Five-step protocol for carotid endarterectomy in the managed health care era.

BACKGROUND: We developed a protocol combining 5 cost-effective strategies to determine whether elective carotid endarterectomy (CEA) could be performed safely without adversely affecting well-established low morbidity and mortality rates and with significant hospital cost savings. METHODS: Between April 1, 1995, and December 31, 1996, 109 of 141 patients were prospectively enrolled as candidates into a 5-step CEA protocol: (1) duplex ultrasonography (DU) performed at an accredited vascular laboratory as the sole diagnostic carotid preoperative study, (2) admission the day of operation, (3) cervical block anesthesia to eliminate intraoperative electroencephalogram monitoring, (4) transfer from the recovery room after a 4-hour observation period to the vascular ward, and (5) discharge the first postoperative morning. The other 32 patients were excluded from analysis; 16 patients were treated by vascular surgeons not participating in the protocol, 9 were treated concomitantly for other medical problems, and 7 were admitted emergently. RESULTS: One patient died of carotid hemorrhage the first postoperative morning, and one had an intraoperative embolic stroke for a combined mortality-stroke rate of 1.8% (2 of 109). Of the 109 patients, 70% (76) underwent operation using DU as the sole diagnostic study, 95% (104) were admitted the day of operation, 76% (83) had cervical block anesthesia, 59% (64) were transferred to the floor the day of operation, and 83% (90) were discharged the morning after operation. None of the 109 patients were adversely affected by these 5 cost-saving strategies except potentially the patient who bled the first postoperative morning. The predicted charges of a patient treated with a perioperative protocol that many vascular surgeons currently use (preoperative arteriography, general anesthesia with intraoperative electroencephalogram monitoring, overnight intensive care unit stay, discharge on postoperative day 2) was $16,073 compared with $10,437 for a patient who completed all 5 steps of the protocol detailed above. CONCLUSIONS: On the basis of these results documenting significant cost savings and acceptably low morbidity and mortality rates, this 5-step protocol may be considered the standard for performing CEA in this era of cost containment. These results may be compared with endovascular intervention, which has recently been proposed as a less expensive technique to treat carotid disease.

Is balloon angioplasty indicated for "short" stenoses of failing vein grafts?

Previous reports have suggested "short" focal stenoses in peripheral vein grafts (PVGs), namely less than 2 cm long, can be successfully balloon dilated with good long-term patency rates. We questioned if enthusiasm for balloon angioplasty of these lesions in failing PVGs is warranted. Between August 1, 1993 and December 31, 1996, we performed balloon angioplasty of "short" stenoses in 19 PVGs in 16 patients. Bypasses included seven femoropopliteal, six femorotibial, and six popliteal-tibial or -pedal PVGs. All bypasses were originally performed for limb salvage. Single lesions were present in 13 grafts and two lesions in six grafts. Ten lesions were located at an anastomosis, 10 were located in the body of the graft, and five were peri-anastomotic. Fifteen procedures were performed percutaneously. Four angioplasties were performed using an open surgical approach because a percutaneous attempt failed in one case and three grafts were either in situ or tunneled subcutaneously making them easy to expose. Completion arteriogram documented excellent initial results in all 19 grafts. Cumulative one-year primary patency rate was 39%. The assisted primary patency rate at one year was 73%. Only five grafts remained patent 7-20 months (mean, 10 months) during follow-up without requiring further revision. One patient died with a patent graft 23 months post-balloon angioplasty. Complications included two hematomas following a percutaneous approach that required surgical repair. These results when compared to publications detailing patency following surgical revision suggest that balloon angioplasty of "short" stenoses less than 2 cm long in PVGs may be better treated by surgical revision. We reserve balloon angioplasty for "short" lesions when surgical revision is associated with inordinate difficulty such as a scarred groin wound in an obese patient.