A pilot study of the enhanced recovery after surgery protocol in aortic surgery

Lessons Learned with Enhanced Recovery for Open Abdominal Aortic Aneurysm Surgery: A Long Term Regional Network Experience

OBJECTIVE

This enhanced recovery programme (ERP) aimed to achieve early recovery for patients undergoing major surgery. Results of a standardised ERP protocol for open infrarenal abdominal aortic aneurysm (AAA) repair within a hub and spoke regional network are presented.

METHODS

In this single centre prospective study (January 2004 - December 2021), consecutive AAAs (≥ 55 mm) were included in the ERP (patient discharge on post-operative day [POD] 4). The four phases of the ERP were pre-admission, pre-operative, intra-operative, and post-operative. Exclusion criteria were BMI > 35 kg/m2, functional capacity < 4 MET, previous aortic or abdominal surgery, and life expectancy < 5 years. Transperitoneal surgery was undertaken with routine AAA resection, graft interposition, and closure.

RESULTS

Consecutive patients (n = 778) were enrolled into the study (mean age 72.3 ± 3.2 years; n = 712 men); 160 (20.5%) were treated in spoke hospitals. Median follow up was 78 (IQR 28, 128) months; median length of stay, procedure time, and blood loss were four days (IQR 3, 5), 190 minutes (IQR 170, 225), and 564 mL (IQR 300, 600). Infrarenal clamping and tube graft configuration were used in 96.5% (n = 751) and 72.5% (n = 564) of patients; 30 day mortality and complication rates were 0.4% (n = 3) and 9.2% (n = 72). Discharge after POD 4 occurred in 15.0%, and most significant predictors for discharge after POD 4 were blood transfusion, re-intervention, and ileus over three days. Overall survival was: 98.2% at one year, 85.0% at five years, and 59.9% at 10 years. Freedom from re-intervention was 97.9% at one year, 94.1% at five years, and 86.8% at 10 years. Short and long term outcomes were comparable between hub and spoke hospitals.

CONCLUSION

The ERP protocol was associated with low short and long term mortality and complication rates. Future studies should apply the ERP protocol in other vascular centres.

Long-term results of endovascular versus open retroperitoneal repair associated with ERAS protocol for abdominal aortic aneurysms

OBJECTIVES

Although the endovascular management of infrarenal abdominal aortic aneurysms (AAAs) is widely performed, many studies have shown better long-term results with open graft repairing, mostly focusing on the classical open repair with midline access. This study aims to evaluate long-term results comparing EVAR (endovascular aneurysm repair) and surgical open repair with retroperitoneal access associated with ERAS (Enhanced Recovery After Surgery) protocol.

METHODS

A retrospective analysis of 156 patients treated for AAA between 2015 and 2018 was conducted. Clinical and demographic characteristics of the two groups were homogeneous except for age, which was significantly higher in patients belonging to the EVAR one, and for previous laparotomies. A total of 100 patients (58.7%) underwent open retroperitoneal repair (ORR group), and 56 (42.3%) underwent EVAR. A mean of 51 ± 28 months of follow-up was conducted. This study aims to evaluate long-term survival by comparing EVAR (endovascular aneurysm repair) and surgical open repair with retroperitoneal access associated with ERAS (Enhanced Recovery After Surgery) protocol. Secondary aims evaluate differences between the two techniques regarding late complications, need for re-interventions, and perioperative results.

RESULTS

Freedom from all-cause mortality, calculated with Kaplan-Meier survival curves equalizing the two population with a Covariate Propensity Score, showed significant better survival rates at 1, 3, and 5 years in ORRs then in EVARs. Late complications (>30 days) and need for late re-intervention rates were greater in the EVAR group (6 late re-interventions needed vs 0 in the ORR group).Perioperative results show longer mean length of hospital stay in patients belonging to the ORR group (5 days vs 2) and significantly higher in-hospital-complication rate.

CONCLUSIONS

The long-term comparison between EVAR and open retroperitoneal repair shows significantly better late outcomes in the ORR group. The perioperative course appears significantly better in EVARs but anyway good in ORRs when a perioperative protocol as ERAS is applied.In a selected population of young patients fit for surgery, the retroperitoneal surgical approach should be highly taken into account in the therapeutical choice.

