The inside-out technique is safe and effective for thoracic central venous obstruction

INTRODUCTION

Thoracic central venous obstruction (TCVO) presents a challenging scenario for patients requiring central venous access. The inside-out technique for crossing occluded veins has been described, but to date, case series report on limited number of patients. The purpose of this study was to evaluate the indications, efficacy and outcomes of the inside-out technique at a single tertiary academic center, paying close attention to the severity of TCVO using the Society of Interventional Radiology (SIR) TCVO classification.

METHODS

Patients who underwent central venous access using the inside-out technique were identified between August 2007 and May 2021. Patient demographics, indication for the procedure, procedural details, SIR TCVO classification, outcomes, and procedure-related complications were recorded. Statistical analysis was performed using analysis of variance (ANOVA).

RESULTS

A total of 338 inside-out procedures were done in 221 patients. Forty-nine patients had the procedure done multiple times (25 twice, 11 three times, 13 more than three times). There were 109 (49.3%) men and 112 (50.6%) women with an average age of 54.7±14.8 years. Indications for the procedure included dialysis access 230 (63.5%), infusion of parenteral nutrition, antibiotics, chemotherapy, or other medication 81 (22.3%), cardiac access 39 (10.8%), and other 12 (3.3%). Of note, there was more than one indication associated with 20 procedures. Type 1 SIR TCVO was present in 147 (43.5%), followed by Type 4 in 142 (42.0%), Type 2 in 36 (10.7%), Type 3 in 6 (1.8%), and unable to determine in 7 (2.0%). The access site was the right femoral vein 322 (95.3%), left femoral vein 14 (4.1%) or transhepatic 2 (0.6%). The exit site location was right supraclavicular 274 (81.3%), right sub-clavicular 52 (15.4%), left supraclavicular 3 (0.9%), left sub-clavicular 6 (1.8%), and not defined 2 (0.6%). Types 3 and 4 were associated with longer fluoroscopy times and more contrast compared to types 1 and 2. Median (IQR) for follow-up and device duration was 56.0 days and 76.5 days, respectively.There was no difference in device duration between SIR TCVO types. Removal of a catheter was documented in 166 with indications for removal including infectious causes (non-catheter related bacteremia orcatheter-related infection or bacteremia) in 70 (36.8%), , catheter malfunction in 34 (20.5%), new hemodialysis access in 19 (11.5%), no longer needed in 19 (11.5%), patient removal of catheter in 13 (7.8%), and replacement of a temporary line with a tunneled device in 11 (6.6%). There were no procedural complications associated with the inside-out technique or with catheter removal.

CONCLUSIONS

For a variety of indications, the inside-out technique is safe and effective for establishing central venous access in patients with TCVO and can be done repeatedly. More complex obstructive patterns are associated with longer fluoroscopy times and more contrast. Durability is primarily limited by infectious complications.

Left innominate vein creation using left internal jugular vein tunneled to right internal jugular vein

BACKGROUND

Left innominate vein occlusion is a known complication of pacemaker and central venous catheter placement. For dialysis-dependent patients with an arteriovenous fistula (AVF), this can prevent successful hemodialysis and may require surgical intervention.

CASE REPORT

An 8-month-old male was diagnosed with hemolytic uremic syndrome and became dialysis-dependent at 11 months of age. After multiple vascular access and peritoneal dialysis complications, the patient had construction of a brachiobasalic AVF in his left arm at 13 years old. While waiting for the AVF to mature, an attempt to remove a previously placed left subclavian vein port-a-cath was unsuccessful and a follow-up imaging revealed that the vessel had become occluded. The fistula remained patent, but due to arm swelling and venous obstruction, his fistula was not accessible. Multiple attempts to percutaneously cross the left innominate vein were unsuccessful and the patient was referred for surgical intervention. At 15 years old, the patient was taken to the operating room for transposition of the left internal jugular vein (LIJ) to the right internal jugular vein (RIJ). The LIJ was transected under the mandible and anastomosed to the RIJ. Subsequently the patient underwent VWING insertion rather than venous transposition for constant site dialysis. Although he has required frequent transcatheter dilation of the LIJ-RIJ anastomosis, the patient was successfully dialyzed using this fistula for 5 years. The patient received a cadaveric renal transplant at 5 years 20 days.

CONCLUSIONS

In cases of left innominate vein stenosis, transposing the LIJ can create a new left innominate vein that can alleviate venous hypertension and preserve fistula function. This procedure avoids sternotomy and only requires one anastomosis.

Treatment of postoperative high-volume lymphatic complications using isosulfan blue

BACKGROUND

Lymphocele (LC) and lymphocutaneous fistula (LF) are infrequent but serious complications that occur when lymphatics are disrupted during a vascular procedure. Conservative management with bed rest, extremity elevation, aspiration, and pressure dressing is often ineffective. This study evaluated the effectiveness of isosulfan blue (ISB) to identify disrupted lymphatics for ligation.

METHODS

Between 1998 and 2016, there were 33 lymphatic complications treated with ISB-directed ligation in 32 patients. The patients' records were retrospectively reviewed, recording demographics, comorbid conditions, index vascular operation causing the lymphatic complication, details of the procedure done to treat the lymphatic complication, and outcomes. In each patient, between 1 and 3 mL of ISB was injected in the subcutaneous tissue of the interdigital web space. The wound associated with the lymphatic complication was opened. The appearance of dye within the wound identified disrupted lymphatic ducts for suture ligation.

RESULTS

The lymphatic complications were either LC (11 [33%]) or LF (22 [66%]) and were associated with femoral vein harvest (9), great saphenous vein harvest (8), exposure of femoral arteries (13), creation of an upper extremity fistula (1), repeated femoral access for coronary angiography, or excision of an LC (1). Most patients were male (66%), and the mean age was 56.8 ± 13.1 years. In comparing patients with LF and LC, the diagnosis of LF was made earlier (13.8 ± 7.0 days vs 23.4 ± 14.1 days; P = .02), and treatment occurred sooner for LF than for LC (22.1 ± 8.1 days vs 48.8 ± 51.2 days; P = .02). In all patients, ISB identified one or more disrupted lymphatics. The appearance of the ISB dye within the wound after injection was rapid, often within 5 to 10 minutes. After ligation of the lymphatics, most wounds were closed primarily (26 [79%]), but a muscle flap (5 [15%]), negative pressure dressing (1 [3%]), and dressing changes (1 [3%]) were also used. Wound healing was achieved in all patients on average 32.5 ± 21.5 days after lymphatic ligation.

