Carol A. Raviola

Impact of clinical pathways on hospital costs and early outcome after major vascular surgery

PURPOSE The purpose of this study was to determine whether major vascular surgery could be performed safely and with significant hospital cost savings by decreasing length of stay and implementation of vascular clinical pathways. METHODS Morbidity, mortality, readmission rates, same-day admissions, length of stay, and hospital costs were compared between patients who were electively admitted between September 1, 1992, and August 30, 1993 (group 1), and January 1 to December 31, 1994 (group 2), for extracranial, infrarenal abdominal aortic, and lower extremity arterial surgery. For group 2 patients, vascular critical pathways were instituted, a dedicated vascular ward was established, and outpatient preoperative arteriography and anesthesiology-cardiology evaluations were performed. Length-of-stay goals were 1 day for extracranial, 5 days for aortic, and 2 to 5 days for lower extremity surgery. Emergency admissions, inpatients referred for vascular surgery, patients transferred from other hospitals, and patients who required prolonged preoperative treatment were excluded. RESULTS With this strategy same-day admissions were significantly increased (80% [145/177] vs 6.2% [9/145]) (p < 0.0001), and average length of stay was significantly decreased (3.8 vs 8.8 days) (p < 0.0001) in group 2 versus group 1, respectively. There were no significant differences between group 1 and group 2 in terms of overall mortality rate (2.1% [3/145] vs 2.3% [4/177]), cardiac (3.4% [5/145] vs 4.0% [7/177]), pulmonary (4.1% [6/145] vs 1.7% [3/177]), or neurologic (1.4% [2/145] vs 0% [0/177]) complications, or readmission within 30 days (11.3% [16/142] vs 9.2% [16/173]) (p > 0.05). There were also no differences in morbidity or mortality rates when each type of surgery was compared. Annual hospital cost savings totalled

Arterial and ischemic aspects of total knee arthroplasty.

1,267,445. CONCLUSION Same-day admission and early hospital discharge for patients undergoing elective major vascular surgery can result in significant hospital cost savings without apparent increase in morbidity or mortality rates.

Use of arm and lesser saphenous vein compared with prosthetic grafts for infrapopliteal arterial bypass: Are they worth the effort?

Prospective and retrospective analyses of 1,182 consecutive patients undergoing primary total knee arthroplasty (TKA) were performed to determine (1) the incidence of chronic lower extremity ischemia (CLEI); (2) the effect of tourniquet occlusion; and (3) guidelines that will allow TKA to be performed safely. Despite the appropriately advanced age of our patients, the incidence of CLEI was only 2%. All ischemic complications occurred in six patients with CLEI (25%), but none resulted in death or amputation. The ischemic complications consisted of pressure-induced necrosis of toes, heel, or foot, atheroembolism, femoral-popliteal graft occlusion, and asymptomatic popliteal occlusion. Tourniquet compression in the 1,158 patients without CLEI produced no untoward effects. Patients with mild CLEI can have a TKA performed safely with a tourniquet if there is no femoropopliteal calcification. When the ischemia is severe or there is a femoropopliteal aneurysm, arterial reconstruction should precede the TKA. In patients with patent femoral-popliteal bypasses or calcification without ischemia, TKA should be performed without a tourniquet. Ischemic pressure necrosis is an additional mechanism of injury.

Selective use of duplex ultrasound to replace preoperative arteriography for failing arterial vein grafts

