Objective(s) Carotid Endarterectomy (CEA) is a commonly performed vascular operation. Yet, post-operative length of stay (LOS) varies greatly even within institutions. In the present study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed in order to establish modifiable factors associated with prolonged hospital stay. Methods The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between 6/1/2011 and 11/28/2014. Pre-operative patient characteristics, intra-operative details, post-operative factors, long-term outcomes and cost data were reviewed using an Institutional Review Board (IRB) approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤ 1 day and >1 day. Results Complete 30-day variable and cost data was available for 219 patients with an average follow-up of 12 months. 79 (36%) patients had a LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included pre-operative creatinine (p=0.02) and severe congestive heart failure (p=0.05) with self-pay status (p=0.02) and pre-operative beta-blocker therapy (p=0.04) being protective. Shunt placement (p=0.04), arterial re-exploration and post-operative cardiac (p=0.001) or neurological (p=0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (p=0.04), drain placement (p=0.05), prolonged operative time (101 minutes vs 125 minutes p=0.01), return to the OR (p=0.01), and post-operative hypertension (p=0.02) or hypotension (p=0.04). Of note, there was no difference in LOS associated with technique (conventional vs eversion), patch use (p=0.49), protamine administration (p=0.60), EEG monitoring (p=0.45), measurement of stump pressure (p=0.63), doppler (p=0.36) or duplex (p=0.92). Both hospital charges (p=0.0001) and costs (p=0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (p=.10). Increased LOS after CEA was associated with an increase in 12-month mortality (p=0.05). Conclusions Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Further, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.
Objective Endovascular aneurysm repair (EVAR) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly, even within institutions. The present study reviewed the morbidity, mortality, and the financial effect of increased LOS to establish modifiable factors associated with prolonged hospital LOS, with the goal of improving quality. Methods The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients under-going primary, elective EVAR at a single institution between January 1, 2011, and May 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤2 days and >2 days. Results Complete 30-day variable and cost data were available for 138 patients with an average follow-up of 12 months; of these, 46 (33%) had a LOS >2 days. Variables determined to be statistically significant predictors of prolonged LOS included aneurysm diameter (P = .03), American Society of Anesthesiologists Physical Status Classification score (P < .001), thromboembolectomy (P = .01), and increased postoperative cardiac (P < .001) and renal (P = .01) complications. Specifically, modifiable risk factors that contributed to increased LOS included performance of a concomitant procedure (P < .001), increased volume of iodinated contrast (P = .05), increased volume of intraoperative crystalloid (P = .05), placement in an intensive care unit (P < .001), return to the operating room (P < .001), and the use of vasoactive medications (P < .001). Hospital charges ($102,000 ± $41,000 vs $180,000 ± $73,000; P = .01) and costs ($27,000 ± $10,000 vs $45,000 ± $19,000 P = .01) were significantly higher in patients with prolonged LOS; however, there was no difference in physician charges ($8000 ± $5700 vs $12,000 ± $12,000; P = .09). Increased LOS after EVAR was associated with an increase in mortality at 1 month (0% vs 4% P = .05) and 12 months (3% vs 13% P = .03). Conclusions This study highlights several modifiable risk factors leading to increased LOS after EVAR, including performance of concomitant procedures, admission to the intensive care unit, and postoperative renal and cardiac complications. Further, increased LOS was associated with increased charges, costs, morbidity, and mortality after EVAR. This study highlights specific areas of focus for decreasing LOS after EVAR and, in turn, improving quality in vascular surgery.
The mean length of covered aorta was significantly shorter in patients undergoing early TEVAR (20.7 vs 23.5 cm; P ¼ .03). In addition, the early TEVAR group received significantly fewer endografts (1.6 vs 2.0; P ¼ .01). Overall longterm survival was significantly higher in those undergoing early compared with late TEVAR (KM 7-year: 93.8% vs 70.8%, respectively; P ¼ .044), although there was no difference late aorta-specific survival between the early and late groups (KM 7-year: 100.0% vs 95.3% respectively; P ¼ .121; Fig). Conclusions: In patients with type B aortic dissection, the timing of TEVAR (early vs late) was not associated with the degree of FLT and aortic remodeling during follow-up, although patients who underwent TEVAR within 3 months of their dissection event required significantly shorter aortic pavement and fewer devices to achieve this similar degree of aortic remodeling. Similarly, long-term aorta-specific survival was not different for patients undergoing TEVAR for type B dissection whether treated early or late. These data suggest that delaying TEVAR after dissection until aortic complications develop may not compromise the ability to prevent aorta-related death, although additional study, ideally with randomized controlled trials, is needed.
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