CONCLUSIONS

The current series is one of the largest reported experiences using ISB to identify injured lymphatics responsible for LC or LF. Lymphatic complications after a vascular procedure usually occur within 3 weeks of the index vascular procedure, with LF being identified and treated earlier than LC. ISB injection rapidly identifies disrupted extremity lymphatics. Ligation of these lymphatics results in reliable resolution of the lymphatic complication.

The Feasibility of Real-Time Intraoperative Performance Assessment With SIMPL (System for Improving and Measuring Procedural Learning): Early Experience From a Multi-institutional Trial

PURPOSE

Intraoperative performance assessment of residents is of growing interest to trainees, faculty, and accreditors. Current approaches to collect such assessments are limited by low participation rates and long delays between procedure and evaluation. We deployed an innovative, smartphone-based tool, SIMPL (System for Improving and Measuring Procedural Learning), to make real-time intraoperative performance assessment feasible for every case in which surgical trainees participate, and hypothesized that SIMPL could be feasibly integrated into surgical training programs.

METHODS

Between September 1, 2015 and February 29, 2016, 15 U.S. general surgery residency programs were enrolled in an institutional review board-approved trial. SIMPL was made available after 70% of faculty and residents completed a 1-hour training session. Descriptive and univariate statistics analyzed multiple dimensions of feasibility, including training rates, volume of assessments, response rates/times, and dictation rates. The 20 most active residents and attendings were evaluated in greater detail.

RESULTS

A total of 90% of eligible users (1267/1412) completed training. Further, 13/15 programs began using SIMPL. Totally, 6024 assessments were completed by 254 categorical general surgery residents (n = 3555 assessments) and 259 attendings (n = 2469 assessments), and 3762 unique operations were assessed. There was significant heterogeneity in participation within and between programs. Mean percentage (range) of users who completed ≥1, 5, and 20 assessments were 62% (21%-96%), 34% (5%-75%), and 10% (0%-32%) across all programs, and 96%, 75%, and 32% in the most active program. Overall, response rate was 70%, dictation rate was 24%, and mean response time was 12 hours. Assessments increased from 357 (September 2015) to 1146 (February 2016). The 20 most active residents each received mean 46 assessments by 10 attendings for 20 different procedures.

CONCLUSIONS

SIMPL can be feasibly integrated into surgical training programs to enhance the frequency and timeliness of intraoperative performance assessment. We believe SIMPL could help facilitate a national competency-based surgical training system, although local and systemic challenges still need to be addressed.

Development of Vascular Surgery Skills During General Surgery Training

Purpose: We previously have shown that performance on the National Board of Medical Examiners (NBME) part II examination does not reflect clinical skills. Many training programs use the American Board of Surgery In-Service Training Examination (ABSITE) as the only objective measure of clinical knowledge. This study evaluates the utility of the ABSITE and an objective structured clinical examination (OSCE) in measuring vascular clinical skills during general surgery residency training.

Methods: Residents' mean scores on the vascular section of an OSCE were compared with their mean overall scores on the OSCE by using a two-way analysis of variance (ANOVA). Residents' performance on each clinical section of the ABSITE (body as a whole; gastrointestinal, cardiovascular, and respiratory systems; genitourinary/head and neck/musculoskeletal, and endocrine) and a vascular subsection (VASC) were evaluated by using ANOVA.

Results: Mean vascular scores were significantly lower than mean overall scores for residents at all levels of training (P < 0.0001). Fischer's PLSD (plausible least significant difference) post hoc test revealed that significant improvement occurred between the intern and junior years (P < 0.05), but not between the junior and senior years. In contradistinction, VASC ABSITE scores were better than all other scores for both junior and senior residents, but not for interns (senior: VASC = 96%, other = 79%, P = 0.04; junior: VASC = 84%, other = 64%, P = 0.02; intern: VASC = 63%, other = 50%, P = 0.12).

Conclusions: It is assumed that residents completing residency training are competent to perform clinical vascular examinations. Our findings paradoxically showed that although residents scored highest on the clinical vascular section of the ABSITE, they scored lowest on the vascular section of the OSCE. Although both tests found evidence of improvement between the intern and junior years, neither test found a significant improvement in vascular performance between the junior and senior years. These results emphasize that ABSITE scores do not necessarily correlate with clinical competence, and they demonstrate the need for providing more objective measures of clinical performance.

Carotid Blowout with Infection: Management with Endovascular and Open Vascular Approaches

The management of patients with head and neck cancer can be complicated by massive carotid artery hemorrhage, often requiring ligation owing to the emergent conditions and scarring from previous surgery and radiation. A case of emergent endovascular management of carotid artery hemorrhage in a patient treated for pharyngeal carcinoma is described. Hemorrhage was controlled, but on follow-up the patient developed a carotid-cutaneous fistula with exposure of the coils. Further management required the use of autogenous vein to replace the involved vessels. This case demonstrates that endovascular control of carotid hemorrhage can be successful, but close follow-up is necessary to identify potential subsequent complications.

Debate: Whether an endovascular-first strategy is the optimal approach for treating acute mesenteric ischemia

Acute mesenteric ischemia continues to be a life-threatening insult in often-elderly patients with many comorbidities. Recognition and correct diagnosis can be an issue leading to delays in therapy that result in loss of bowel or life, or both. The basic surgical principals in treating acute mesenteric ischemia have long been early recognition, resuscitation, urgent revascularization, resection of necrotic bowel, and reassessment with second-look laparotomies. Endovascular techniques now offer a less invasive alternative, but whether an endovascular-first or open surgery-first approach is preferred in most patients is unclear. Our discussants will attempt to clarify these issues.

A Regional Experience With Vascular Surgery Mock Oral Examinations

INTRODUCTION

In 2006 the Southern Association for Vascular Surgery (SAVS) implemented a mock oral examination program to prepare trainees for the Vascular Surgery Certifying Examination (VCE).

METHODS

Participating examinees and examiners were identified from SAVS Recorder records and contacted via e-mail with a request to participate in an anonymous online survey. Examinees were asked about passage on American Board of Surgery examinations and perceptions of the mock oral program. Examiners were asked for their perceptions of the examination, applicant performance, and perceived areas for training improvement. Board passage rates for the group and national comparison data were provided in a de-identified fashion by American Board of Surgery.

