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Not Your Mother’s OR: The Evolution of Endovascular Surgery
GUEST EDITORIAL Not Your Mother’s OR: The Evolution of Endovascular Surgery NANCY J. GIRARD PhD, RN, FAAN, GUEST EDITOR
I
was honored when asked to serve as the guest editor for this special focus issue of the AORN Journal covering endovascular surgery. It has been an interesting undertaking and one I enjoyed immensely. As I read the articles for this issue, I was pleased that they clearly show the innovations and technological changes in endovascular surgery that have occurred during the past several decades. The content in this issue includes discussions of the OR environment; room setups and design; new instrumentation and how to handle and care for it; knowledge and education needs of the perioperative team; management concerns, including costbenefit analysis; and effects of new endovascular surgery technology on patients. A CHANGING ENVIRONMENT My first exposure to a patient with an abdominal aortic aneurysm (AAA) was in 1985. He was a man I went to talk with and prepare for surgery for an open aortic aneurysm repair. He had discussed all of his options with his physicians and knew exactly what would be happening. After a while, he became quiet and said, “I don’t think I want this surgery.” His wife sat in the corner, quiet, tears rolling down her cheeks. I asked him if he wanted to see the surgeon again, and he said that he did. He cancelled the surgery and left the hospital shortly thereafter. Before they left, his wife said she would like to tell
me what happened with her husband, and asked whether it would it be OK if she could call me to let me know. I reassured her that it would be, and four months later, I received a call. Her husband had decided to go to Mexico after discharge and participate in nonsurgical care that promised to “harden” the aneurysm with diet and thus minimize the potential of it blowing out. This treatment was unsuccessful, and the patient had passed away. Today, that patient may have survived because today’s surgery might not have seemed as threatening, given the advances in endovascular surgical procedures. According to Gordon and Toursarkissian,1 whose article appears in this issue of AORN Journal, national screening recommendations and advancements in treatment modalities during the past 20 years have improved morbidity and mortality. To illustrate, they cite an article by Beck et al,2 which shows that the 30-day mortality rate for endovascular aneurysm repair is significantly lower than the rate for open repair (0.5% and 2.3%, respectively), although the one-year mortality rates are similar (5.7% and 5.8%, respectively). In addition, Gordon and Toursarkissian1 discuss the major risk factors, pathophysiology, and diagnosis of AAA; patient selection for endovascular repair; common adverse events and complications; and perioperative implications for the patient undergoing endovascular repair of an AAA.
http://dx.doi.org/10.1016/j.aorn.2014.06.017
238 j AORN Journal
September 2014 Vol 100
No 3
Ó AORN, Inc, 2014
GUEST EDITORIAL Surgical treatment is transitioning from open procedures to endovascular surgery for many vascular conditions, including AAA. It has been estimated that 25% to 45% of descending thoracic aortic aneurysm repairs are now performed via endovascular methods.3 Today, there are spirited discussions among surgeons endorsing open repair versus endovascular repair. Total endovascular repairs may not be the first method chosen today for several reasons. For example, not all surgeons, anesthesia professionals, and perioperative nurses have the necessary knowledge and expertise yet. Additional factors that can affect treatment decisions include stent durability issues, lengthy approval times for new products with the US Food and Drug Administration (FDA), and anatomical limitations of the blood vessels affecting endovascular surgery. However, solutions to these problems are being developed by health care personnel as well as medical industry research and development personnel.4 What is happening now is that a combination of these two approaches are being used because of increased imaging abilities, continual refinements of technology, and increased use and development of hybrid ORs.3 Hybrid ORs are designed with space and equipment to change from endovascular to open surgery quickly and efficiently if the need arises. It is important to consider the facility and team needs during construction of this type of OR suite, which is an enormous project, according to Eder and Register.5 In this issue of AORN Journal, they discuss considerations for building an endovascular suite or retrofitting an existing OR. One vital step is performing a cost-benefit analysis (eg, identifying community needs, determining provider requirements, considering infection control concerns, specifying planned use of the hybrid room or equipment) so that facility planners can carefully weigh benefits against available funding to determine feasibility. The article also explains that the overall benefit for patients with vascular disease may make the efforts of building a hybrid OR well worthwhile.
