Ambulatory Percutaneous Endovascular Abdominal Aortic Aneurysm Repair

Abstract

with open repair; however, concerns about long-term durability remain. This analysis evaluated the incidence of secondary interventions (SI) after TEVAR and determined functional outcomes and survival.Methods: A retrospective review was completed of all TEVAR patients from 2004 to 2011. Patients with SI were further analyzed. A validated questionnaire (Eastern Cooperative Oncology Group score) was used to assess ability to perform activities of daily living. Kaplan-Meier analysis was used to estimate survival.Results: Of 587 patients, 78 (13%) required SI at median Ϯ standard deviation of 4.7 months (11.5 Ϯ 16.5, Fig 1). Seventeen (22%) underwent multiple SI. Forty (6.8%) initially underwent endovascular revision, with six (15%) requiring subsequent open reintervention. Thirty-eight (6.5%) initially had open revision, with six (16%) requiring subsequent endovascular remediation. Median time to endovascular SI was 7.6 months (16.0 Ϯ 18.8), which was significantly longer than time to open SI (1.9; 6.9 Ϯ 12.3 months; P ϭ .01). SI incidence differed significantly amongst various indications (P ϭ .005): acute dissection (24.7%), chronic dissection (16.5%), degenerative aneurysm (14.1%), traumatic transection (8.3%), penetrating ulcer (1.5%), and other miscellaneous (thoracoabdominal aneurysms, mycotic aneurysms, pseudoaneurysms, 17.8%. Most common indications for SI after acute/chronic dissection were persistent false lumen perfusion and/or proximal/distal extension of disease, whereas for degenerative aneurysms, SI was performed primarily to treat type I/III endoleaks. SI patients had more comorbidities (P Ͻ .0001) and greater number of postoperative complications after the index TEVAR (P Ͻ .0001) compared with those without SI. No survival difference was noted between the groups (SI vs No SI; P ϭ .93; Fig 2). At median follow-up of 20.4 months (range, 6-52 months), functional status was significantly better among patients first treated with endovascular SI compared with open revision (Eastern Cooperative Oncology Group scale: 1.7 Ϯ 2.1 vs 2.7 Ϯ 2.1; P ϭ .04).Conclusions: SI after TEVAR is common, particularly amongst patients treated for acute dissection, which underscores the need for vigilant surveillance. Although significant functional impairment is noted after SI for TEVAR, patients can be successfully treated with open and endovascular techniques with no significant increase in long-term mortality.

Potential clinical feasibility and financial impact of same-day discharge in patients undergoing endovascular aortic repair for elective infrarenal aortic aneurysm

“…In our earlier VA study, one third of patients were safely discharged within 6 hours postoperatively. 11 Our current study reaffirms these results; 42% of our sample had an uncomplicated postoperative course and used standard monitoring services only. These individuals would be candidates for early discharge.…”

“…Through prospective screening by these criteria, we safely discharged one third of patients within 6 hours of EVAR. 11 It has been well established that SDD or discharge by the first POD is associated with significant reduction in costs compared with a longer LOS. 9,10 However, it remains unanswered whether SDD is significantly less costly than overnight hospitalization.…”

Preoperative Methylprednisolone Enhances Recovery After Endovascular Aortic Repair

“…10 A technically successful EVAR should lead to a length of stay (LOS) of about 1 to 2 days even in high-risk patients if the increased organ demands due to SIRS could be eliminated. In this context, the literature is inconclusive because some centers have reported a short LOS and even an outpatient procedure in selected EVAR patients 11,12 in contrast to other reports of LOS of more than 4 days. 4,5,9,13,14 Several trials have demonstrated a reduction in the inflammatory response, postoperative nausea and vomiting, and pain by administration of preoperative glucocorticoids.…”

Tratamento Endovascular do Aneurisma da Aorta Abdominal por Via Percutânea e Anestesia Local – One Day Surgery

“…15,16 Numa tentativa de otimizar este período de internamento, e uma vez que a grande maioria das complicações do acesso percutâneo têm sido documentadas intraoperatoriamente ou nas primeiras após o procedimento, estudos para avaliar a eficácia e segurança do pEVAR em ambulatório têm vindo a ser conduzidos. 4,16,17 Um estudo por Dosluoglu et al 16 visou avaliar a possibilidade de ambulatorização dos doentes com aneurisma da aorta abdominal (AAA) tratados por EVAR. A sua série demonstrou que aproximadamente 33% dos doentes tratados por pEVAR podem ter alta para o domicílio com segurança depois de um período de observação de 6 horas, desde que o procedimento tenha decorrido sem complicações, apresentem boa capacidade funcional e não sejam portadores de comorbilidades de risco.…”

“…Para esta baixa taxa de ambulatorização contribuiu largamente a técnica anestésica escolhida, uma vez que a grande maioria dos doentes (81%) foi intervencionada sob anestesia geral, limitando este processo. 16 Com base nestas informações, e tendo em conta a possibilidade real de ocorrência de complicações arteriais tardias, assim como a própria preferência do doente, instituiuse no nosso departamento um protocolo ambulatorial de pEVAR pela técnica de Preclose, sob anestesia local, com uma pernoita após intervenção, num modelo de one day surgery.…”