RESULTS

From 2006 to 2014, 158 examinees and 86 examiners participated in the SAVS mock orals program. In all, 33% of examinees and 35% of examiners completed the anonymous survey. Of the examinees, 27 (60%) reported passage of the mock oral examination on their first attempt and 7 of 9 (78%) reported passage on the second attempt. Second year in training was significantly associated with passage of the mock oral (p = 0.002). Of the examinees questioned, 100% "would recommend" the SAVS mock oral examinations to future trainees. Of the responding examiners, 90% felt that the SAVS mock oral examinations were "comparable" to the VCE and 87% "strongly agreed" that the exercise was a valuable preparatory tool. Examiners identified "ability to describe technical aspects of open vascular techniques" and "management of complications associated with vascular disease processes and operations" as commonly displayed deficits among examinees (80% and 77%, respectively). In all, 115 examinee participants from the SAVS mock orals had taken the VCE between 2006 and 2014. Of them, 90 (78%) passed the VCE on their first attempt. During the same time interval, the national first-time pass rate for the VCE was 86%.

CONCLUSIONS

Although participation in the SAVS mock orals was overwhelmingly assessed as a positive preparatory experience by examinees and examiners, no incremental advantage in VCE passage was observed. Explanations for the worse-than-average performance on the VCE are not clear but likely involve numerous factors, including participation bias. Importantly, examiners in the SAVS mock oral process felt that the exercise closely simulated the VCE and uniformly reported pervasive deficits in the areas of demonstrated understanding of open surgical techniques and management of complications. This investigation guides further examination of VCE simulation exercises to assist in guiding the use of educational resources at both institutional and professional society levels.

Abdominal compartment syndrome associated with endovascular and open repair of ruptured abdominal aortic aneurysms

BACKGROUND

Abdominal compartment syndrome (ACS) is a known complication of ruptured abdominal aortic aneurysm (rAAA) repair and can occur with either endovascular (EVAR) or open repair. We hypothesize that the underlying mechanism for the development of ACS may differ for patients treated with EVAR or open operation.

METHODS

All patients who presented with rAAA at a tertiary care medical center between January 2005 and December 2010 were included in the study. Demographic factors, type of repair (open vs EVAR), development of ACS, intraoperative and postoperative fluid requirements, estimated blood loss, length of stay, and morbidity and mortality were recorded. Student t-test and Fisher exact test were performed. A P value < .05 was considered significant.

RESULTS

Seventy-three patients, 62 men and 11 women with an average age of 70.5 years, were treated for rAAA. Forty-four (60%) underwent open repair; 29 (40%) had EVAR. Overall mortality was 42% (31 of 73), with mortality being 31% (9 of 29) in EVAR and 48% (21 of 44) in open repair. ACS developed in 21 patients (29%), more frequently in open repair than in EVAR (15 of 44 [34%] vs 6 of 29 [21%]; P = NS). Mortality was higher in patients who developed ACS compared with those without ACS (13 of 21 [62%] vs 17 of 52 [33%]; P = .022). This finding was especially pronounced in the EVAR group, in which mortality in patients with ACS was 83% (5 of 6) compared with 17% (4 of 23) without ACS (P = .005). Intraoperative fluid requirements were significantly higher in EVAR patients who developed ACS compared with those without ACS, including packed red blood cells (5600 mL vs 1100 mL; P < .0001), total blood products (9300 mL vs 1500 mL; P < .001), crystalloid (11,200 mL vs 4500 mL; P < .001), and estimated blood loss (5000 mL vs 660 mL; P = .006). In patients treated with open repair, there were no significant differences in intraoperative fluid requirements between those who developed ACS and those without ACS. However, patients who developed ACS after open repair required significantly more crystalloid on the first and second postoperative days (first postoperative day, 8300 mL vs 5600 mL [P = .01]; second postoperative day, 6500 mL vs 3800 mL [P = .004]).

CONCLUSIONS

This study demonstrates that the development of ACS after repair of rAAA is associated with increased mortality, especially in EVAR-treated patients. The higher intraoperative blood and blood product requirements associated with ACS in EVAR patients suggest that one potential cause of early ACS is continued hemorrhage from lumbar and inferior mesenteric vessels through the ruptured aneurysm sac. Hence, open ligation of such vessels should be considered in patients developing early ACS after EVAR for rAAA.

Endoluminal thermal ablation versus stripping of the saphenous vein: Meta-analysis of recurrence of reflux

BACKGROUND

Catheter-based minimally invasive techniques developed to treat saphenous vein insufficiency include endovenous laser and radiofrequency ablation. Their long-term results are under evaluation. A meta-analysis of trials was performed, comparing endovenous versus surgical saphenous vein ablation with focus on long-term (greater than 365 days) outcomes of recurrence of varicosities, reflux and symptomatic disease.

METHODS

A systematic search of published studies reporting on the treatment of varicose veins was performed. The databases searched included Medline/PubMed, OVID, EMBASE, CINAHL, ClinicalTrials.gov, the Cochrane central register of controlled trials and the Cochrane database of systematic reviews. Search terms included saphenous vein ligation, stripping, radiofrequency ablation, laser ablation and endovenous ablation. Reports in all languages from 1966 to 2009 were considered. The 'related articles' function was used to broaden the search. All article titles, abstracts and subject headings were screened by one reviewer for potential relevance. Abstracts of articles selected by title were read online to reduce the number of articles for full-text examination. Finally, additional titles were sought in the bibliographies of the retrieved articles. Only studies reporting outcomes after more than 365 days were selected. Analyzed outcomes included recurrence of varicosities and reflux, as documented by duplex ultrasound, and recurrence of signs and symptoms. Data extraction was performed from life tables, text or graphs. Statistical analysis was performed using the commercially available software CMA Version 2 (Biostat Inc, USA). The random effects model was used to calculate the ORs and 95% CIs. Statistical heterogeneity was evaluated using the Q value and considered present if P<0.05.

RESULTS

Eight randomized controlled trials were included; these reported on 497 patients. Two hundred twenty-six patients underwent ligation and stripping and 271 underwent endoluminal thermal ablation. The mean (± SD) follow-up period was 584±182 days. There was no difference in the age and sex distribution between the groups. There was no difference in the long-term recurrence rate between the two techniques (OR 0.97, 95% CI 0.48 to 1.9, P=0.9). Statistical heterogeneity was not significant (Q value P=0.5) and publication bias was limited.

CONCLUSIONS

The analysis indicates that catheter-based treatments and traditional venous stripping with high ligation have similar long-term results. Establishing preoperative criteria for each method may improve outcomes but presently neither technique appears to confer an advantage in terms of mid- to long-term freedom from recurrent symptoms.

