Management of ambulatory (day case) endovascular procedures for peripheral arterial disease.

INTRODUCTION: Thanks to exceptional improvements in technological developments and vascular teams' expertise, endovascular repair of peripheral arterial disease (PAD) has drastically increased these past decades. Incidence of PAD rising, pressure to reduce costs and patient's empowerment make outpatient endovascular procedures for PAD an attractive alternative to conventional hospitalization. This review describes outpatient endovascular procedures for PAD in the literature. EVIDENCE ACQUISITION: We used PRISMA guidelines and Medline to conduct this systematic review. 448 relevant articles were found. Twelve articles, all published after year 2000 were included and reviewed by two independent investigators. EVIDENCE SYNTHESIS: Among 12 selected articles, 10762 outpatient endovascular procedures were performed and 3883 procedures were realized for arterial lower limb revascularization. Average age was 65.2. Major exclusion criteria were social isolation (no available accompanying adult for the first 24 hours, no available communication system) and high-risk patients (ASA 4 and above). During the perioperative period, no death was noted. Major hematoma rate was 0% to 3%, minor hematoma rate went from 1.6% to 20%. Conversion to in-patient status for overnight observation occurred in 0% to 16% in ten real life studies and was mostly due to complications at puncture site. Reintervention over the first month occurred in 0% to 4%. Readmission in the first month after being discharged occurred in 0% to 3.2%. Diabetes and critical limb ischemia were not related to higher complication rate. CONCLUSIONS: This review indicates that outpatient endovascular procedures for PAD are safe and efficient. Guidelines are necessary to enforce patients' selection and insure high quality perioperative care.

Utility of electrofusion for the femoral approach in vascular surgery: a randomized prospective study.

BACKGROUND: The local complications are frequent after a femoral approach in vascular surgery and are often the cause of a delay in healing. Electrofusion showed its effectiveness to decrease the complications in general surgery but was not tested in vascular surgery. The aim of our study was to evaluate if the use of electrofusion in the approach to femoral vessels improved healing at 1 month by decreasing the local complications. METHODS: This prospective randomized study was conducted in 2 centers from May 1, 2012 to April 30, 2013. All the patients requiring a surgical access of the femoral trigone were included in 2 French teaching hospitals. Femoral artery surgical exposure was carried out using electrofusion or according to the conventional technique (diathermy or cold scalpel) according to a protocol of randomization. The principle criterion of the study was a complete healing at 1 month. The secondary criteria were the appearance of cutaneous, infectious, or lymphatic local complications. RESULTS: Two hundred ninety-two femoral approaches were carried out in 221 consecutive patients. One hundred forty-eight approaches were carried out with electrofusion and 144 according to the conventional technique. The demographic and operative characteristics were similar between the 2 groups. At 1 month, 86.3% of the approaches were healed without statistically significant difference between the 2 groups (88.5% vs. 84%, P = 0.241). There were less local complications (P = 0.012) and seromas (P = 0.012) in the electrofusion group. This difference could be linked with the least quantities (P = 0.036) and durations (P = 0.014) of drainage observed after approaches carried out with electrofusion. On the other hand, the incidence of cutaneous or infectious complications was not different between the 2 groups. CONCLUSIONS: In our series, the use of electrofusion decreased the lymphatic complications after a femoral approach. However, the correction of this single parameter was not sufficient to improve the rate of healing at 1 month.

Successful hybrid management of a left vertebral artery aneurysm secondary to type-1 neurofibromatosis.

A 32-year-old man with type-1 neurofibromatosis (NF1) was diagnosed with a left vertebral artery aneurysm of 4 cm maximal diameter. A hybrid procedure was conducted associating the exclusion of the origin of the left vertebral artery with a covered stent in the left subclavian artery and a cervical incision for ligation of the vertebral artery to completely exclude the aneurysm and perform the aneurysm resection. The histologic findings confirmed the diagnosis of NF1 with a vascular localization in the aneurysm. The postoperative course was uneventful. The 1-year clinical and morphologic results were satisfactory.