The case for day-case EVAR: Benefits and challenges

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This article is an advertorial by Lombard Medical.

Endovascular aneurysm repair (EVAR) is an established treatment modality in vascular practice which continues to develop, as new devices and technology continuously provide a greater range of options for the treatment of aneurysm patients. Implementing day-case EVAR into practice can further enable clinicians to increase patient satisfaction and quality of life.

Rachel Bell, a vascular surgeon at Guy’s and St Thomas’ NHS Foundation Trust (London, UK), notes that “in general, most patients and their families prefer a day-case procedure, as they would like to be able to recover in the comfort of their own home.” Bell adds, “Lots of patients have worries about spending time in hospital, and being able to go home at the end of the day allay these concerns and improves their quality of life.”

Beyond the comfort of the patient, Bell also points to “obvious clinical benefits” including reduction in hospital acquired infections and reduction in the incidence of deep venous thrombosis or pulmonary embolism, which can occur as patients stay immobile in the hospital. “There is no doubt,” Bell says, “that day-case procedures encourage patients to be more mobile after surgery and help them to recover more quickly. It is common for older patients to suffer some functional decline when they have been an in-patient in hospital, and day surgery would go some way to reducing that and encourage patients to get back to normal life as quickly as possible.”

Grainne Nicholson, vascular anaesthetist at St George’s University Hospitals in London, UK, agrees: “Provided the selected patients were informed about what to expect and reassured that their care will be of the highest standard, day-case EVAR may improve patient satisfaction and quality of life. In general, patients prefer to be at home rather than in hospital.”

Nicholson further points out, “Implementation of a day-case EVAR process could potentially improve service provision, as the whole in-hospital process is streamlined, suitable patients are identified, operated on early and discharged early. Reducing the length of time any patient spends as an in-patient will have a direct cost-saving effect.”

This impact on cost as well as efficiency is an important factor, particularly in centres where bed space is a rare resource. For vascular surgeon David Murray (Manchester University NHS Foundation Trust, Manchester, UK), the main benefit of day-case EVAR is the “reduction in requirement and cost for high dependency or monitored bed days and in-patient bed days per case.” Similarly, Bell acknowledges there are “enormous pressures on most hospitals’ bed capacity, particularly over the winter months”, a problem which can be alleviated with the implementation of day-case EVAR. “However it is necessary to ensure that we provide appropriate support for the day-case patients to ensure that they are safe and appropriately supported at home, with good lines of communication to the hospital team if required”, Bell says.

Patient selection

Murray and Nicholson both place an emphasis on the importance of patient selection for day-case EVAR, with Murray arguing that patient education is paramount. He explains, “We select patients for day-case EVAR on a number of parameters. We select anatomically straightforward abdominal aortic aneurysms for EVAR, with good access and friendly common femoral arteries for percutaneous EVAR. We exclude chronic kidney disease stage 4 and 5 patients, and patients with more than 30 minutes’ travel time to the hospital. Selected patients must also buy in to the concept and be motivated. We offer local and general anaesthesia depending on patient preference and always have the day-case EVAR as first patient on the list. If necessary, the patient can stay overnight to be discharged early next day, with less than 24 hours’ total in-patient stay.”

Nicholson similarly believes that the key issues to introducing successful day-case EVAR into practice are “careful patient selection, both with regard to the patient’s attendant co-morbidities and the anticipated complexity of the procedure as well as comprehensive preoperative assessment so that all investigations are carried out and reviewed to determine if the patient is indeed a suitable day-case candidate. Patient information and education is also important so that the patient is involved in the decision-making process and knows what to expect.”

In setting up a day-care EVAR practice, Bell adds: “It is really important that the new pathway is discussed with all stakeholders so that everyone is on board with the changes—that there is no tendency to revert to the in-patient pathway.”

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