Thrombin injection for the treatment of mycotic gluteal aneurysm

Gluteal aneurysms are rare entity, whose surgical or endovascular management is traditionally challenging. Infectious source being increasingly more common as the underlying etiology. We herein describe successful implementation of direct thrombin injection as another therapeutic option for these patients.

Spontaneous Superior Mesenteric Artery Dissection: Report of 2 Patients and Review of Management Recommendations

Spontaneous superior mesenteric artery dissection is rare and presents with variable symptomatology. Optimal treatment depends on the presentation; asymptomatic patients can be managed expectantly. Endoluminal intervention or open reconstruction is warranted in patients with persistent symptoms or intestinal ischemia. As more of these patients are identified with increasing utilization of computed tomography (CT), our understanding of the pathophysiology and best treatment will improve.

Deglutition syncope: a manifestation of vagal hyperactivity following carotid endarterectomy

A 61-year-old man with left amaurosis fugax and bilateral >80% internal carotid artery stenoses underwent a left carotid endarterectomy. On the first postoperative day, he developed hypotension, bradycardia, and chest pain with food ingestion. He was diagnosed as having deglutition syncope and was treated with oral anticholinergics. Similar symptoms occurred when he underwent a right carotid endarterectomy. Deglutition syncope is a neurally mediated situational syncope resulting from vagus nerve over-activity. This is the first report of deglutition syncope associated with carotid endarterectomy. It is important to recognize and differentiate these symptoms from other causes of postendarterectomy hemodynamic instability.

Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization

BACKGROUND

Little is known about the significance of blood transfusion in patients with peripheral arterial disease. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to examine the effect of intraoperative blood transfusion on the morbidity and mortality in patients who underwent lower extremity revascularization.

METHODS

We analyzed data from the participant use data file containing vascular surgical cases submitted to the ACS NSQIP in 2005, 2006, and 2007 by 173 hospitals. Current procedural terminology codes were used to select lower extremity procedures that were grouped into venous graft, prosthetic graft, or thromboendarterectomy. Thirty-day outcomes analyzed were (1) mortality, (2) composite morbidity, (3) graft/prosthesis failure, (4) return to the operating room within 30 days, (5) wound occurrences, (6) sepsis or septic shock, (7) pulmonary occurrences, and (8) renal insufficiency or failure. Intraoperative transfusion of packed red blood cells was categorized as none, 1 to 2 units, and 3 or more units. Outcome rates were compared between the transfused and nontransfused groups using the chi(2) test and multivariable regression adjusting for transfusion propensity, comorbid and procedural risk.

RESULTS

A total of 8799 patients underwent lower extremity revascularization between 2005 and 2007. Mean age was 66.8 +/- 12.0 years and 5569 (63.3%) were male. Transfusion rates ranged from 14.5% in thromboendarterectomy patients to 27.1% in prosthetic bypass patients (P < .05). After adjustment for transfusion propensity and patient and procedural risks, transfusion of 1 or 2 units remained significantly predictive of mortality, composite morbidity, sepsis/shock, pulmonary occurrences, and return to the operating room. The adjusted odds ratios for 30-day mortality ranged from 1.92 (95% confidence interval [CI] 1.36-2.70) for 1 to 2 units to 2.48 (95% CI 1.55-3.98) for 3 or more units.

CONCLUSION

In a large number of patients undergoing lower extremity revascularization, we have found that there is a higher risk of postoperative mortality, pulmonary, and infectious complications after receiving intraoperative blood transfusion. Additional studies are necessary to better define transfusion triggers that balance the risk/benefit ratio for blood transfusion.

Gender and 30-day outcome in patients undergoing endovascular aneurysm repair (EVAR): an analysis using the ACS NSQIP dataset

PURPOSE

Prior studies have demonstrated higher in-hospital mortality in women undergoing open abdominal aortic aneurysm repair. The current study evaluates the relationship between gender and 30-day outcomes for endovascular aneurysm repair (EVAR) in a multicenter, contemporary patient population.

METHODS

Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file that underwent EVAR of abdominal aortic aneurysm (AAA) from 2005 to 2007 were identified by CPT codes. Outcomes analyzed were 30-day mortality, morbidity (one or more of 21 complications defined by the ACS NSQIP protocol), length of hospital stay, and six complication subgroups. Preoperative risk factors, intraoperative variables, and outcomes were compared across genders using chi(2) (binary and categorical variables) and t tests (continuous variables). The relationship of gender to outcomes was further evaluated using multivariate logistic regressions to adjust for pre- and intraoperative risk variables.

RESULTS

In 3662 EVAR patients, 647 (17.7%) were women and 3015 (82.3%) men with mean ages of 75.1 +/- 9.0 and 73.7 +/- 8.5 years (P < .001). Tube graft (360, 9.8%); bifurcated, one docking limb (1624, 44.3%); bifurcated, two docking limbs (1294, 35.3%); unibody (218, 5.9%); and aorto-uni-iliac/femoral (166, 4.4%) repairs were performed. Tube and aorto-uni-iliac/femoral grafts were more common in women (21.4% vs 12.8%, P < .001) than men, as were femoral/femoral crossovers (3.9% vs 1.8%, P = .011) and iliac or brachial exposures (2.8% vs 1.0%, P = .009). Overall morbidity and mortality were 11.9% and 2.1%, respectively. Mortality in women was significantly higher (3.4% vs 2.1%, P = .014), as was morbidity (17.8% vs 10.6%, P < .001). Of thirteen independent preoperative risk factors for mortality or morbidity, women had a higher incidence in five: emergent operation, functional dependence, recent weight loss, underweight status or morbid obesity, and severe chronic obstructive pulmonary disease (COPD). After adjustment for these variables, the odds ratio (OR) for mortality in women vs men was 1.52 (95% confidence interval [CI] 0.85-2.69, P = .157); OR for morbidity was 1.65 (95% CI 1.28-2.14, P < .001). Female gender was also found to be an independent risk factor for length of stay (Beta 0.7 days, 95% CI 0.2-1.2, P = .006), infectious complications (OR 1.49, 95% CI 1.10-2.03, P = .011), wound complications (OR 1.80, 95% CI 1.12-2.90, P = .015) and postoperative transfusion (OR 2.92, 95% CI 1.39-6.13, P = .002).

CONCLUSIONS

Mortality and morbidity were higher in women than men undergoing EVAR. Multivariate analysis showed that the increased risk of mortality was related to women presenting more emergently, more debilitated (recent weight loss and functional dependence), and requiring iliac or brachial exposure. After adjustment for multiple preoperative and operative factors, women remained at significantly higher risk for the development of a broad range of complications and increased length of stay.

