Specialized vascular floors after open aortic surgery: cost containment while preserving quality outcomes

BACKGROUND

Postoperative care of open abdominal aortic surgery (OAAS) traditionally involves the intensive care unit (ICU). We hypothesized that in patients without an indication for postoperative ICU admission, admission to a specialized vascular floor unit (hemodynamic monitoring, 2:1 nursing) offers cost savings to both payer and institution without compromising care.

METHODS

The electronic medical record was used to collect perioperative data for patients who underwent OAAS between July 2007 and July 2011. The university's cost accounting system provided information on revenue, total margin, and professional billing. Patients with ICU indications (spinal drain, Swan-Ganz monitoring, vasopressors, intubation, or blood product resuscitation) were excluded. Comparative cost and outcome analysis was performed on vascular ward and ICU admissions using the Fisher's exact test for dichotomous categorical variables and the Student's t-test for continuous variables. Long-term survival comparison was calculated using Kaplan-Meier survival estimates.

RESULTS

One hundred thirty of 215 patients were included for analysis (85 excluded, 51 floor, 79 ICU). Perioperative data amongst the floor and ICU cohorts were similar. Day of operation professional billing fees were comparable (ICU $13,365 vs. floor $12,626; P = 0.18); however, postoperative professional fees were significantly higher in the ICU cohort (ICU $3,258 vs. floor $2,101; P = 0.001) primarily because of intensivist billing. The hospital generated an average of 8.7% more revenue from the ICU cohort (ICU $37,770 vs. floor $34,756; P = 0.023). This was offset by greater expenses in the ICU cohort (ICU $30,756 vs. floor $25,144; P = 0.02), yielding a hospital profit margin of 107.5% favoring floor admission (ICU $2,858 vs. floor $5,931; P = 0.19). Duration of stay was similar (ICU 8.0 days vs. floor 7.8 days; P = 0.86). Kaplan-Meier survival analysis was not significantly different between cohorts (ICU 10.1%, median follow-up, 1,070 days vs. floor 0%, median follow-up, 405 days; P = 0.13).

CONCLUSIONS

Postoperative admission to the ICU is not always necessary after OAAS. Specialized vascular floors offer a financial savings to both payer and institution, which allows for simultaneous cost containment while preserving quality outcomes.

Surgical treatment of Kommerell's diverticulum and other saccular arch aneurysms

BACKGROUND

Saccular aneurysms of the aortic arch are rare, and their surgical repair is challenging with potentially significant morbidity and mortality.

METHODS

We examined our experience over a 3-year period with nine consecutive patients that include nine hybrid repairs with initial extra-anatomic carotid and/or subclavian bypass and subsequent endovascular exclusion of the saccular arch aneurysm.

RESULTS

Three patients presented with dysphagia from aberrant right subclavian arteries with aneurysm at the origin of the artery, two had asymptomatic aneurysms at the origin of the left subclavian, and four patients had isolated saccular aneurysms of the arch, three of whom presented with thoracic pain. A total of 16 extra-anatomic bypasses were done in the nine patients. Ten endografts and one nitinol plug were used for exclusion in the nine hybrid cases. There were no perioperative deaths, no strokes, or myocardial infarction events. During follow-up, two patients (22%) were found to have type II endoleaks, but no reinterventions were required. Symptoms resolved in six patients, whereas persistent dysphagia and pain occurred in one.

CONCLUSIONS

Repair of saccular aneurysms of the aortic arch by hybrid approach can be done with minimal morbidity and mortality and a reasonable rate of symptom resolution.

A diffusion-weighted magnetic resonance imaging-based study of transcervical carotid stenting with flow reversal versus transfemoral filter protection

BACKGROUND

Transfemoral carotid artery stenting (CAS) has been associated with a high incidence of embolic phenomena and silent brain infarction. The goal of this study was to compare the incidence of new ischemic cerebral lesions on diffusion-perfusion magnetic resonance imaging (MRI) sequences after transcervical CAS performed with carotid flow reversal vs stenting via transfemoral approach with distal filter protection.

METHODS

During a 26-month period, 64 consecutive patients diagnosed with significant carotid stenosis by ultrasound imaging were assigned to transcervical CAS with carotid flow reversal or a transfemoral approach with a distal filter. The Rankin stroke scale was administered by an independent neurologist, and diffusion-weighted MRI (DW-MRI) studies were performed ≤24 hours before and ≤24 to 48 hours after the procedure. DW-MRI studies were compared by two neuroradiologists not involved in the study and blinded for time, clinical status, and treatment option. Hyperintense DW-MRI signals found after the procedure were interpreted as postoperative ischemic infarcts. All patients were assessed at 1, 6, and 12 months after the intervention.

RESULTS

The distribution of demographic and pathologic variables was similar in both groups. All procedures were technically successful, with a mean carotid flow reversal time of 22 minutes. Twenty-one (70%) and 23 patients (69.69%) were symptomatic in the transcervical and transfemoral groups, respectively (P=.869). After intervention, new postprocedural DW-MRI ischemic infarcts were found in four transcervical (12.9%) and in 11 transfemoral (33.3%) patients (P=.03), without new neurologic symptoms. No major adverse events occurred at 30 days after the intervention. All patients remained neurologically intact, without an increase in stroke scale scoring. All stents remained patent, and all patients remained stroke-free during follow-up. In multivariate analysis, age (relative risk [RR], 1.022; P<.001), symptomatic status (RR, 4.109; P<.001), and open-cell vs closed-cell stent design (RR, 2.01; P<.001) were associated with a higher risk of embolization in the transfemoral group but not in the transcervical group.