PURPOSE Arm and lesser saphenous veins (ALSVs) are generally considered to be the best alternative for infrapopliteal arterial bypass grafts when greater saphenous vein is not available. The need for additional incisions and repositioning of the patient, along with occasional use of general anesthesia for arm vein harvesting, led to our perception that the use of ALSVs increased operative time and possibly patient discomfort. Therefore, we compared the outcome of ALSVs with that of prosthetic infrapopliteal arterial bypass procedures performed at our hospital. METHODS Between July 1, 1991, and Dec. 31, 1996, we performed 96 infrapopliteal arterial bypass procedures using 45 ALSVs (28 arm vein, 17 lesser saphenous) and 51 polytetrafluoroethylene (PTFE) grafts. Seventy grafts were single-length ALSV or PTFE bypass grafts, and 26 grafts were placed as the distal segment of a sequential or composite bypass graft. Every attempt was made to use ALSV and avoid the use of PTFE, even if a short segment of the vein graft measured less than 4.0 mm in diameter. There were no significant differences between patients with ALSV compared with PTFE grafts in terms of age, sex, indication for surgery, or number of previous revascularization procedures (2.1 vs 1.7), respectively (p > 0.05). However, ALSV grafts had more factors associated with an expected worse outcome: they were more commonly anastomosed to pedal arteries (17% [8 of 45] vs 0%; p = 0.0009), less commonly single-segment grafts (62% [28 of 45] vs 82% [42 of 51]; p = 0.03), had higher average runoff resistance values (2.3 vs 1.5; p = 0.001), and were less frequently treated with lifelong warfarin (65% [29 of 45] vs 95% [48 of 51]; p = 0.0001). RESULTS The hospital mortality rate was 3.1% (3 of 96; 3 PTFE). All deaths were cardiac-related. Despite the potential factors associated with worse patency rates for ALSVs, 2-year assisted primary patency rates tended to be higher for arm veins (46%) than for lesser saphenous veins (23%) and PTFE grafts (26%), although this difference was not statistically significant. Limb salvage rates were similar between ALSV and PTFE grafts (76% vs 71%, respectively). The average operative time was significantly longer for ALSV bypass procedures (mean, 6.2 hours) than for PTFE bypass procedures (mean, 4.9 hours; p = 0.003), and for single-length conduits when revision of previously placed grafts was not attempted, the operative time was 4.0 hours for ALSV grafts and 2.5 hours for PTFE grafts. CONCLUSION In our experience ALSV bypass grafts to infrapopliteal arteries do not function as well as reported by some others. In spite of the extra effort involved, arm vein grafts are preferred over PTFE grafts for their likely higher assisted primary patency rates and equivalent, if not better, limb salvage rates.

Femoropopliteal tibial bypass: What price failure?

PURPOSE In an effort to minimize costs and patient discomfort, we determined whether duplex ultrasound (DU) could selectively replace preoperative arteriography performed in the radiology suite to diagnose failing arterial bypass grafts (FABs) constructed of autogenous vein. METHODS Between January 1, 1994, and December 31, 1996, we treated 106 FABs. Graft revision solely on the basis of DU was performed only if a focal stenosis was clearly identified in the graft (peak systolic velocity [PSV] > 300 cm/sec, ratio of adjacent PSVs > 3.0) or in inflow or outflow arteries (resulting in uniform graft PSVs < 45 cm/sec). Intraoperative arteriograms were frequently obtained to confirm DU findings. Preoperative arteriograms were obtained if DU revealed multiple or ill-defined stenoses, diffuse inflow or outflow arterial disease, uniformly low PSVs without an identifiable lesion, or equivocal stenosis despite clinical evidence of an FAB. RESULTS Seventy-three (69%) FABs with 81 lesions were revised on the basis of DU only. Of 76 stenotic lesions, an intraoperative arteriogram or surgical findings confirmed a diameter stenosis of 75% to 99% in 69 grafts (91%) and stenosis of 50% to 74% in three grafts (4%). DU incorrectly identified the site of stenosis or underdiagnosed the extent of disease in four grafts (5%). DU correctly identified the site of missed arteriovenous fistulas in five grafts. The 73 FABs were treated with intraoperative balloon angioplasty (30 grafts), patch angioplasty (20), interposition or jump grafts (12), ligation of arteriovenous fistula (3), a new bypass graft (1), or a combination of these interventions (7). A significant change in intraoperative strategy potentially could have been avoided if a preoperative arteriogram had been obtained in three of the 73 FABs (4.1%). CONCLUSIONS DU can reliably be used to revise FABs and avoid the morbidity, discomfort, and cost of confirmatory arteriography in two thirds of cases.