Long-term outcome of infrapopliteal catheter-based intervention for critical limb ischemia

CONTEXT

Percutaneous treatment of tibioperoneal occlusive disease is associated with decreased morbidity compared with bypass surgery. The long-term patency and limb salvage rates are not well documented.

AIMS

To evaluate the long-term outcome of endoluminal interventions for tibioperoneal lesions.

METHODS

A retrospective study was performed to determine the outcomes of patients undergoing infrapopliteal catheter-based intervention for critical limb ischemia. Collected data included demographics, comorbidities, clinical presentation, pre- and postintervention noninvasive vascular measurements (segmental pressure and waveforms, and ankle-brachial index [ABI]), type of intervention, limb loss rate, patient follow-up and need for surgical revascularization. Statistical analysis was performed with the two-tailed t test. P<0.05 was considered significant; results were reported as mean ± SD. Cox regression analysis and Kaplan-Meier limb survival analysis were performed to demonstrate freedom from amputation over time.

RESULTS

Thirty-five patients underwent intervention from 2003 to 2008; technical success was achieved in 26 patients (75%). Arterial segmental pressure studies revealed a significant increase in ABI - preprocedure ABI was 0.62±0.24 versus a postintervention ABI of 0.81±0.29 (P=0.02). The limb salvage rate was 63% during the follow-up period. Limb salvage was better for patients who underwent isolated infrapopliteal intervention versus combined above and below the knee intervention.

CONCLUSION

Percutaneous interventions for tibioperoneal occlusive disease offer an acceptable limb salvage rate and may be the preferred initial treatment for critical limb ischemia.

The influence of body mass index obesity status on vascular surgery 30-day morbidity and mortality

OBJECTIVE

Mild obesity may have a protective effect against some diseases, termed an "obesity paradox." This study examined the effect of body mass index (Kg/m(2) BMI) on surgical 30-day morbidity and mortality in patients undergoing vascular surgical procedures.

METHODS

As part of the National Surgical Quality Improvement Program (NSQIP), demographic and clinical risk variables, mortality, and 22 defined complications (morbidity) were obtained over three years from vascular services at 14 medical centers. At each medical center, patients from the operative schedule were prospectively and systematically enrolled according to NSQIP protocols. Outcomes and risk variables were compared across NIH-defined obesity classes (underweight [BMI<or=18.5], normal [18.5<BMI<25], overweight [25<BMI<or=30], obese I [30<BMI<or=35], obese II [35<BMI<or=40], and obese III [BMI>40]) using analysis of variance and means comparisons. Logistic regression was used to control for other risk factors.

RESULTS

Vascular procedures in 7,543 patients included lower extremity revascularization (24.6%), aneurysm repair (17.4%), cerebrovascular procedures (17.3%), amputations (9.4%), and "other" procedures (31.3%). In the entire cohort, there were 1,659 (22.0%) patients with complications and 295 (3.9%) deaths. Risk factors of hypertension and diabetes increased with BMI (analysis of variance [ANOVA] P < .05) as expected; smoking, disseminated cancer, and stroke decreased (ANOVA P < .01). Twenty other risk factors, as well as mortality and morbidity, had "U" or "J"-shaped distributions with the highest incidence in underweight and/or obese class III extremes but reduced minimums in overweight or obese I classes (ANOVA P < .05). After controlling for age, gender, and operation type, mortality risk remained lowest in obese class I patients (Odds ratio [OR] 0.63, P = .023) while morbidity risk was highest in obese class III patients (OR 1.70, P = .0003), due to wound infection, thromboembolism, and renal complications.

CONCLUSION

Underweight patients have poorer outcomes and class III obesity is associated with increased morbidity. Mildly obese patients have reduced co-morbid illness, surprisingly even less than normal-class patients, with correspondingly reduced mortality. Mild obesity is not a risk factor for 30-day outcomes after vascular surgery and confers an advantage.

Endovascular retrieval of an intraaortic greenfield vena cava filter

Aberrant placement of vena cava filters has been documented. Only one case of intraaortic deployment, in which the filter was left at the aortic bifurcation with no adverse effects over a 4-year follow-up period, has been reported. We describe the endovascular retrieval of an intraaortic Greenfield filter using a snare and large sheath to protect the aortic intima from injury during removal of the device.

The emergency use of endografts in the carotid circulation to control hemorrhage in potentially contaminated fields

We report our experience with the use of endoluminal grafts to control emergency bleeding in two patients with tracheoinnominate fistulas and three patients with carotid blowouts. Systemic infectious complications were not seen. However, rebleeding occurred in one patient, and extensive stent coverage to control bleeding was required in a second. Survival was usually limited by the patient's cancer. There was one long-term survivor without cancer whose tracheostomy was placed for neurologic compromise. A review of the literature for similar cases identified 18 additional endografts placed for carotid blowout and 3 placed for tracheoinnominate fistulas. Overall, infectious complications occurred in only two patients, whereas rebleeding occurred in eight patients. On the basis of these findings, we believe that endografts are useful to control emergency hemorrhage in these two pathologies because treatment is usually palliative, given the poor survival secondary to the underlying disease. However, more extensive graft coverage may be necessary considering the erosive nature of these processes.

Peripheral atherectomy in TransAtlantic InterSociety Consensus type C femoropopliteal lesions for limb salvage

BACKGROUND

The optimal therapy for TransAtlantic Societal Consensus (TASC) type C femoropopliteal lesions remains a critical issue in the treatment of infrainguinal occlusive disease. The purpose of this study was to evaluate the outcome of limbs with TASC C femoropopliteal lesions and critical limb ischemia treated with the FoxHollow SilverHawk atherectomy catheter.

METHODS

From September 2004 to September 2005, 18 consecutive femoropopliteal procedures performed in 17 limbs in 16 patients were reviewed. Demographic data, baseline angiographic findings, and indications for the procedures were recorded. Clinical outcomes including symptom resolution and limb salvage were determined for the 17 primary procedures. Hemodynamic improvement was compared by using the paired Student t test. Stenosis-free patency was determined by the Kaplan-Meier method.

