Ambulatory EVAR an Option for One-Third of AAA Patients
Same-day discharge is safe and feasible in about one-third of patients who undergo endovascular abdominal aortic aneurysm repair (EVAR) with a percutaneous closure device, according to a study published online August 23, 2013, ahead of print in the Journal of Vascular Surgery.
Hasan H. Dosluoglu, MD, of the Veterans Affairs Western New York Healthcare System (Buffalo, NY), and colleagues looked at 64 male veterans who underwent abdominal aortic aneurysm (AAA) repair with elective percutaneous EVAR from March 2011 to December 2012. Same-day discharge after 6 hours of bed rest was considered an option for patients who had uneventful procedures, were functionally independent, were without substantial comorbidities, and had favorable anatomy.
One in 3 Patients Safely Discharged Same Day
Mean aneurysm diameter was 5.7 ± 0.9 cm. Most patients (84%) had bilateral percutaneous attempts, while 11% had unilateral percutaneous access and 5% had bilateral femoral endarterectomies. The success rate for percutaneous EVAR was 96% for attempted closures and 94% for patients who underwent bilateral procedures. The majority (81%) of procedures used general anesthesia and the following grafts:
- Endurant (16%; Medtronic, Minneapolis, MN)
- Zenith (25%; Cook Medical, Bloomington, IN)
- Excluder (27%; Gore, Newark, DE)
- AFX (33%; Endologix, Irvine, CA)
One-third (33%) of patients were discharged on the same day as their procedure, while 36% went home the day after, 27% between days 2 and 3, and 5% between days 4 and 6. The mean length of stay was 1.3 ± 1.4 days and mean ICU stay was 0.1 ± 1.1 days. There was no 30-day mortality and only 1 unplanned readmission.
Reasons for patients being required to stay overnight were poor medical condition (eg, COPD or ischemic cardiomyopathy), transportation issues, patient preference, inability to void, poor renal function, and femoral cutdown.
Postoperative complications were observed in 17% of patients, the most common being urinary retention (6%) and postimplantation syndrome (23%).
After a mean follow-up of 8.3 months, there were no aneurysm-related deaths. No type I or III endoleaks were seen, but 4 type II endoleaks persisted after 6 months. One patient presented with left leg embolization and 1 patient started dialysis at 15 months.
“Our study showed that about one-third of patients who undergo EVAR can be safely discharged home after a 6-hour observation period, despite the use of general anesthesia in the majority of patients,” Dr. Dosluoglu and colleagues write. “With more widespread [percutaneous EVAR] and decreased device profiles of available EVAR devices, this approach is likely to become more attractive.”
They caution, however, that because the technique has a “steep learning curve,” percutaneous EVAR should not be performed by operators who are still learning.
The main advantage of percutaneous EVAR over femoral cutdown is that it leads to “fewer groin wound complications, decreased operative time, and decreased time to ambulation,” the investigators note. The technique is also likely to reduce readmission rates, they add.
Cost-Effectiveness the Next Question
“One potential concern of sending patients home on the same day is life-threatening bleeding or limb ischemia after discharge,” the authors acknowledge. “[But in] our experience, all percutaneous failures occurred in the OR, with no patient returning to the OR in the early or late postoperative period, similar to previous reports.”
They emphasize, however, that ensuring hemostasis and pedal perfusion is essential before considering same-day discharge.
According to Dr. Dosluoglu and colleagues, device cost is the main component driving the overall cost of EVAR, and the associated decreases in duration of surgery, ICU and overall length of stay, blood product usage, and laboratory tests do not adequately counteract these costs. “Since device costs are outside of surgeons’ control, decreasing [length of stay] remains the main component on which cost decrease can be accomplished,” they say.
The authors estimate that same-day discharge is feasible in about 40% of EVAR cases “if transportation and home issues are resolved preoperatively.” The remainder of patients are unlikely to be discharged the same day “as their factors for hospitalization are not modifiable, or in some cases, [are] unpredictable.”
Dr. Dosluoglu and colleagues note that until the Centers for Medicare and Medicaid Services allows reimbursement for outpatient percutaneous EVAR, the procedure may not be financially feasible in private sector hospitals.
Patients discharged the same day as the procedure were younger, had smaller aneurysms and less blood loss, and required less operating time. There were fewer American Society of Anesthesiologists class 4 patients among those discharged on the same day and fewer on home oxygen than patients discharged on post-operative day 1. In addition, all same-day discharge patients had successful total percutaneous EVAR.
Dosluoglu HH, Lall P, Blochle R, et al. Ambulatory percutaneous endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2013;Epub ahead of print.
- Dr. Dosluoglu reports no relevant conflicts of interest.