Abstract
Keywords
The concept of “fast-track” surgery also known as “multimodal rehabilitation after surgery” has found mention in the surgical literature over the past 2 decades.1,2 The interventions involved in a fast-track protocol target the patient in each phase before, during, and after surgery. Overall, surgery is undergoing revolutionary changes due to newer approaches for pain control, the introduction of techniques that reduce the perioperative stress response, and the use of minimally invasive operations, which in turn are expected to reduce postoperative complications, length of hospital stay, and time to recovery.
In the February 2018 issue of the JEVT, Krajcer et al 3 present outcomes from the Least Invasive Fast-track EVAR (LIFE) registry, which used a protocol made possible by the development of new ultralow-profile delivery systems. Their goals were to further decrease morbidity, reduce hospital stay, lower overall costs, and improve patient satisfaction. In the current economic climate, these goals are commendable, and shorter hospitalization without intensive care unit stay is particularly appealing, but the fast-track endovascular aneurysm repair (EVAR) protocol cannot be proposed for all patients. According to Krajcer et al, 3 two-thirds of their patients (66%) were eligible, highlighting that correct patient selection is crucial. Inappropriate selection of patients can lead to fast-track failure and may prolong the hospital stay. 4
Key inclusion criteria in the fast-track LIFE registry were anatomy suitable for endovascular repair with the Ovation Prime Abdominal Stent Graft (Endologix, Inc, Irvine, CA, USA) and the pre-close technique using the Perclose ProGlide Suture-Mediated Closure System (Abbott Vascular, Santa Clara, CA, USA). Surprisingly, only 10% of the 376 patients screened for eligibility were excluded based on unsuitability for the Ovation stent-graft, which reveals a very high eligibility rate (89.9%) for EVAR with this particular device.
Typically, the feasibility of EVAR for infrarenal abdominal aortic aneurysm (AAA) has been mainly related to aortic morphology, with the majority of manufacturers’ original instructions for use (IFU) requiring an adequate nonaneurysmal proximal neck of 10 to 15 mm, an aortic diameter <30 mm, and infrarenal angulation <60°. A recent study reported that 72% of 158 consecutive AAA patients were eligible for EVAR with the Ovation device among all endograft IFUs compared (Incraft, 63%; Nellix, 60%; Endurant-II, 59%; Excluder, 55%; Zenith-Flex, 36%; Aorfix, 35%; p<0.001). 5 Unsuitable proximal neck anatomy followed by inadequate access vessels were the primary reasons for ineligibility.
Having been designed for circumferential rather than longitudinal sealing, the Ovation was the first stent-graft to be approved for a proximal neck <10 mm when it was launched on the market. In April 2014, the Food and Drug Administration (FDA) approved changes to the indication statement for the Ovation, and since then it has been the only FDA-approved AAA stent-graft that is not restricted by the conventional measurement of aortic neck length in its labeling.6,7 This means that the Ovation system may be used in all aneurysmal necks when the inner wall diameter is within the range of compatibility with the polymer-filled rings (16–30 mm). This fact may somewhat explain why the eligibility rate was particularly high in the LIFE registry: 27% of patients had a proximal neck <15 mm.
Although a selective protocol for the use of a percutaneous approach (Supplemental Table 2 in the Krajcer article 3 ) was applied, only 5% of the screened population was excluded from percutaneous EVAR. Most important, only a few failures of percutaneous vessel closure occurred in the registry (2 at initial access and 6 were converted at the end of EVAR). None occurred after procedure completion, making the 1-day discharge extremely safe with regard to access-related complications.
Room type may also play a role in a fast-track program. Hybrid suites are becoming available in hospitals all over the world as more practitioners lobby their administrations for the possibility to advance their practice and provide superior technical alternatives. In the present registry, more patients completed the fast-track procedure having their EVAR in a hybrid suite/catheterization laboratory (89.6%; 138/154) rather than in the operating room (81.3%; 78/96). Although this difference was not significant, these data are clinically relevant since they demonstrate that EVAR can be performed outside of a traditional operating room, which may ultimately yield cost savings.
Regarding concerns about premature discharge and life-threatening early complications, the 1.4% 30-day hospital readmission rate in patients who completed the fast-track protocol was particularly remarkable considering that the incidence of major adverse events through 30 days was as low as 0.4%.
Finally, taking into account the predefined exclusion criteria for a fast-track procedure (unstable angina, severe peripheral artery disease, severe congestive heart failure, previous myocardial infarction or stroke) and the risk predictors from the logistic regression analysis (small external iliac artery diameter and congestive heart failure), results from the LIFE registry set a well-defined subgroup of patients who can really benefit from a fast-track EVAR procedure. The application of such a protocol may not only result in efficient perioperative resource utilization but also provide a better patient experience.
Bearing in mind that the perioperative risk of vascular disease patients is particularly high owing to greater prevalence of cardiovascular comorbidity, the benefits of quick periprocedural management and early patient mobilization become obvious. The fast-track concept may currently represent uncharted territory in the field of vascular surgery. However, a study such as the one by Krajcer et al 3 that demonstrates the feasibility of a fast-tract protocol in well-selected patients, the efficient use of perioperative resources, and excellent safety and effectiveness opens a new door for the future of endovascular aneurysm repair.