RESULTS

The mean age was 72.5 years (range, 47-88 years). Fifty percent of the patients had four or more of the following risk factors: hypertension, diabetes, tobacco use, hyperlipidemia, renal insufficiency, and coronary artery disease. The indication was tissue loss in 13 limbs and rest pain in 4. All patients had a second level of disease, either inflow or tibial/pedal, which was treated concurrently when appropriate. Initial resolution of symptoms was achieved in 12 limbs, and partial healing was achieved in 2 others. Early amputation was necessary in the remaining three patients, but this was likely due to severe inframalleolar disease and advanced forefoot ischemia at the time of presentation. Five patients have remained symptom-free without restenosis at a mean follow-up of 6 months. Two patients have required late amputation for hemodynamic failure. The ankle-brachial index improved from 0.39 +/- 0.08 (mean +/- SEM) before surgery to 0.75 +/- 0.08 in the immediate postoperative period (P = .02). However, it returned toward baseline at 6 months after surgery, with a mean of 0.48 +/- 0.07. Stenosis-free patency of the femoropopliteal segment was 22% at 12 months.

CONCLUSIONS

Peripheral atherectomy can achieve good early clinical and hemodynamic success in patients with TASC C lesions and critical limb ischemia. However, mid-term restenosis rates are high in this challenging cohort of patients.

The Endowedge and Kilt Techniques to Achieve Additional Juxtarenal Seal during Deployment of the Gore Excluder Endoprosthesis

The proximal 4 mm of the Gore Excluder endoprosthesis are scalloped. Our purpose is to describe our initial experience of a novel technique, referred to as the "endowedge," that takes advantage of this scalloped configuration in aneurysms with short proximal necks. The technique utilizes a balloon in the renal artery to aid alignment of a scallop and allow additional juxtarenal seal. A retrospective review of aneurysms treated with the endowedge technique at our institution was initiated. Renal balloons were placed via the brachial approach. Excluder endografts were deployed by flowering the first one or two rings, then advancing upward against the inflated balloon during completion of deployment. In patients with dumbbell-shaped morphology, an aortic cuff was deployed in the distal seal zone prior to the main body (kilt technique). Eight patients were identified, three of whom underwent an adjuvant kilt procedure. Average preoperative proximal neck length was 8.5 mm (range 6-12). Average additional juxtarenal seal was 2.3 mm. Mean follow-up was 5 months (range 2.5 weeks to 9 months). There were no type I endoleaks. There were two type II endoleaks. Average aneurysm size decreased from 6.0 to 5.5 cm. No aneurysm has enlarged or ruptured. We conclude that the endowedge technique allows additional juxtarenal seal during endograft placement. Our early results suggest that this technique may allow for safe treatment of aneurysms with short necks.

Technique of slow deployment of Gore Excluder endograft improves accuracy of placement

The standard deployment of Gore Excluder endoprostheses involves rapid pulling of the deployment knob once the graft is thought to be properly positioned. We describe an alternative technique that involves the slow pulling of the deployment knob. The key features of this technique include anticipating the asymmetric flowering of the graft that occurs toward the contralateral limb, prompt correction of any graft malpositioning, and maintaining the slow deployment until the contralateral gate is released. Our experience with this technique demonstrates that it is accurate, safe, and reduces the need for proximal extension cuffs.

Surgical management of peripancreatic arterial aneurysms

Peripancreatic artery aneurysms--gastroduodenal (GDA) and pancreaticoduodenal (PDA)--are highly unusual. We report 4 such aneurysms and have collated reports of true peripancreatic artery aneurysms based on an extensive review of the English literature. From this review, patient characteristics, clinical behavior, outcome and management strategies are assessed.

Surveillance Venous Duplex Is Not Clinically Useful after Total Joint Arthroplasty When Effective Deep Venous Thrombosis Prophylaxis Is Used

The early detection of deep venous thrombosis (DVT) and treatment with systemic anticoagulation to prevent pulmonary embolism (PE) are essential in the management of patients undergoing total joint arthroplasty (TJA). However, improvements in prophylactic measures have significantly decreased the occurrence of DVT in these patients. The purpose of this study was to determine whether routine postoperative duplex surveillance for DVT remains clinically useful. The medical records of all patients undergoing total knee or total hip arthroplasty between October 1997 and January 2002 at a University Hospital and its Veterans Affairs (VA) affiliate were reviewed. The type of operation and occurrence of complications (e.g., DVT, PE, and hemorrhage) were noted. All patients were treated postoperatively with both enoxaparin 30 mg b.i.d. and bilateral lower extremity sequential compression devices (SCDs). A venous duplex scan was performed prior to discharge. Three hundred ninety-eight patients underwent 441 TJAs for 149 hips and 292 knees. The average age was 65 years (range, 23-95). Venous duplex scans were performed within 1 week (median, 4 days) of operation. Initial inpatient scans revealed acute, ipsilateral DVT in five patients (1.3%). Three patients experienced documented PE-one as an inpatient and two after hospital discharge; both outpatients had negative inhospital duplex scans. One of the 398 patients did not have a duplex scan as an inpatient and returned 6 weeks later with a popliteal DVT. Complications included one upper gastrointestinal hemorrhage, and one patient died postoperatively of unknown causes. These data demonstrate that routine postoperative venous duplex scans rarely found DVT (5 of 398 patients) after TJA when effective prophylaxis was used. Furthermore, surveillance scanning did not enable reliable prediction of PE. Therefore, we conclude that postoperative inpatient surveillance duplex scans for DVT provide very minimal benefit and that a routine screening program is not clinically useful for patients managed with effective DVT prophylaxis.

Endovascular Exclusion of a Postendarterectomy Carotid Pseudoaneurysm

Carotid pseudoaneurysms are rare occurrences. They often result from trauma, but can also present following carotid endarterectomy. Treating such pseudoaneurysms can be difficult due to previous surgery and limited access to the high internal carotid artery. A case involving a postendarterectomy carotid pseudoaneurysm treated via a femoral approach with a covered stent using endoluminal techniques is presented.

Pseudoaneurysm of the lateral plantar artery after foot laceration

Two children with lateral plantar artery pseudoaneurysms are presented. Both cases were associated with a plantar laceration and were successfully treated with ligation. Only one other report of a lateral plantar artery pseudoaneurysm was found in the literature; no reports involving the medial plantar artery have been reported. A cadaver dissection supports the hypothesis that the lateral plantar artery is more superficially located and therefore more vulnerable to injury compared with the medial plantar artery. Clinicians treating patients with lacerations of the foot should be aware that an arterial injury may be present, even in the absence of active bleeding.

