One-day surgery for endovascular repair, made possible by good patient selection and planning, is “safe and cost-effective” according to a talk given by Peter Schneider, Honolulu, USA, at the 2016 Controversies and Updates in Vascular Surgery meeting (CACVS, 21–23 January, Paris, France).
Schneider reported on his experiences of one-day surgery in Hawaii, telling delegates that, if it can be achieved safely and with good results, one-day surgery can offer greater patient comfort and a more efficient use of hospital resources.
Outpatient and office peripheral vascular interventions are increasing in popularity in the USA. From 2006–2011, the age- and sex-adjusted rate of interventions per 100,000 Medicare beneficiaries rose from 184.7 to 228.5 for outpatient procedures, and from 6 to 37.8 for office-based labs. Over the same period, inpatient interventions fell from 209.7 to 151.6 per 100,000 Medicare beneficiaries. Thus by 2011, there were 1.8 times as many peripheral vascular reconstructions performed as outpatients.
The move towards endovascular surgery also continued from 2006–2011, with five times more endovascular than open procedures being performed. Peripheral interventions increased 5% over these five years, while the use of open surgery for lower extremity revascularisation decreased by 31%.
Schneider told the audience that these changes are being driven by vascular surgeons, the percentage of interventions performed by vascular surgeons increasing from 37.2% in 2006 to 45% in 2011. While the percentage performed by cardiologists has stayed relatively stable (41.3% in 2006 and 42.2% in 2011), radiologists have seen their share fall from 21.5% to 12.9% in the same period.
A wide range of procedures are now being performed as one-day surgeries in the USA, according to Schneider. “For arterial procedures (subclavian, iliac, superficial femoral artery and below-the-knee), varicose vein surgery, dialysis access creation and revision, and embolisations, in our practice more than 90% of patients are now treated as outpatients,” he said. For some patients, including those with active cardiac/pulmonary decompensation, significant dementia, bleeding diathesis and active requirement for anticoagulation, one-day surgery is still unsuitable. This is also the case for endovascular aneurysm repair, carotid and renovascular disease patients, “mainly because these patients need blood pressure control,” Schneider noted.
Successful one-day surgery requires detailed pre-procedural planning, not just clinically but also logistically. Given that Hawaii is made up of eight main islands and that one third of Schneider’s patients come from neighbouring islands, this preparation is made even more important. These include identifying a companion to accompany the patient (and possibly for the patient to live with, at least temporarily), organising any necessary flight arrangements to neighbouring islands and scheduling follow-up phone calls to check on progress.
For the procedure itself, local anaesthesia with sedation is used. Ultrasound guidance and micropuncture allow for “perfect access” while a closure device and stitch at the puncture site allow for “perfect closure”, Schneider said. “If you do not have perfect access and perfect closure,” he continued, “do not send the patient home on the same day”. He told the audience that previous studies show that ultrasound guidance with a retrograde femoral approach can reduce complication rates to as low as 3.4%.
“The ultrasound guidance also helps us not just to reduce complications but also to use closure, which we use on pretty much every peripheral vascular intervention that we send home,” Schneider explained to delegates. He cited a 2004 study—one of “many” studies— indicating that collagen plugs and suture mediated devices were better than manual compression for closure, resulting in a 26% reduction in complications overall, with a 38% reduction with collagen plug usage.
One-day surgery offers hospital cost benefits as well as patient clinical benefits, with costs significantly lower for ambulatory/outpatient “whether the procedure is performed in the operating room or radiology suite,” Schneider explained. This, he said, “is the primary driver for us.” Schneider’s team have “a tremendous shortage of hospital beds” and “a day in the hospital costs about US$3,600”, hence the attraction of being able to send a patient home (providing that they stay for at least four hours post-procedure and are ambulatory) on the same day as surgery.
A 2008 study in the Journal of Vascular Surgery showed that inpatient procedures cost US$7,331±US$764 or US$12,278±US$595 in the radiology suite and operating room, respectively, compared with US$5,714±US$245 and US$7,591±US$616 for ambulatory patients in radiology suites and operating rooms, respectively (p<0.001). More recently, a 2015 study published in the Journal of the American College of Cardiology showed that for atherectomy, stenting and angioplasty, outpatient interventions reduced costs by approximately 50% when compared with inpatient interventions.
Schneider closed by touching on office-based labs. In the USA, “there has been a big move towards office-based labs,” Schneider told the audience, which he described as “a really interesting phenomenon”. He gave the example of one group in Kalamazoo, USA, for whom 13% of procedures were peripheral vascular, half of which were interventions. Complication rate was 5.2% for patients undergoing peripheral interventions, most of which were a result of bleeding or clotting.