The findings from a Canadian study suggest cases could be performed on an ambulatory basis, researchers say.
The vast majority of complications from elective endovascular coiling of unruptured aneurysms are identified during surgery or within 6 hours of anesthesia reversal, according data from a single Canadian center. If such findings can be confirmed in larger trials, the study hints that some patients may be able to receive this treatment on an ambulatory basis.
Investigators led by Michelle Masayo Kameda-Smith, MD (McMaster University, Hamilton, Canada), write that there is increasing pressure to adopt a day case surgery, when feasible, in order to save healthcare dollars, particularly in the setting of socialized medicine. Noneconomic benefits of day surgery, they point out, are improved efficiencies and reduced patient exposure to nosocomial infection, thromboembolic complications, and medical error.
To find out whether elective coiling of unruptured aneurysms could be amenable to a day surgery approach, at least in some cases, the authors conducted a retrospective chart review of 150 patients who underwent elective endovascular aneurysm coiling between March 2006 and October 2013 in a large Eastern Canadian neurointerventional service. Their findings were published online June 26, 2017, ahead of print in the Journal of NeuroInterventional Surgery.
Overall, 16% of patients experienced a coiling-related complication, although none resulted in death. Intraoperative complications occurred in 6.7% of patients, of which thromboembolism was the most common type. A total of 5.3% of patients experienced a complication after the operation during inpatient stay, and 4.0% experienced one after discharge. Most complications were identified within 6 hours of anesthesia reversal, with only a small proportion identified the next morning.
Only 3.3% of patients had persistent neurological deficits after the procedure on last follow-up. There was a strong association between the duration of the operation and the occurrence of procedure-related complications. There were no other clear predictors of complications.
Applies to Healthcare Systems Worldwide
While this study was conducted in Canada, Kimon Bekelis, MD (Dartmouth-Hitchcock Medical Center, Lebanon, NH), who commented on the study for Neurovascular Exchange, said that it is “absolutely” generalizable to other countries and health systems. “There is increasing incentive to discharge patients from the hospital as early as possible even in the US,” he noted in an email. “Recent legislation mandates value-based care and targets long length of stay.”
Currently, most patients undergoing elective coiling spend 1 night in hospital, said Bekelis. “The most important implication [of this study] is that ambulatory interventions for unruptured cerebral aneurysms should be studied further to determine feasibility and safety.”
Of course, the findings of a single-center retrospective analysis will need to be confirmed via multicenter investigations using larger datasets, he noted.
Indeed, the authors agree. “These findings warrant further investigation with a larger cohort to guide preoperative communication with patients and to identify a select group of patients who may not necessarily require a prolonged hospital admission for observation,” they write, adding, “We hope to follow on with a prospective registry of patients deemed suitable for day case surgery and evaluation of which patient subgroups undergoing elective endovascular treatment of an intracranial aneurysm can successfully and safely be discharged home on the same day as their surgery.”
Kameda-Smith MM, Klurfan P, van Adel BA, et al. Timing of complications during and after elective endovascular intracranial aneurysm coiling. J NeuroInterv Surg. 2017;Epub ahead of print.
Kameda-Smith and Bekelis report no relevant conflicts of interest.
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