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Abstract

Purpose: To determine the feasibility, perioperative resource utilization, and safety of a fast-track endovascular aneurysm repair (EVAR) protocol in well-selected patients. Methods: Between October 2014 and May 2016, the LIFE (Least Invasive Fast-track EVAR) registry ( ClinicalTrials.gov identifier NCT02224794) enrolled 250 patients (mean age 73±8 years; 208 men) in a fast-track EVAR protocol comprised of bilateral percutaneous access using the 14-F Ovation stent-graft, no general anesthesia, no intensive care unit (ICU) admission, and next-day discharge. The primary endpoint was major adverse events (MAE) through 30 days. The target performance goal for the MAE endpoint was 10.4%. Results: Vascular access, stent-graft delivery, and stent-graft deployment success were 100%. A total of 216 (86%) patients completed all elements of the fast-track EVAR protocol. Completion of individual elements was 98% for general anesthesia avoidance, 97% for bilateral percutaneous access, 96% for ICU avoidance, and 92% for next-day discharge. Perioperative outcomes included mean procedure time of 88 minutes, median blood loss of 50 mL, early oral nutrition (median 6 hours), early mobilization (median 8 hours), and short hospitalization (median 26 hours). Fast-track EVAR completers had shorter procedure time (p<0.001), less blood loss (p=0.04), faster return to oral nutrition (p<0.001) and ambulation (p<0.01), and shorter hospital stay (p<0.001). With 241 (96%) of the 250 patients returning for the 30-day follow-up, the MAE incidence was 0.4% (90% CI 0.1% to 1.8%), significantly less than the 10.4% performance goal (p<0.001). No aneurysm rupture, conversion to surgery, or aneurysm-related secondary procedure was reported. There were no type III endoleaks and 1 (0.4%) type I endoleak. Iliac limb occlusion was identified in 2 (0.8%) patients. The 30-day hospital readmission rate was 1.6% overall. Conclusion: A fast-track EVAR protocol was feasible in well-selected patients and resulted in efficient perioperative resource utilization with excellent safety and effectiveness.

Keywords

abdominal aortic aneurysm anesthesia complications endoleak endovascular aneurysm repair enhanced recovery after surgery next-day discharge percutaneous access stent-graft

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References

Ansari

Gianotti

Schroder

et al . Fast-track surgery: procedure-specific aspects and future direction. Langenbecks Arch Surg. 2013;398:29–37.

Greenhalgh

Brown

Powell

et al . Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1863–1871.

Lederle

Freischlag

Kyriakides

et al . Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302:1535–1542.

Nagarsheth

Schor

Singh

et al . Predictors of hospital length of stay following endovascular abdominal aortic aneurysm repair: analysis of patients from the National Surgical Quality Improvement Program [abstract]. J Vasc Surg. 2015;61:65S.

Stone

Horvath

Goodney

et al . The financial implications of endovascular aneurysm repair in the cost containment era. J Vasc Surg. 2014;59:283–290, 290.e1.

Dosluoglu

Lall

Blochle

et al . Ambulatory percutaneous endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2014;59:58–64.

Lachat

Pecoraro

Mayer

et al . Outpatient endovascular aortic aneurysm repair: experience in 100 consecutive patients. Ann Surg. 2013;258:754–758.

Moscato

O’Brien-Irr

Dryjski

et al . Potential clinical feasibility and financial impact of same-day discharge in patients undergoing endovascular aortic repair for elective infrarenal aortic aneurysm. J Vasc Surg. 2015;62:855–861.

Sousa

Brandao

Barreto

et al . Percutaneous endovascular aortic repair with local anesthesia—one day surgery [in Portuguese]. Acta Med Port. 2016;29:381–388.

10.

Cao

Zhao

et al . Safety and efficacy of totally percutaneous access compared with open femoral exposure for endovascular aneurysm repair. J Endovasc Ther. 2017;24:246–253.

11.

Setacci

Sirignano

Kamargianni

et al . Inguinal field block for femoral artery exposure during endovascular aneurysm repair. J Endovasc Ther. 2013;20:655–662.

12.

Edwards

Andrews

Edwards

et al . Results of endovascular aortic aneurysm repair with general, regional, and local/monitored anesthesia care in the American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg. 2011;54:1273–1282.

13.

Broos

Stokmans

Cuypers

et al . Effects of anesthesia type on perioperative outcome after endovascular aneurysm repair. J Endovasc Ther. 2015;22:770–777.

14.

Krajcer

Ramaiah

Huetter

et al . Fast-track endovascular aortic repair: interim report from the prospective LIFE registry. Catheter Cardiovasc Interv. 2016;88:1118–1123.

