Impact of Enhanced Recovery After Surgery protocol with multimodal anesthesia on perioperative outcomes after open abdominal aortic aneurysm repair.

Abstract

Objective: Enhanced Recovery After Surgery (ERAS) clinical pathways have demonstrated improved perioperative outcomes after major surgery. However, its adoption within vascular surgery has been limited. In this study, we examined the impact of an ERAS protocol with multimodal anesthesia on open abdominal aortic aneurysm (AAA) repair by comparing early outcomes before and after its implementation.

Methods: This retrospective study analyzed early outcomes after elective open repairs of intact AAA performed from 2013 to 2023 at a single institution. Eighty consecutive patients treated after implementation of an ERAS protocol with multimodal anesthesia were compared with 161 patients treated before its implementation. Propensity score matching based on age, gender, body mass index, Vascular Quality Initiative AAA Mortality Risk Score, Rockwood Frailty Scale, aortic cross clamp location, aneurysm size, and type of exposure was performed to achieve one:one matching using the nearest neighbor technique. Quantile and logistic regression assessed the impact of the ERAS protocol on length of stay, 30-day mortality, opioid consumption (morphine milligram equivalents), hospital cost, complications, and readmissions.

Results: Both groups (ERAS vs pre-ERAS, respectively) were predominantly male (80% vs 73%; P = .27), with a median age of 74 years. Similar mean Vascular Quality Initiative predicted mortality (2.9% vs 4.0%; P = .13), clinical frailty score (3.1 vs 3.3; P = .17), aneurysm size (60 mm vs 62 mm; P = .06), rates of suprarenal cross-clamp (76% vs 88%; P = .07), chronic obstructive pulmonary disease (29% vs 31%; P = .73), chronic kidney disease (14% vs 16%; P = .66), myocardial disease (16% vs 20%; P = .54), and cerebrovascular disease (15% vs 19%; P = .53) were observed in the matched groups. ERAS was associated with a reduction in length of stay by 3 days (P < .001), a decrease in opioid consumption by 37 morphine milligram equivalents (P < .001), and a reduction in hospital costs by US$4704 (P < .001). There was a trend toward a lower risk of major complications (odds ratio, 0.44; 95% confidence interval, 0.2-1.1; P = .06). Thirty-day mortality (5% vs 6.3%; P = .73) and readmission (7.9% vs 13.2%; P = .29) rates were similar in both groups.

Conclusions: An ERAS protocol using a multimodal anesthesia was associated with improved early outcomes compared with patients treated before ERAS implementation. These results mirror similar benefits seen in nonvascular ERAS programs, and broader application should be considered in institutions that perform a high volume of open aortic repairs.