A review of telemedicine in vascular surgery

Telemedicine refers to the delivery of medical care through telecommunications and has been utilized by many medical specialists. In its basic form, telemedicine can involve the use of a telephone or fax. More advanced forms are the transmission of still images, often referred to as "store-and-forward" technology, or real-time two-way interactive video. The former is possible over existing phone lines or the Internet and has enjoyed success in visually oriented disciplines such as radiology and dermatology. The latter requires high bandwidth communication lines and is therefore considerably more expensive. This article reviews the use of telemedicine as applied specifically to vascular surgery. Initial studies indicate that store-and-forward technology can be used to adequately assess and treat wounds in vascular patients. A recent study reported the use of two-way interactive video for remote assessment of a wide variety of vascular patients. Diagnosis and treatment recommendations by the remote physician were found to be comparable to conventional on-site examinations. Patient satisfaction with the telemedicine examination was noted to be extremely high. In conclusion, telemedicine, although not commonly used in vascular surgery, has the potential of increasing patient access to specialty care, while decreasing patient or physician travel. The use of telemedicine in vascular surgery will likely continue to expand as technology improves and costs decrease.

Enoxaparin treatment in high-risk trauma patients limits the utility of surveillance venous duplex scanning

OBJECTIVE

The value of surveillance venous duplex scanning for detecting unsuspected deep venous thrombosis (DVT) in trauma patients who are receiving enoxaparin prophylaxis is open to question. This study was undertaken to determine whether enoxaparin reduced the clinical utility of surveillance scanning and whether management of these patients was altered by findings of the scans.

METHODS

The medical records of trauma patients who met defined criteria for high DVT risk, admitted during 30 consecutive months, were reviewed. These patients received enoxaparin 30 mg every 12 hours for the duration of their admissions. Per protocol, surveillance lower extremity venous duplex scans were performed within 72 hours of enoxaparin administration and then weekly until patients were discharged from the hospital. The records were reviewed for thromboembolic events (DVT or pulmonary embolism [PE]), patient location and ambulatory status, therapeutic interventions (systemic anticoagulation, vena cava filter), and complications of enoxaparin therapy.

RESULTS

A total 241 patients underwent 513 venous duplex examinations (1-13 per patient). Eight patients had DVT on the initial scan; seven of these patients were asymptomatic. Five were treated with anticoagulation and/or vena cava filter placement. Of the 233 patients with initially negative duplex scan results, five patients (2%) developed clinically unsuspected lower extremity DVT while hospitalized. All of these five patients were in an intensive care unit. Three of the five patients had no change in treatment. Two of the five underwent anticoagulation, and one vena cava filter was placed. PE occurred in two hospitalized patients, one of whom was ambulatory, with negative duplex scan results. After hospital discharge, six other patients had symptomatic DVT or PE despite in-hospital scans with negative results. Complications associated with enoxaparin included hemorrhage (2) and thrombocytopenia (8).

CONCLUSIONS

After initial negative scan results, repeat surveillance duplex scanning during hospitalization detected a low incidence (2%) of DVT in high-risk patients. Furthermore, the detection of unsuspected DVT altered the clinical management of less than 1% of the patients tested. Thus, after a venous duplex scan with negative results and initiation of enoxaparin prophylaxis, subsequent surveillance duplex examinations are not warranted in asymptomatic trauma patients.

Surgical management of thrombotic acute intestinal ischemia

OBJECTIVE

To evaluate the University of Kentucky experience in treating acute intestinal ischemia to elucidate factors that contribute to survival.

SUMMARY BACKGROUND DATA

Acute intestinal ischemia is reported to have a poor prognosis, with survival rates ranging from 0% to 40%. This is based on several reports, most of which were published more than a decade ago. Remarkably, there is a paucity of recent studies that report on current outcome for acute mesenteric ischemia.

METHODS

A comparative retrospective analysis was performed on patients who were diagnosed with acute intestinal ischemia between May 1993 and July 2000. Patients were divided into two cohorts: nonthrombotic and thrombotic causes. The latter cohort was subdivided into three etiologic subsets: arterial embolism, arterial thrombosis, and venous thrombosis. Patient demographics, clinical characteristics, risk factors, surgical procedures, and survival were analyzed. Survival was compared with a collated historical series.

RESULTS

Acute intestinal ischemia was diagnosed in 170 patients. The etiologies were nonthrombotic (102/170, 60%), thrombotic (58/170, 34%), or indeterminate (10/170, 6%). In the thrombotic cohort, arterial embolism accounted for 38% (22/58) of the cases, arterial thrombosis for 36% (21/58), and venous thrombosis for 26% (15/58). Patients with venous thrombosis were younger. Venous thrombosis was observed more often in men; arterial thrombosis was more frequent in women. The survival rate was 87% in the venous thrombosis group versus 41% and 38% for arterial embolism and thrombosis, respectively. Compared with the collated historical series, the survival rate was 52% versus 25%.

CONCLUSIONS

These results indicate that the prognosis for patients with acute intestinal ischemia is substantially better than previously reported.

Telemedicine in vascular surgery: does it work?

Telemedicine (TM) using closed-circuit television systems allows specialists to evaluate patients at remote sites. Because an integral part of the vascular examination involves palpation of peripheral pulses the applicability of TM for the evaluation of vascular surgery patients is open to question. This study was carried out to test the hypothesis that TM is as effective as direct patient examination for the development of a care plan in vascular patients. Sixty-four vascular evaluations were done in 32 patients. The patients presented with a variety of vascular problems and were seen in regularly scheduled rural outreach vascular clinics. Two faculty vascular surgeons evaluated each patient; one was on site and the second, using TM, remained at the medical center. Each surgeon was blinded to the other's findings. The TM physician was aided by a nonphysician assistant, who obtained blood pressures, utilized a continuous-wave Doppler probe, positioned the patient, and operated the TM equipment. The results of each surgeon's evaluations were compared. Patient and physician satisfaction with the TM evaluation was appraised by questionnaires. Eight patients were seen for initial evaluations; 24 patients were seen for follow-up visits. Patients were seen with a variety of diagnoses, including aneurysm (seven), cerebrovascular disease (five), lower extremity occlusive disease (13), multiple vascular problems (three), and other disease (four). The average duration for the TM and on-site evaluations were 20.6+/-1.4 and 19.0+/-1.3 minutes, respectively (P = not significant). Physician concordance, as determined by treatment recommendations, was the same in 29 (91%) patients. Physician confidence in the ability to obtain an accurate history via TM was rated as excellent in 97 per cent; confidence in the TM physical examination was rated as excellent in 70 per cent. All patients rated the TM evaluation as the "same as" or "better than" the on-site examination, and all indicated a preference for being seen locally using TM as opposed to traveling to a regional medical center. We conclude that the TM evaluation of vascular patients is accurate and is as effective as on-site evaluations for a variety of vascular problems. Important adjuncts to enhance the success of a TM evaluation are physician experience with the technology and the presence of a knowledgeable on-site assistant. This technology can be easily adapted to other clinical situations.