15.

Foundation Wong-Baker FACES Foundation. Wong-Baker FACES Pain Rating Scale. 2015. http://wongbakerfaces.org/. Last accessed May 22, 2017.

16.

Mehta

Valdes

Nolte

et al . One-year outcomes from an international study of the Ovation Abdominal Stent Graft System for endovascular aneurysm repair. J Vasc Surg. 2014;59:65–73.e1-3.

17.

Zhang

Variable selection with stepwise and best subset approaches. Ann Transl Med. 2016;4:136.

18.

McLeod

Aarts

Chung

et al . Development of an enhanced recovery after surgery guideline and implementation strategy based on the knowledge-to-action cycle. Ann Surg. 2015;262:1016–1025.

19.

Ljungqvist

Scott

Fearon

KC.

Enhanced recovery after surgery: a review. JAMA Surg. 2017;152:292–298.

20.

Abeles

Kwasnicki

Darzi

Enhanced recovery after surgery: current research insights and future direction. World J Gastrointest Surg. 2017;9:37–45.

21.

Lyon

Solomon

Harrison

JD.

A qualitative study assessing the barriers to implementation of enhanced recovery after surgery. World J Surg. 2014;38:1374–1380.

22.

Haulon

Hassen Khodja

Proudfoot

et al . A systematic literature review of the efficacy and safety of the Prostar XL device for the closure of large femoral arterial access sites in patients undergoing percutaneous endovascular aortic procedures. Eur J Vasc Endovasc Surg. 2011;41:201–213.

23.

Al-Khatib

Zayed

Harris

et al . Selective use of percutaneous endovascular aneurysm repair in women leads to fewer groin complications. Ann Vasc Surg. 2012;26:476–482.

24.

Jaffan

Prince

Hampson

et al . The Preclose technique in percutaneous endovascular aortic repair: a systematic literature review and meta-analysis. Cardiovasc Intervent Radiol. 2013;36:567–577.

25.

Krajcer

Strickman

Mortazavi

et al . Single-center experience of percutaneous abdominal aortic aneurysm repair with local anesthesia and conscious sedation: technique and results. J Cardiovasc Surg (Torino). 2012;53:695–706.

26.

Bensley

Hurks

Huang

et al . Ultrasound-guided percutaneous endovascular aneurysm repair success is predicted by access vessel diameter. J Vasc Surg. 2012;55:1554–1561.

27.

Nelson

Kracjer

Kansal

et al . A multicenter, randomized, controlled trial of totally percutaneous access versus open femoral exposure for endovascular aortic aneurysm repair (the PEVAR trial). J Vasc Surg. 2014;59:1181–1193.

28.

Krajcer

Matos

JM.

Totally percutaneous endovascular abdominal aortic aneurysm repair: 30-day results from the independent access-site closure study of the PEVAR trial. Tex Heart Inst J. 2013;40:560–561.

29.

Krajcer

Nelson

Bianchi

et al . Percutaneous endovascular abdominal aortic aneurysm repair: methods and initial outcomes from the first prospective, multicenter trial. J Cardiovasc Surg (Torino). 2011;52:651–659.

30.

Ioannou

Kontopodis

Kehagias

et al . Endovascular aneurysm repair with the Ovation TriVascular Stent Graft System utilizing a predominantly percutaneous approach under local anaesthesia. Br J Radiol. 2015;88:20140735.

31.

Kontopodis

Tsetis

Kehagias

et al . Totally percutaneous endovascular aneurysm repair using the preclosing technique: towards the least invasive therapeutic alternative. Surg Laparosc Endosc Percutan Tech. 2015;25:354–357.

32.

Nano

Mazzaccaro

Stegher

et al . Early experience with Ovation endograft system in abdominal aortic disease. J Cardiothorac Surg. 2014;9:48.

33.

Irace

Venosi

Gattuso

et al . Initial single-site experience with the Ovation abdominal stent-graft system in patients with challenging aortoiliac anatomy. J Cardiovasc Surg (Torino). 2016;57:846–852.

34.

US Centers for Medicare & Medicaid Services. Readmissions Reduction Program (HRRP). 2016. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed May 22, 2017.

35.

Greenblatt

Greenberg

Kind

et al . Causes and implications of readmission after abdominal aortic aneurysm repair. Ann Surg. 2012;256:595–605.

36.

Gupta

Fernandes-Taylor

Ramanan

et al . Unplanned readmissions after vascular surgery. J Vasc Surg. 2014;59:473–482.

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Perioperative Outcomes From the Prospective Multicenter Least Invasive Fast-Track EVAR (LIFE) Registry

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