Discussion

Article Outline

• Copyright

Dr Thomas Naslund (Nashville, Tenn). The authors have addressed an important negative feature of the NAIS [neoaortoiliac system]: that being the operation is lengthy and tedious. They have devised a staged procedure without altering the basic operative principles. In this report, the desired result was reached in that lengthy operative time was avoided and outcomes were not changed. Fasciotomy rate is noted to be lower with the staged approach, but we are not informed of the relative incidence of prior saphenous vein harvest in the two groups. This risk factor as well as evolving judgment in performing fasciotomy could explain this observation.

In general, if safety is equivalent, one operation is better than two. Furthermore, the overall efficiency of the operating room is diminished by this staged approach consuming more operating room resources by creating two separate procedures. I have three questions:

First, was there a sentinel case that resulted in the change to utilize a staged approach? Second, have you considered an institutional cost analysis? And third, have you considered cold preservation of the deep veins to allow excision and thigh closure at the first operation and not subject the thighs to added surgery with the second stage?

Dr Ahsan T. Ali. In regards to the first question, there was no sentinel case. We had a patient, we had some information on him, and he was scheduled for a NAIS on a Wednesday. The idea came to us to harvest his veins and mobilize them on Tuesday that will save 2 or 3 hours. I would like to emphasize that harvest of the vein by someone who hasn't done it before can be tedious and actually should be done a nonhurried manner.

To answer the second question; I completely agree. I think it is more costly. It involves a second anesthesia, but these are very complex patients. There is no simple solution. I think the hospital regards this as a very specialized procedure that I don't think there is a pattern to these patients.

Lastly, we did consider having vein completely harvested a day before and placed in a preservation solution and just closing the incisions permanently, but if you come up short by a centimeter or two, you are going to be kicking yourself, that why didn't I take the appropriate length. I guess you can take extra length, but we have not done that.