Invited commentary

Abstract

In their article, Drs Hanley and colleagues describe a recent series from McGill University Health Centre and Jewish General Hospital in Montreal, Quebec. In this series, 110 patients were targeted for same-day discharge after endovascular treatment of their abdominal aortic aneurysm. Ultimately, 87 of these patients had a “successful” same-day discharge, raising some important questions about the feasibility and potential broader application of this concept. Could patients really go home on the same day as their aortic aneurysm repair? The authors took several important steps to try to smooth the pathway after an early discharge. Careful attention to social support, excluding those with major comorbidity or anatomically complex repair, and extra attention to early educational efforts were all likely to be important contributions toward a safe and early discharge among the 87 patients in whom this approach was successful. But what about the 23 patients who had complications after early discharge? One in five patients needed emergency department attention for potentially troublesome problems, such as access site complications or limb occlusions. Even among this highly select population, failure of same-day discharge occurred somewhat commonly. Early discharge is a laudable goal after surgery, as complications related to hospital-based care are common.1Makary M.A. Daniel M. Medical error—the third leading cause of death in the US.BMJ. 2016; 353: i2139Crossref PubMed Scopus (1726) Google Scholar Furthermore, early recovery after surgery programs have gained traction in other specialties,2Holm B. Thorborg K. Husted H. Kehlet H. Bandholm T. Surgery-induced changes and early recovery of hip-muscle strength, leg-press power, and functional performance after fast-track total hip arthroplasty: a prospective cohort study.PLoS One. 2013; 8: e62109Crossref PubMed Scopus (37) Google Scholar, 3Bardram L. Funch-Jensen P. Jensen P. Crawford M.E. Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation.Lancet. 1995; 345: 763-764Abstract PubMed Scopus (440) Google Scholar and spillover effects will likely affect the care of patients being treated for vascular disease. But a cautionary approach may be the best pathway forward for vascular patients facing endovascular aneurysm repair (EVAR). Mortality in most reports is <2% with EVAR, and an event such as hemorrhage related to access may contribute more potential morbidity and mortality if it occurs outside a hospital setting. Furthermore, payment mechanisms in the United States require a 24-hour hospital stay for remuneration after EVAR.4Warner C.J. Horvath A.J. Powell R.J. Columbo J.A. Walsh T.R. Goodney P.P. et al.Endovascular aneurysm repair delivery redesign leads to quality improvement and cost reduction.J Vasc Surg. 2015; 62: 285-289Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 5Stone D.H. Horvath A.J. Goodney P.P. Rzucidlo E.M. Nolan B.W. Walsh D.B. et al.The financial implications of endovascular aneurysm repair in the cost containment era.J Vasc Surg. 2014; 59: 283-290, 290.e1Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Early reports of “safe” 24-hour discharge may have the unintended consequence of convincing payers that all patients could be discharged this rapidly after a major aortic intervention. This would very likely be too much, too soon. Safety and feasibility of endovascular aortic aneurysm repair as day surgeryJournal of Vascular SurgeryVol. 67Issue 6PreviewThe adoption of endovascular aneurysm repair (EVAR) during the past two decades has led to significantly shorter length of stay as well as lower hospital resource use. Currently, most patients are admitted to the hospital after EVAR; however, there are no standard observation periods, and timing of discharge is based on clinical judgment. The aim of this study was to confirm the safety and feasibility of performing EVAR as outpatient surgery. Full-Text PDF Open Archive