Comparison of Hospital Stay After Open Abdominal Aortic Aneurysm Repair With or Without Enhanced Recovery Protocol

Objective

Enhanced recovery after surgery (ERAS) is a protocol of evidence based practices applied in major surgery. Open aortic aneurysm repair is major surgery in terms of complications and mortality. This study aimed to compare early outcomes of ERAS with a traditional post-operative protocol in patients undergoing elective open aortic surgery.

Methods

This retrospective cohort study was conducted between 2018 - 2022 in two tertiary vascular surgery centres. The ERAS program was routinely implemented in one centre, while the other one used a standard peri-operative protocol. The primary outcome was post-operative length of stay (pLOS). Secondary outcomes were 30 day mortality rate, complications, re-interventions, and re-hospitalisations. Propensity score weighting was used to balance the two groups by comorbidities. Inverse probability of treatment weight (IPTW) was used to estimate the average treatment effect on the treated patients.

Results

A total of 198 patients were enrolled: 128 in the ERAS group (EG) and 70 in the standard group (SG). Mean age was 70.8 ± 6.7 years in EG and 71.1 ± 6.7 in SG (p = 0.39). No significant differences were observed in pre-operative cardiovascular risk factors. The median pLOS was 5 days (IQR 3, 6) in the EG group and 8 days (IQR 6, 11) in the SG group (p < 0.001). No differences in terms of mortality, re-operations, and re-hospitalisations were observed. The IPTW analyses showed a 40% reduction in pLOS and a significant reduction in major complications in EG (OR 0.41, 95% CI 0.26-0.66; p < 0.001). A 45% increase in pLOS in patients with chronic obstructive pulmonary disease was found in both groups.

Conclusion

Enhanced recovery after surgery is safe and feasible for elective open aortic surgery and is associated with earlier hospital discharge without differences in terms of mortality and lower complication rates compared with a standard protocol. Chronic obstructive pulmonary disease is a major risk factor for an increase in pLOS. The ERAS protocol is promising in terms of resource utilisation.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Lower Extremity Amputation Protocol (LEAP): A pilot enhanced recovery pathway for vascular amputees

Vascular patients, an inherently older, frail population, account for >80% of major lower extremity amputations (transtibial or transfemoral) in the United States. Retrospective data have shown that early physical therapy and discharge to an acute rehabilitation facility decreases the postoperative length of stay (LOS) and expedites ambulation. In the present study, we sought to determine whether patients treated with the lower extremity amputation protocol (LEAP) will have improved outcomes. We performed a nonrandomized prospective study of vascular patients undergoing an amputation from January 2019 to February 2020. Patients who were nonambulatory or had undergone a previous contralateral major amputation were excluded. LEAP is a multidisciplinary team approach to the perioperative care of amputees using an outlined protocol. The prospective patients were compared with historic controls treated before the initiation of LEAP (January 2016 to December 2018). The primary outcomes included the postoperative LOS, time to receipt of a prosthesis, and time to ambulation. Of the 141 included patients, 130 were in the retrospective group and 11 in the LEAP group. The demographics and comorbidities were similar. All 11 LEAP patients had undergone a below-the-knee amputation, with 1 requiring revision to an above-the-knee amputation. Of the 130 retrospective patients, 122 (94%) had undergone a below-the-knee amputation, with 1 requiring revision to an above-the-knee amputation. The LEAP patients were more likely to be discharged to acute rehabilitation (100% vs 27%; P < .001), receive a prosthesis (100% vs 45%; P < .001), and ambulate with the prosthesis (100% vs 43%; P < .001). The LEAP patients had received physical therapy 2 days sooner than had the retrospective controls (P = .006) with a shorter postoperative LOS (3 days vs 6 days; P < .001). Of the patients who had received their prosthesis, the LEAP patients had received their prosthesis, on average, 2 months sooner than had the retrospective cohort (81 ± 39 days vs 137 ± 97 days, respectively; P = .002) and had ambulated with their prosthesis sooner (86 ± 53 days vs 146 ± 104 days, respectively; P = .002). No differences were found in the incidence of surgical site complications or unplanned readmissions between the two groups. The results from the present pilot study have demonstrated that the use of LEAP can significantly decrease postoperative LOS and expedite the time to independent ambulation with a prosthesis for vascular patients undergoing a major lower extremity amputation. These findings suggest a powerful ability to bridge the healthcare gap for this high-risk, underserved, and ethnically diverse population using a disease-specific standardized protocol.