www.aornjournal.org
As ORs change, so does surgical care. Some use one team and some use multispecialty teams to perform surgery. One study looked at the differences between using a single team compared with using multispecialty teams for performing endovascular surgeries. The researchers looked at 7,269 endovascular aneurysm repair procedures, of which, 7,086 surgeries (97.5%) were completed by a single surgical team and 183 surgeries (2.5%) were completed by multispecialty teams. Although the number of surgeries were greatly skewed between the groups, there were few significant differences between groups for infections, transfusion rates, or changes from endovascular to open surgery. Multispecialty teams had longer operating times, and researchers theorized that communication was less effective among these personnel, which could increase misunderstandings and handover errors.6 According to the historical review article by Buckley and Buckley7 in this issue of AORN Journal, whether facility managers decide to use one team or multispecialty teams, a new education paradigm is necessary for vascular surgeons. This paradigm shift should ensure that manufacturers provide didactic and hands-on training and that they should supervise the surgeons who choose to use their devices in clinical practice. The article also indicates that, to learn new wire and catheter skills specific to endovascular aneurysm repair, perioperative nurses must be proficient in radiation safety and enhanced imaging techniques. LIFELONG LEARNING Regardless of whether a single or multispecialty approach to surgery is used, a perioperative nurse from several decades past walking into an AAA repair would find the OR of today to be almost unbelievable. Everything has changed. This is definitely not the OR I grew up in, and today’s OR will not be around in future decades. The dramatic changes emphasize the continual need for learning and upgrading one’s skills. Perioperative nurses
AORN Journal j 239
September 2014 Vol 100
must be lifelong learners and constantly update their knowledge and technical abilities by using all resources, including AORN, for education that affects their specialty areas. This AORN Journal issue only touches the surface of the changes in surgical endovascular procedures. Rapidly developing technology may enable better, faster, and less costly care in the near future. Endovascular procedures will continue to increase for every surgical specialty, and this method is now being used in specialties such as neurology, trauma, and other surgeries. This issue of AORN Journal reviews existing information and brings new ideas to the reader regarding endovascular surgery. Readers will find, in this issue, information and details on the history of endovascular surgery, managerial concerns for running an endovascular room, and details about endovascular AAA and aortoiliac aneurysm repair. I would like to thank the authors who took time from their very busy schedules to write these articles. I also would like to thank Editor-in-Chief Joy Don Baker, PhD, RN-BD, CNE, CNOR, NEA-BC, for her forward-thinking approach and encouragement to bring these exciting advances to our readers.
240 j AORN Journal
GUEST EDITORIAL
No 3
References 1. Gordon PA, Toursarkissian B. Treatment of abdominal aortic aneurysms: the role of endovascular repair. AORN J. 2014;100(3):241-259. 2. Beck AW, Goodney PP, Nolan BW, Likosky DS, EldrupJorgensen J, Cronenwett JL; Vascular Study Group of Northern New England. Predicting 1-year mortality after elective abdominal aortic aneurysm repair. J Vasc Surg. 2009;49(4):838-843. 3. Coselli JS, Green SY. Open aortic arch surgery: doomed to extinction? Tex Heart Inst J. 2012;39(6):836-837. 4. Hughes GC. Endovascular repair will be the best option for thoracoabdominal aortic aneurysm in 2020. Tex Heart Inst J. 2012;39(6):834-835. 5. Eder SP, Register JL. 10 management considerations for implementing an endovascular hybrid OR. AORN J. 2014; 100(3):260-270. 6. Mazer LM, Chiakof EL, Goodney PP, Edwards MS, Corriere MA. Single versus multi-specialty operative teams: association with perioperative mortality after endovascular abdominal aortic aneurysm repair. Am Surg. 2012;78(2):207-212. 7. Buckley SD, Buckley CJ. Advances in endovascular repair of aortoiliac aneurysmal disease: device design and nursing implications. AORN J. 2014;100(3):271-279.
