How to Manage Complications in the Outpatient Setting Michael L. Schwartz, MD, RVT, FACS Division Chief Vascular Surgery Nyack Hospital Division Chief Vascular Surgery Good Samaritan Hospital Complications in the Office • Facility complications • Fire • Equipment failure • Power outage • Anesthesia Issues • Procedural Complications QuickTime™ and a decompressor are needed to see this picture. hink!…What are your contingencies?…Be prepared! Implications of Off-site Surgery •No blood bank •No ventilators •No ICU care •Low manpower •Advanced equipment may not be available. What’s at Risk? • Patient risk • 10 fold increase in risk of adverse outcomes including death in the office setting (Vila, Soto, Cantor, Arch Surg. 2003;138:991-995) • Reputation risk • Referring physicians • Prospective patients • Accreditation risk QuickTime™ and a decompressor are needed to see this picture. Accreditation Risk American Association of Ambulatory Surgery Facilities Accreditation Association for Ambulatory Health Care Joint Commission Reportable incidents to the accreditation agency • • • • • • Office based surgery is very scrutinized Any patient death within 30 days Wrong patient or wrong site surgery Any “serious or life threatening event” Any hospital transfer Any hospital admission within 72 hours of the procedure Sign a transfer agreement with your hospital • Written agreement between an ASC and a local Medicareparticipating hospital to accept any emergency from the ASC • Required in 30 states anyway • Make sure you’re on staff at the transfer hospital - you want to deal with your own complication Do not be a cowboy in your outpatient center to avoid complications • How to be a cowboy… • • • • • Poor patient selection Trying to push the envelope Persevering when you should abandon the procedure Not being prepared to handle a complication Delaying transfer in trying to salvage the complication QuickTime™ and a decompressor are needed to see this picture. Specific Scenarios • • These are our management protocols Make your own based on your specific situation • • • • • Distance from transfer hospital What is your staffing? (nurses/assts) Is anesthesia present? What is your personal experience? Do you have required equipment? • Is your C-arm up to snuff? Varicose Vein Complications • • Bleeding complication Junction thrombus at sapheno-femoral junction. (Hingorani/Ascher) • • Lovenox / 1 week follow-up then reevaluate Long term A/C? pending U/S followup Central Access Complications • Case selection • Potentially devastating • Use ultrasound guidance to minimize complications • Don’t persist!! • Diagnose with C-Arm • Stabilize the pneumothorax for transfer, have a pigtail available Dialysis Access Complications • Vein rupture (AVF) • Anastamosis rupture • Pulmonary embolism • Arterial embolism #@!% Vein Rupture • In many cases it’s expected (BAM) limited controlled extravasation. • Moderate extravasation Balloon occlude and pressure • Covered stent? • Occlude the access and bring back for OR revision another time Anastamosis Rupture • More difficult to compress • Covered stent useful • May require closure of AVG • Transfer only if continued expansion after closure Pulmonary Embolism • Common but most asymptomatic • Can be confused with CHF/systemic problems • Large AVF vs. AVG (clot burden small) • Declot first before treating outflow • Use TPA in addition to declot • Asymptomatic, but…cumulative effect for repeat treatments Arterial Embolism • Usually occur during arterial plug dislodgement • Use Fogarty OTW catheter • Plug is resistant to tPA • May require OR treatment Peripheral Intervention Complications • • • • Patient Selection • • • TASC A iliac TASC A and B fem pop Avoid TASC C and D Hospitals have some advantages Complications in an O/P center can be lethal for iliac lesions Long SFA occlusions take too long What to avoid? • • • Patients to avoid • • Significant medical comorbidities Poorly cooperative Lesions to avoid • • • Heavily calcified Single vessel runoff Anastamotic vein graft lesions No Renals, aortas or carotids Peripheral Interventions • • • • • Access Site Thrombosis Access Site Bleeds Arterial Perforations Distal Embolization Arterial/Stent Thrombosis Access site thrombosis • Access Site Thrombosis (T/F to OR) • Closure device complications (T/F to OR) Access site bleeds • Use Angioseal (patient selection) • Observe for 2 hours post • Don’t clog RR • Small hematoma, US compression • Large hematoma (T/F) Arterial Perforation • More common with age / DM • Can tamponade with balloon inflation • If significant extravasation, covered stent ($) • Observe for 2 hours, if any instability ...transfer. QuickTime™ and a decompressor are needed to see this picture. Distal Embolization • • • • • Tough to manage in center Avoid single vessel runoff OTW Fogarty technique T/F if symptomatic Elective if asymptomatic Arterial or Stent Thrombosis • Consider lysis • We have no Angiojet • If symptomatic arrange T/F while brief attempt at recanalization • Set a time limit! In Conclusion.... • • • • • • • The office is a terrible place to have a complication Dangerous for the patient Dangerous for your business Good initial case selection is the key to success Have a policy on how to deal with each complication Have the equipment (pigtails/cov stents/OTW Fogartys) Not a sin to deal with a complication safely in the hospital. Thank You