists 4 patients in the SDD group (24% vs 48%; P = .056). The majority (81%) of patients in all groups had general anesthesia (86% vs 79% SDD vs others; P = .523). CONCLUSIONS: Ambulatory PEVAR was found to be feasible and safe in one-third of patients undergoing elective EVAR who did not have excessive medical risk, had good functional capacity, and underwent an uneventful procedure. The impact of SDD on cost-effectiveness needs to be further assessed and may not be feasible in hospitals reimbursed based on admission status.
OBJECTIVE: Percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) has been associated with fewer groin wound complications and shorter operative times, but same-day discharge (SDD) has not been reported. The goal of our article is to assess the feasibility and safety of ambulatory PEVAR and identify patient characteristics that are eligible for this approach. METHODS: Consecutive patients who underwent elective endovascular abdominal aortic aneurysm repair (EVAR) between March 2011 and December 2012 were reviewed. SDD was discussed during the preoperative visit with patients who were functionally independent, without significant comorbidities, and had favorable anatomy. These patients were given the option to be discharged in the evening of the PEVAR after 6 hours of bed rest if the procedure was uneventful. Causes for discharge delay and early outcomes were analyzed. RESULTS: During the study period, 79 patients underwent abdominal aortic aneurysm (AAA) repair, 64 of whom (mean age, 70.2 ± 9.9; range, 59-97) had elective EVAR (3 ruptures, 5 acute presentations, 3 fenestrated EVARs, 4 elective open AAA repairs were excluded). Fifty-three patients (83%) had bilateral percutaneous access, seven had unilateral percutaneous (11%) access, and the remaining four (6%) had bilateral femoral endarterectomies. The percutaneous closure success rate was 96% in 113 attempts (three conversions for inadequate hemostasis, one for inability to deploy device). Mean length of stay was 1.3 ± 1.4 days (median, 1 day) with no 30-day mortality. Twenty-one patients (33%) were discharged the same day (SDD group), 24 (37%) on postoperative day (POD) 1, 16 (25%) on POD 2/3, and 3 (5%) stayed ≥ 4 days. One patient in the SDD group was readmitted on POD 3 after EVAR for severe postimplantation syndrome. Of the 23 patients who were discharged on POD 1, 10 were kept overnight due to severe chronic obstructive pulmonary disease, coronary artery disease, or advanced age, three transportation issues, two inability to void, two patient preference, two for renal protection, and four due to unplanned femoral cutdown. Patients in the SDD group were significantly younger (66.5 ± 5.4 years vs 72.0 ± 10.6 years; P = .029), had smaller AAAs (5.3 ± 0.5 cm vs 5.9 ± 1.0 cm; P = .013), less blood loss (115 ± 90 mL vs 232 ± 198 mL; P = .012), and shorter operating time (79 ± 24 minutes vs 121 ± 73 minutes; P = .013). There were fewer American Society of Anesthesiologists 4 patients in the SDD group (24% vs 48%; P = .056). The majority (81%) of patients in all groups had general anesthesia (86% vs 79% SDD vs others; P = .523). CONCLUSIONS: Ambulatory PEVAR was found to be feasible and safe in one-third of patients undergoing elective EVAR who did not have excessive medical risk, had good functional capacity, and underwent an uneventful procedure. The impact of SDD on cost-effectiveness needs to be further assessed and may not be feasible in hospitals reimbursed based on admission status.
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