Reflec%ng on a Ten-Year Experience with Over 10,000 Outpa%ent Office- Based Endovascular Procedures
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1 Reflec%ng on a Ten-Year Experience with Over 10,000 Outpa%ent Office- Based Endovascular Procedures Peter H. Lin, MD, Lauren E. Jones, MS, Samuel S. Ahn, MD University Vascular Associates, Los Angeles, CA DFW Vascular Group, Dallas, TX
2 Introduc%on Paradigm ships from hospitals to outpa1ent facili1es due to advances in anesthesia care, minimally-invasive technologies, and expedient procedural experience. Office-based lab (OBL) advantages: Increased pa1ent sa1sfac1on Efficient management of physician s schedule Cost-effec1ve care compared to hospital system OBL cri1cisms: Unsafe in cri1cally ill pa1ents Not suitable for high risk procedures Less available resources compared to hospitals
3
4 Objec%ves of Current Study Analyze the evolu1on of OBL procedures in our prac1ce during a ten-year period Evaluate treatment complica1ons of pa1ents undergoing OBL procedures during a ten-year period
5 Methods Retrospec1ve review of all OBL cases performed during a ten-year period. All procedures by board cer1fied vascular surgeons in OBL in California and Texas. Treatment evolu1on and complica1ons were analyzed. Procedural related complica/on defined as: any event which required further treatment, unplanned hospitaliza1on, or mortality within 30 days Minor complica/on defined as: any event which required extended recovery without further treatment or hospitaliza1on, such as anesthesia-related drowsiness, hematoma, or N&V.
6 OBL Facili%es 1 st OBL established in 2006 in Los Angeles, CA 2 nd OBL established in 2006 in Dallas, TX 3 rd OBL established in 2010 in Dallas, TX 4 th OBL established in 2017 in Los Angeles, CA OBL #2 OBL #3 OBL #1 OBL #4
7 Methods Procedural Indica%ons: Arteriovenous malforma1on Chronic venous insufficiency / varicose veins / venous ulcer End stage renal disease / malfunc1oned access Peripheral vascular disease (claudica1on / ischemic rest pain / non-healing wounds) Renal artery disease Visceral artery disease Vertebrobasilar insufficiency Thoracic Outlet Syndrome
8 Methods Pa%ent selec%on criteria: Exclusion criteria: ASA Classifica1on of I-IV Baseline crea1nine 2.0 mg/dl Potassium <5 meq/ml BMI <30 Procedure selec%on criteria: Diagnos1c angiogram Endovascular interven1ons Angioplasty and sten1ng interven1ons Atherectomy Dialysis access angioplasty or thrombectomy DVT thrombectomy & thrombolysis Aor1c aneurysm endograp procedure Caro1d artery interven1ons Complex cases an1cipated to require: 2-3 hours >150 cc of contrast Overnight thrombolysis
9 Demographic Information No (%) Male : Female 56% : 44% Age (range) 63 ± 14.8 (11 102) Co-morbidity Hypertension 7943 (74%) Diabetes 4508 (42%) Coronary artery disease 2147 (20%) ASA classifica1on Class I 21 (2%) Class II 1395 (13%) Class III 8695 (81%) Class IV 322 (3%)
10 Arterial Procedure No (%) Diagnos1c arteriogram Aortogram 182 (1.7%) Aortogram with lower extremity angiogram 450 (4.2%) Upper extremity angiogram 225 (2.1%) Lower extremity angiogram 493 (4.6%) Caro1d angiogram 301 (2.8%) Mesenteric artery angiogram 23 (<1%) Renal artery angiogram 16 (<1%) Therapeu1c Arterial Interven1on Lower leg angioplasty 912 (8.5%) Lower leg angioplasty + sten1ng 1019 (9.5%) Lower leg atherectomy 1502 (14.1%) Lower leg atherectomy + sten1ng 644 (6.2%) Coil emboliza1on 56 (<1%) Mesenteric artery sten1ng 28 (<1%) Renal artery OEIS 2017 sten1ng Annual Mee1ng March 31, 2017 Santa Monica, 42 (<1%) CA
11 Venous & Others No (%) Venous Saphenous vein abla1on 773 (7.2%) Varicose vein microphlebectomy 386 (3.6%) Venous abla1on and microphlebectomy 547 (5.1%) Diagnos1c venogram 451 (4.2%) Venous thrombectomy 536 (5.1%) IVC filter placement 128 (1.2%) IVC filter removal 37 (<1%) Venous angioplasty 343 (3.2%) Venous angioplasty and stent 483 (4.5%) Dialysis access interven1ons 1545 (14.4%) Central venous catheter placement 740 (6.9%)
12 Procedure Related Complica%ons Procedure related complications totaled 122 (1.14%) 27 patients died within 30 days (0.25%) 8 deaths were procedure related (0.075%) 19 deaths were unrelated (0.18%) Procedure Related Complica/on n % 30 day mortality bp/hr hematoma hospital for monitoring hospital for further interven1on bleeding retroperitoneal bleed pain chest pain ischemia respiratory distress thrombus/thrombosis allergic reac1on perforated artery sheath broke off aphasia bleeding; bp/hr; chest pain bloody bm edema; itching hemorrhage internal bleed largngospasm migrated stent tore femoral artery possible aneurysm leak possible bleed or MI possible reperfusion pseudoaneurysm respiratory arrest suspected CVA thromboembolus Total
13 Minor Complica%ons Minor Complica1ons not requiring treatment occurred in 3.5% of cases, and included: Minor hematomas not requiring treatment or hospitaliza1on Nausea and vomi1ng Superficial bleeding Drowsiness Blood pressure and heart rate irregulari1es
14 Complica%ons By Year 3.00 % Complica%ons By Year % Procedure Related Complica/ons Year
15 Puncture Site Arterial (66.2%) Venous (23.5%) Vascular access (10.3%) Arterial N=7200 % femoral brachial radial bial dorsalis pedis poplteal iliac peroneal axillary plantar Venous N=2558 % GSV femoral vein jugular basilic vein LSV cephalic vein brachial vein supervicial venous popliteal vein axillary vein antecubital vein bial vein perforator vein brachiocephalic iliac vein subclavian vein Access N % vascular access
16 Closure Devices USED FAILED Closure Device N % N % Angioseal Perclose Mynx Starclose Exoseal Vascade TR Band Fish Total *Closure Device Failure: 5.78%
17 Annual Case Volume PAD ESRD VV DVT
18 Office-based Volumes vs. Hospital-based Volumes 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% OBL Hospital
19 Conclusions The outpa1ent endovascular procedures can be performed safely with excellent outcomes Complica1on rate will decrease with OBL experience Accrual of OBL experience will result in clinical paradigm ship Wider therapeu1c adapta1on Broader treatment indica1on ShiP from hospital-based prac1ce to office-based prac1ce
20 Acknowledgements DFW Vascular Group Dallas, TX Dr. Joseph Caruso Dr. Robert Feldtman Dr. Craig Ferrara Dr. Kenneth Kollmeyer Dr. Karen McQuade Dr. Pablo Uceda University Vascular Associates Los Angeles, CA Dr. Todd Reil Dr. Marius Saines Dr. Rhoda Leichter Dr. James Burke Dr. Mathew Cheung
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