Duplex ultrasonography to diagnose failing arterial prosthetic grafts.

BACKGROUND: Although several reports have documented the usefulness of a surveillance program with duplex ultrasonography (DU) to diagnose failing autologous vein bypasses, the effectiveness of DU to detect failing arterial prosthetic grafts has not been confirmed. We attempted to determine whether our program, which included DU and other noninvasive techniques (NonDU), was useful for this purpose. METHODS: Between July 1, 1991, and September 30, 1994, 85 prosthetic bypasses in 59 patients performed for lower extremity ischemia were entered into a graft surveillance protocol. There were 35 femoropopliteal, 16 femorotibial, 15 iliofemoral, 13 axillofemoral, and 6 femorofemoral bypasses. Both DU and NonDU were performed 1 week and every 3 months after the initial bypass or after graft revision. NonDU criteria of a failing graft included changes in symptoms or pulses, decreased ankle/brachial index greater than 0.15, or diminution of ankle pulse volume recordings greater than 50%. Normal grafts were bypasses that had less than 50% stenosis documented by arteriography or remained patent. Problem grafts were those that required revision or thrombosed before intervention. Follow-up of patient grafts ranged between 3 and 36 months (mean, 11 months). RESULTS: DU predicted 17 (81%) of 21 problem grafts versus only 5 (24%) diagnosed by NonDU (p = 0.001). Lesions associated with these 21 grafts were perianastomotic in 10 cases, in adjacent inflow or outflow arteries in 8 cases, and intrinsic to the graft in 3 cases. The likelihood of a graft thrombosing in the presence of a normal test was 7% (4 of 58) for DU compared with 21% (16 of 76) for NonDU (p = 0.04). CONCLUSIONS: DU is more sensitive than NonDU in predicting failure of prosthetic grafts. This study suggests that DU should routinely be performed as part of a surveillance program for peripheral arterial prosthetic bypasses.

Safety and cost-efficiency of 24-hour hospitalization for carotid endarterectomy.

The safety and cost savings of carotid endarterectomy (CEA) were determined with guidelines developed after vascular "critical pathways" were implemented. Using these guidelines, our goal was to admit patients the day of surgery and to discharge them the next morning. Morbidity, mortality, readmission rates, same-day admissions, duration of stay, and hospital costs were compared between patients undergoing CEA who were electively admitted between September 1, 1992 and August 31, 1993 (group 1) and January 1, 1994 and March 31, 1995 (group 2). Between these two time periods, vascular critical pathways were instituted and all preoperative examinations were performed on an outpatient basis. The majority of CEAs were performed with the patient under general anesthesia. We found no significant differences between group 2 (n = 68) vs. group 1 (n = 40) in terms of mortality (1.5% [1 of 68] vs. 2.5% [1 of 40]), cardiac events (2.9% [2 of 68] vs. 2.5% [1 of 40]), neurologic events (2.9% [2 of 68] vs. 2.5% [1 of 40]), or readmission rate (1.5% [1 of 68] vs. 0% [0 of 40]). Same-day admissions were significantly higher (94% [64 of 68] vs. 5% [2 of 40]; p < 0.0001), and average duration of stay was significantly lower (1.3 vs. 5.1 days; p < 0.0001) in group 2 vs. group 1, respectively. Hospital charges were decreased by $5510 per patient in group 2. We conclude that hospital costs can be significantly reduced for most patients undergoing CEA when they are admitted on the day of surgery and discharged the following morning, with no negative impact on morbidity and mortality.

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 $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.

Death and adverse cardiac events after carotid endarterectomy.

PURPOSE: This study evaluated operative mortality rate and adverse cardiac events after carotid endarterectomy. Efficacy of preoperative cardiac evaluation was studied and stroke mortality rate was determined. METHODS: This was a retrospective review of 562 patients undergoing carotid endarterectomy at a 740-bed community hospital. Data were analyzed with chi 2 analysis, logistic regression analysis, and Goldman criteria for cardiac risk. RESULTS: The mortality rate was 1.6% (nine patients). There were 10 myocardial infarctions (1.8%). Six of these (1.1%) were fatal. The Goldman Index allowed us to classify 530 patients in a low-risk group (Goldman classes I and II, operative mortality rate = 1.1%) and 32 patients in a high-risk group (Goldman classes III and IV, mortality rate = 9.4%). Independent risk variables were identified for myocardial infarction and overall operative death. These variables were then used to develop a probability model for prediction of operative death and adverse cardiac events. The stroke rate in the 562 patients was 0.7% (four patients). For the 345 patients with symptoms, the stroke rate was 0.6% (two patients); for the 217 symptom-free patients, it was 0.9% (two patients). The combined stroke mortality rate was 2.3%. For patients with symptoms, it was 2.9%; for symptom-free patients, it was 1.4%. CONCLUSIONS: Independent clinical variables can help determine patients at increased risk for perioperative myocardial infarction or operative death. Patients in Goldman classes III and IV are at increased risk for adverse events. Carotid surgery can be performed safely in our medical community.

Laparoscopic colectomy: at what cost?

The purpose of this study was to compare laparoscopic to open colectomy with respect to: 1) morbidity and mortality, 2) adequacy of resection for cancer (margins and number of nodes), 3) operative time, 4) postoperative time for tolerating diet and discharge, and 5) total hospital charges. A historical control group of open colon surgery patients was used. Laparoscopic colectomy was completed in 18/24 patients and 6 were converted to open colectomy. There were no operative or perioperative mortalities. In procedures for cancer, all margins were free of tumor. The average number of nodes in the laparoscopic group (LC) was higher than in open colectomy (OC) group. The average operative time was slightly longer in the LC group compared to the OC group. Postoperative length of stay was shorter in the LC group, and considerably shorter in the elective LC group. Corrected average total hospital cost was lower in the LC group than in the OC group. Laparoscopic colectomy has acceptable morbidity and mortality, is cost-efficient and seems to provide adequate resection for cancer, although long-term data will be crucial to this issue.

Bilateral femoral nerve neuropathy following blunt trauma. Case report.

A unique case of bilateral compressive injury of the femoral nerves is reported in a 19-year-old man. Traumatic femoral nerve neuropathy following operative injury, penetrating injury, anticoagulant therapy with hemorrhage, and stretch injury has been described previously, and the literature concerning this unusual clinical problem is reviewed. Bilateral traumatic femoral nerve neuropathy resulting from compressive injury has not been previously reported.