Dexmedetomidine infusion for emergence coughing prevention in patients undergoing an endovascular interventional procedure: A randomized dose-finding trial

OBJECTIVE

Dexmedetomidine has been introduced in emergence coughing, agitation, and shivering prevention. This study aimed to investigate the optimal dose of dexmedetomidine for emergence cough prophylaxis.

METHODS

In this randomized, double-blinded, and prospective trial, 356 patients scheduled for an endovascular interventional procedure were randomly assigned to 0.3 (D 0.3), 0.4 (D 0.4), 0.5 (D 0.5), and 0.6 (D 0.6) μg·kg^-1·h^-1 dexmedetomidine rate, or saline control (C), from anesthesia induction until the end of surgery. The primary outcomes measured were cough grade and frequency. Additionally, groups were compared according to mean arterial pressure (MAP), heart rate, agitation, shivering, postoperative nausea and vomiting (PONV), extubation time, sedation scores, and postoperative first night sleep quality (secondary outcomes).

RESULTS

A total of 351 patients were included in the analysis. The respective incidences of D 0.3, D 0.4, and D 0.5 versus C group were: 78.6%, 68.6%, 53.4% and 42.9% vs 89.7% for cough (p = 0.002, p < 0.001, and p < 0.001 between group D 0.4, D 0.5 and D 0.6 vs C, respectively); 30%, 27.1%, 20.5%, 15.7% vs 44.1% for agitation (p = 0.04, p = 0.003, and p < 0.001 between group D 0.4, D 0.5 and D 0.6 vs C, respectively); 8.6%, 7.1%, 6.8%, 5.7% vs 22.1% for shivering (p = 0.027, p = 0.013, p = 0.01, and p = 0.01 between D 0.3, D 0.4, D 0.5 and D 0.6 vs C, respectively); and 52.9%, 57.1%, 42.5%, 44.3% vs 61.8% for poor sleep quality (p = 0.02 and p = 0.04 between group D 0.5 and D 0.6 vs C, respectively). D 0.4, D 0.5 and D 0.6 showed lower MAP during extubation, compared with the C group. Also, D 0.5 and D 0.6 presented a slight delay in extubation (3.1 and 3.3 min longer than C; p = 0.002 and p < 0.001, respectively). Meanwhile, the frequency of atropine, vasopressor administration, PONV and dizziness were similar to the control.

CONCLUSIONS

Both 0.5 and 0.6 μg·kg^-1·h^-1 dexmedetomidine infusion rates effectively mitigated emergence coughing with prolonged extubation time, besides sleep disturbance. D 0.4, D 0.5, and D 0.6 reduced agitation and sustained hemodynamic stability. Finally, the four doses applied were effective in shivering attenuation.

Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE)

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

A Systematic Review and Meta-Analysis of Enhanced Recovery for Open Abdominal Aortic Aneurysm Surgery

Introduction: Open abdominal aortic aneurysm (AAA) surgery is associated with significant morbidity, mortality and high length of stay (LOS). Enhanced recovery is now commonplace and has been shown to decrease these in other non-vascular surgery settings. This systematic review and meta-analysis aimed to assess the benefits of enhanced recovery (ERAS) in aortic surgery. Method: Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to undertake a systematic review via Ovid MEDLINE and Embase on 10.07.2021. The search terms were "aortic aneurysm" and "fast track" or "enhanced recovery". Data was obtained on major complications, 30-day mortality and LOS. Results: 107 papers were identified and 10 papers included for meta-analysis. Complication rates were significantly reduced with ERAS compared to non-ERAS protocols (ERAS n = 709, non-ERAS n = 930) (odds ratio .38, .22 to .65: P = .0005). LOS was also significantly reduced with an ERAS protocol (ERAS n = 708, non-ERAS n = 956) with a mean reduction of 3 .18 days (-5.01 to -1.35 days) (P = .0007: I2 = 97%). There was no significant difference however in 30-day mortality (P = .92). Conclusion: This meta-analysis demonstrates significant benefits to an enhanced recovery programme in open AAA surgery. There is a need for a multi-centre randomized controlled trial to assess this further.