CONCLUSIONS

These data suggest that transcervical carotid stenting with carotid flow reversal carries a significantly lower incidence of new ischemic brain infarcts than that resulting from transfemoral CAS with a distal filter. The transcervical approach with carotid flow reversal may improve the safety of CAS and has the potential to improve results in especially vulnerable patients such as the elderly and symptomatic.

Endovascular repair of ruptured aortic aneurysms using carbon dioxide contrast angiography

BACKGROUND

Endovascular aneurysm repair (EVAR) has become a common approach to the management of ruptured abdominal aortic aneurysms (rAAA). The use of iodinated contrast during EVAR for rAAA has several disadvantages, including contrast nephropathy, potential allergic response, and the need for high-pressure injection. We evaluated the use of carbon dioxide (CO(2)) as the primary contrast agent for endovascular repair of ruptured aortic aneurysms.

METHODS

Between December 2007 and July 2009, we retrospectively reviewed our experience with patients undergoing endovascular repair of rAAA, with CO(2)as the principal contrast agent, and compared them with patients who underwent EVAR using iodinated contrast.

RESULTS

Four patients underwent endovascular repair of rAAA with CO(2) angiography (group 1) and seven with iodinated contrast (group 2). The mean age of the patients was not different between groups (p = 0.353). Patients in group 1 received a mean of 443 ± 99 mL of CO(2) and 4.3 ± 8.5 mL of iodinated contrast. Patients in group 2 received 110.2 ± 37.6 mL of iodinated contrast (p < 0.001). Overall mortality was not different between group 1 (0.0%) and group 2 (28.6%, p = 0.491). In patients who survived to discharge, the change in creatinine between admission and discharge was greater in group 2 although not statistically significant (0.25 ± 0.19 mg/dL for group 1 vs. 0.58 ± 0.25 mg/dL for group 2, p = 0.066). There was no significant difference in length of stay between group 1 (intensive care unit, 1.00 ± 0.82 days; hospital, 4.25 ± 0.96 days) and group 2 (intensive care unit, 3.60 ± 3.44 days; hospital, 9.00 ± 6.60 days).

CONCLUSIONS

Endovascular repair of rAAA using CO(2) as a contrast agent is technically feasible and safe. The potential benefits of CO(2) angiography support the continued use of CO(2) in cases of ruptured aneurysms. Further studies are necessary to determine whether CO(2) improves survival and limits the progression of renal dysfunction after endovascular repair of rAAA.

Transcervical carotid artery stenting with flow reversal eliminates emboli during stenting: why does it work and what are the advantages with this approach

Carotid artery stenting (CAS) remains under scrutiny because of the controversial results of major trials that compared it with carotid endarterectomy. However, the question of how the results of carotid stenting are influenced by the access technique and cerebral protection methods has not been properly addressed in any trial. Most unresolved technical weaknesses of transfemoral carotid stenting are related to instrumentation of the arch and proximal supra-aortic trunks, crossing of the carotid lesion without protection, and use of distal filter protection devices of unproven benefit. All these problems can be avoided by using a transcervical approach with carotid flow reversal for protection. The potential advantage of transcervical carotid artery stenting (CAS) is demonstrated by the fact that it can be done in octogenarians without increased morbidity, produces a lower incidence of middle cerebral artery transcranial Doppler (TCD)-detected embolic signals during the procedure, carries a significant reduction in the incidence of ischemic brain infarcts as detected by diffusion weighted magnetic resonance imaging (MRI), when compared to transfemoral stenting with distal filter protection, and can be done with a remarkably low incidence of major adverse events.

Triple-wire: a variation of the "Preclose" technique

We describe a technical modification of the "Preclose" technique that changes the cross-pattern sutures created with the Prostar XL as in a previously described variation using the Proglide device for longitudinal interrupted sutures. This technique was used in 19 femoral arteries, with satisfactory hemostasis achieved in 17. The variation we describe creates a percutaneous longitudinal interrupted suture that closely resembles a surgical interrupted suture. It adds minimal operative time, no additional technical demands, and no significant material cost. Additionally, it allows better control over suture placement and insertion of a balloon catheter for better proximal bleeding control.

Catheter-less angiography for endovascular aortic aneurysm repair: a new application of carbon dioxide as a contrast agent

OBJECTIVE

Avoidance of nephrotoxic contrast agents during endovascular repair of abdominal aortic aneurysms (EVAR) may reduce the incidence of renal dysfunction following the procedure. Carbon dioxide (CO(2)) angiography is a safe alternative to iodinated contrast media vastly under-utilized by vascular surgeons. We herein describe our experience with a simple angiographic technique using CO(2) for EVAR guidance that does not require a separate angiographic catheter.

METHODS

Eighteen patients underwent EVAR using angiography with CO(2) delivered through the endograft sheath. The renal and hypogastric arteries were localized for endograft deployment exclusively with CO(2) in all patients. Completion angiography was done with CO(2) in all patients and an additional angiogram with iodinated media was done in 13 cases.

RESULTS

All endograft deployments were done successfully with CO(2) angiography injected through the endograft delivery systems and femoral access sheaths. Additional iodinated media completion angiography did not modify the procedure in any case. All patients were discharged within two days after surgery. There were no ischemic or systemic complications related to CO(2) administration. Follow-up CT-scan revealed well positioned endografts with the expected patent renal and hypogastric arteries in all patients, and no additional endoleaks. No significant deterioration in renal function occurred in any case.

CONCLUSION

Carbon dioxide angiography conducted through the endograft delivery sheath is reliable for endograft deployment, safe, non-toxic and inexpensive. In addition, it may expedite EVAR by eliminating a number of angiographic catheter placements and exchanges during the procedure. This favorable experience warrants further utilization of this technique.