Telemedicine in Vascular Surgery: Does it Work?

Telemedicine (TM) using closed-circuit television systems allows specialists to evaluate patients at remote sites. Because an integral part of the vascular examination involves palpation of peripheral pulses the applicability of TM for the evaluation of vascular surgery patients is open to question. This study was carried out to test the hypothesis that TM is as effective as direct patient examination for the development of a care plan in vascular patients. Sixty-four vascular evaluations were done in 32 patients. The patients presented with a variety of vascular problems and were seen in regularly scheduled rural outreach vascular clinics. Two faculty vascular surgeons evaluated each patient; one was on site and the second, using TM, remained at the medical center. Each surgeon was blinded to the other's findings. The TM physician was aided by a nonphysician assistant, who obtained blood pressures, utilized a continuous-wave Doppler probe, positioned the patient, and operated the TM equipment. The results of each surgeon's evaluations were compared. Patient and physician satisfaction with the TM evaluation was appraised by questionnaires. Eight patients were seen for initial evaluations; 24 patients were seen for follow-up visits. Patients were seen with a variety of diagnoses, including aneurysm (seven), cerebrovascular disease (five), lower extremity occlusive disease (13), multiple vascular problems (three), and other disease (four). The average duration for the TM and on-site evaluations were 20.6 ± 1.4 and 19.0 ± 1.3 minutes, respectively ( P = not significant). Physician concordance, as determined by treatment recommendations, was the same in 29 (91%) patients. Physician confidence in the ability to obtain an accurate history via TM was rated as excellent in 97 per cent; confidence in the TM physical examination was rated as excellent in 70 per cent. All patients rated the TM evaluation as the “same as” or “better than” the on-site examination, and all indicated a preference for being seen locally using TM as opposed to traveling to a regional medical center. We conclude that the TM evaluation of vascular patients is accurate and is as effective as on-site evaluations for a variety of vascular problems. Important adjuncts to enhance the success of a TM evaluation are physician experience with the technology and the presence of a knowledgeable on-site assistant. This technology can be easily adapted to other clinical situations.

Popliteal artery thrombosis associated with trampoline injuries and anterior knee dislocations in children

Recent reports have emphasized the benign nature of trampoline-associated injuries. However, this study describes the limb-threatening problem of popliteal artery thrombosis occurring in association with anterior knee dislocation and trampoline injuries. Three children (ages 11, 13, and 17) were referred to the emergency room within the past 12 months with anterior dislocations of the knee, which occurred while jumping on trampolines. All patients had reduction of their dislocations at outside facilities and were referred within 6 to 12 hours after their injuries, with pulse, motor, and sensory deficits. All patients were taken directly to the operating room, where arteriography confirmed thrombosis of the popliteal artery below the knee. One patient had transection of the artery, whereas two patients had stretch injuries with intimal separation. Each patient required interposition grafting with reversed saphenous vein and underwent concomitant four-compartment fasciotomy. All patients had persistent sensory and motor deficits postoperatively, which were presumed to be a combination of ischemic injury and neuropraxia. All patients have functioning grafts with an average follow-up of 1 year (range, 9-15 months). One patient required a second interposition graft to treat an area of intimal hyperplasia, which developed at the proximal anastomosis, at 6 months postoperatively. Eighty per cent of trampoline injuries are associated with minor injuries with minimal long-term complications. However, dislocations of the knee may be associated with significant arterial injury and amputation rates of up to 30 per cent in many blunt trauma series. Based on our experience, physicians should recognize the possibility of significant arterial injuries occurring in children with anterior knee dislocations while jumping on trampolines.

Nontraumatic lower-extremity acute arterial ischemia

BACKGROUND

The outcome of arterial bypass reconstruction in the setting of acute arterial ischemia has not been well defined.

METHODS

This retrospective review consists of 71 consecutive patients (54 with native arterial thrombosis, 17 with graft thrombosis) who underwent an urgent/emergent arterial bypass reconstruction for acute arterial ischemia with threatened limb viability.

RESULTS

The 30-day mortality and major amputation rates were 9.9% and 7.1%, respectively. Death, limb loss, or both, were associated with a paralytic limb (P = 0.001) and congestive heart failure (P = 0.03). Overall, 45 of 71 (63%) patients were discharged with limb salvage and ambulatory function. Cumulative graft patency was 77% and 65% at 1 and 2 years, respectively, and closely approximated the 1- and 2-year limb-salvage rates of 76% and 63%, respectively.

CONCLUSIONS

Arterial bypass reconstructions appear warranted in acute arterial ischemia, in that a majority of patients retain a functional viable limb. Late graft thrombotic complications limit long-term benefit.

Process improvements reduce utilization of resources for aortic aneurysm repair

In conjunction with the VA reorganization to promote greater efficiency of health care provision, ambulatory surgery (AS) programs have been created. These programs institute outpatient preoperative assessment and operative management. This study examines the impact of these process changes on resources utilized by patients requiring repair of abdominal aortic aneurysms (AAAs). The medical records of 15 consecutively treated patients undergoing elective, infrarenal AAA repair before (1992-1993) and after (1995-1996) AS implementation were reviewed. Resource utilization was assessed by evaluating preoperative tests performed (inpatient or outpatient), ICU days, and inpatient length of stay (LOS). Postoperative morbidity and mortality were noted. Patient age, AAA size, and prevalence of diabetes mellitus, hypertension, cardiac disease, COPD, and tobacco use were similar between the two groups. Abdominal ultrasound, CT scanning, and angiography were significantly more frequently performed on an outpatient basis after implementation of the AS program. The median preoperative LOS was reduced in the AS group (1 vs 6 days, P = 0.001, Student t test), resulting in a lower inpatient LOS (11 vs 16, P < 0.01, Student t test). All patients survived and the incidence of complications was similar between the groups. Hospital resource utilization was significantly decreased, largely by shifting preoperative assessment to the outpatient setting. This study illustrates that benefits of an ambulatory surgery program can be extended beyond facilitating outpatient operations and should result in decreased length of hospitalization for other major surgical procedures, such as abdominal aortic aneurysm repair.