Same-day admissions and other cost-saving strategies for elective aortoiliac surgery

The consequences of failure in 235 femoropopliteal and femorotibial operations are reviewed and compared with the benefits of success so that an accurate perspective of risk-benefit analysis can be achieved. In 72 operations performed for claudication, 10 grafts thrombosed early. The cost included nine reoperations to achieve eight patent grafts and a 12 day average increase in hospital stay. There were no deaths. The benefit obtained was 70 of 72 (97 percent) asymptomatic limbs. In 163 grafts placed for limb salvage, there were 58 initial thromboses. Reoperation in 28 produced an additional 14 patent grafts. The cost of thrombosis was an increase in mortality from 5.6 to 10.7 percent, a 12 day average increase in hospital stay, and raising of preoperative predicted amputation level from below to above the knee in 11 patients with thrombosed grafts whose distal anastomoses were below the knee. This contrasted with a 73 percent limb salvage rate in 104 patients whose preoperative predicted amputation level was below the knee, and a 54 percent limb salvage and a 12 percent lowering of amputation level in 39 patients whose preoperative amputation level was above the knee. Of patients with patent grafts, 89 percent achieved limb salvage. We conclude that the benefits of success in attempted vascular reconstruction for threatened limb loss far outweigh the risks of failure and that the combined results were far superior to the expected outcome in comparable patients undergoing primary amputation.

The limitations of predictability of success of femoral-popliteal bypass grafts.

PURPOSE We retrospectively analyzed whether same-day admissions and other resource utilization methods for patients undergoing elective infrarenal aortoiliac surgery (AoIS) were safe and cost-effective. METHODS Morbidity and mortality rates and costs were compared between 71 patients admitted before the day of surgery (group I) and 57 patients admitted the day of surgery (group II) who underwent elective AoIS between July 1, 1992, and December 31, 1995. After January 1, 1994, a concerted effort was made to decrease hospital costs by performing out-patient preoperative assessment, admitting patients the morning of surgery, and planning early discharge through implementation of clinical pathways. Patients were excluded (total, 33; 20%) from analysis if they were admitted before the day of surgery for intravenous hydration (5), optimizing cardiac function (4), or prolonged preoperative antibiotics (2), or if they required emergency surgery (10) or were transferred from another service or hospital (12). After exclusion, there were no significant differences (p > 0.05) between groups I and II in terms of age, sex, race, diabetes, hypertension, pulmonary disease, cardiac disease, renal insufficiency, type of incision (midline or retroperitoneal), indication for surgery (aneurysm or occlusive disease), or inflow site (aorta or common iliac artery). RESULTS There were no significant differences between groups I and II in terms of mortality rate (0%); cardiac (1.4% [1/71] vs 0%), pulmonary (9.9% [7/71] vs 5.3% [3/57]), or renal (1.4% [1/71] vs 0%) complications; or readmission rates within 30 days (5.6% [4/71] vs 5.2% [3/57]), respectively (p > 0.05). There were significant decreases in length of hospital stay (mean, 6.4 vs 11.2 days; p < 0.0001) and hospital cost per patient (

Thrombolytic and endovascular treatment of peripartum iliac vein thrombosis: A case report

34,198 vs

Carotid stump pressure, stump pulse, and retrograde flow

45,694; p = 0.001) for group II compared to group I, respectively. CONCLUSIONS The majority of patients who require elective infrarenal aortoiliac surgery can be admitted the day of surgery and undergo early discharge with significant hospital cost savings and without apparent increase in morbidity or mortality rates.

Pulmonary Risk Factors of Elective Abdominal Aortic Surgery

This study was carried out to determine whether we could develop a model to identify predictive factors for success of femoral-popliteal (FP) bypass grafts. In a retrospective review of 199 operations, 24 factors influencing outcome were selected by stepwise logistic regression analysis, a sophisticated, multifactorial computer program. The top five indicators (excluding intraoperative technical problems) were runoff status, previous ipsilateral FP bypass, preoperative prediction of potential amputation level, concurrent proximal vascular reconstruction, and site of the distal anastomosis. We chose to validate the predictive model developed before applying it clinically. Data from 67 subsequent cases were presented to the computer without the known outcome, and the probability of 30-day patency was calculated. The model predicted 11 failures; there were actually eight thromboses in the 67 grafts. However, only three of the failures were predicted correctly, and eight cases of computer-anticipated thromboses were patent at 30 days. The high false positive rate makes the clinical application of the predictive model inappropriate. The success of FP bypass grafts appears to be related to factors that cannot be assessed preoperatively, such as technical problems during surgery. Even those which seem to have a poor runoff and other high-risk factors may succeed; thus an aggressive approach is justified in lower extremity reconstructions.