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Preoperative Risk Factor Profiling To Identify Candidates For Evar In Ambulatory Surgery Centers
Maciej L. Dryjski, MD, PhD1, Monica S. O'Brien-Irr1, Hasan H. Dosluoglu2, Gregory S. Cherr1, Mariel Rivero2, Linda M. Harris1.
1Kaleida Health, Buffalo, NY, USA, 2VA Western NY Healthcare System, Buffalo, NY, USA.
Objective(s): Same day discharge (SDD); feasible in 20%-46% of elective endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA) has generated interest in using free-standing ambulatory surgery centers (ASC). This would require high level selectivity. We evaluated the potential ability to pre-operatively identify candidates in whom EVAR could be safely performed in an ASC.
Methods: Elective EVARs performed over a 1 ½ year period were identified. Demographics, comorbidities, complications, care were analyzed: Chi Sq., Odds Ratio (SPSS 23). Sensitivity/ negative predictive values (NPV) were calculated. Results: Sixty-seven (73%) EVAR were elective. Intra/post-operative complications were blood loss/transfusion 4.5%, thrombosis 3%, femoral artery injury 1.5%, urinary retention 4.5%, MI 3%, respiratory failure 1.5%, CHF 1.5%, hemodynamic/rhythm alterations 37%. Ten (15%) required ICU admission. Twenty-eight (46%) without complication, who required monitoring services only were deemed SDD candidates (SDD-C). Preoperative risks were less common in SDD-C: 54% vs. 90%; P= .001, age >75: 49% vs.71%; P= 0.021, minority: 55% vs. 100%; P= 0.05, atrial fibrillation: 53% vs. 90%; P= 0.03, renal insufficiency: 53% vs.90%; P= 0.03 and COPD: 48% vs. 74%; P=0.03 (independent predictor; OR 4.0 (1.03-15.4); P= 0.05). Presence of at least 1 risk was associated with ICU admission and postoperative complication /treatment but not operative complication (Table I). Sensitivity and NPV declined for each outcome in the presence of any single risk. Seventeen (25%) had no preoperative risks: 13(19%) SDD-C; 4(6%) complicated: 2 non-treated arrhythmia, 1 urinary retention requiring straight catheterization (minor), 1(2%) intraoperative arterial injury/ blood loss requiring transfusion. Sensitivity and NPV was 97%/93% in those without risk and minor complications.
Conclusions: Nearly 25% of elective EVAR might reasonably be performed in ASCs. Preoperative risk profiling although restrictive, can identify patients requiring ICU admission, those with uncomplicated courses or who require minor treatment/monitoring that could be provided in an ASC. However, operative complication is not as reliably predictable. This small but incontrovertible risk must be considered if contemplating EVAR in free-standing ACS’s.
|Indicators||#Preoperative Risks||P=||Profile:Patients with NO Risks|
|Postoperative Complication or Need for Treatment||24%||53%||86%||100%||100%||0.001||90%||75%|
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