Nancy J. Girard, PhD, RN, FAAN, is a consultant/owner of Nurse Collaborations, San Antonio, TX. Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
I
was honored when asked to serve as the guest editor for this special focus issue of the AORN Journal covering endovascular surgery. It has been an interesting undertaking and one I enjoyed immensely. As I read the articles for this issue, I was pleased that they clearly show the innovations and technological changes in endovascular surgery that have occurred during the past several decades. The content in this issue includes discussions of the OR environment; room setups and design; new instrumentation and how to handle and care for it; knowledge and education needs of the perioperative team; management concerns, including costbenefit analysis; and effects of new endovascular surgery technology on patients. A CHANGING ENVIRONMENT My first exposure to a patient with an abdominal aortic aneurysm (AAA) was in 1985. He was a man I went to talk with and prepare for surgery for an open aortic aneurysm repair. He had discussed all of his options with his physicians and knew exactly what would be happening. After a while, he became quiet and said, “I don’t think I want this surgery.” His wife sat in the corner, quiet, tears rolling down her cheeks. I asked him if he wanted to see the surgeon again, and he said that he did. He cancelled the surgery and left the hospital shortly thereafter. Before they left, his wife said she would like to tell
me what happened with her husband, and asked whether it would it be OK if she could call me to let me know. I reassured her that it would be, and four months later, I received a call. Her husband had decided to go to Mexico after discharge and participate in nonsurgical care that promised to “harden” the aneurysm with diet and thus minimize the potential of it blowing out. This treatment was unsuccessful, and the patient had passed away. Today, that patient may have survived because today’s surgery might not have seemed as threatening, given the advances in endovascular surgical procedures. According to Gordon and Toursarkissian,1 whose article appears in this issue of AORN Journal, national screening recommendations and advancements in treatment modalities during the past 20 years have improved morbidity and mortality. To illustrate, they cite an article by Beck et al,2 which shows that the 30-day mortality rate for endovascular aneurysm repair is significantly lower than the rate for open repair (0.5% and 2.3%, respectively), although the one-year mortality rates are similar (5.7% and 5.8%, respectively). In addition, Gordon and Toursarkissian1 discuss the major risk factors, pathophysiology, and diagnosis of AAA; patient selection for endovascular repair; common adverse events and complications; and perioperative implications for the patient undergoing endovascular repair of an AAA.
http://dx.doi.org/10.1016/j.aorn.2014.06.017
238 j AORN Journal
September 2014 Vol 100
No 3
Ó AORN, Inc, 2014
GUEST EDITORIAL Surgical treatment is transitioning from open procedures to endovascular surgery for many vascular conditions, including AAA. It has been estimated that 25% to 45% of descending thoracic aortic aneurysm repairs are now performed via endovascular methods.3 Today, there are spirited discussions among surgeons endorsing open repair versus endovascular repair. Total endovascular repairs may not be the first method chosen today for several reasons. For example, not all surgeons, anesthesia professionals, and perioperative nurses have the necessary knowledge and expertise yet. Additional factors that can affect treatment decisions include stent durability issues, lengthy approval times for new products with the US Food and Drug Administration (FDA), and anatomical limitations of the blood vessels affecting endovascular surgery. However, solutions to these problems are being developed by health care personnel as well as medical industry research and development personnel.4 What is happening now is that a combination of these two approaches are being used because of increased imaging abilities, continual refinements of technology, and increased use and development of hybrid ORs.3 Hybrid ORs are designed with space and equipment to change from endovascular to open surgery quickly and efficiently if the need arises. It is important to consider the facility and team needs during construction of this type of OR suite, which is an enormous project, according to Eder and Register.5 In this issue of AORN Journal, they discuss considerations for building an endovascular suite or retrofitting an existing OR. One vital step is performing a cost-benefit analysis (eg, identifying community needs, determining provider requirements, considering infection control concerns, specifying planned use of the hybrid room or equipment) so that facility planners can carefully weigh benefits against available funding to determine feasibility. The article also explains that the overall benefit for patients with vascular disease may make the efforts of building a hybrid OR well worthwhile.
www.aornjournal.org
As ORs change, so does surgical care. Some use one team and some use multispecialty teams to perform surgery. One study looked at the differences between using a single team compared with using multispecialty teams for performing endovascular surgeries. The researchers looked at 7,269 endovascular aneurysm repair procedures, of which, 7,086 surgeries (97.5%) were completed by a single surgical team and 183 surgeries (2.5%) were completed by multispecialty teams. Although the number of surgeries were greatly skewed between the groups, there were few significant differences between groups for infections, transfusion rates, or changes from endovascular to open surgery. Multispecialty teams had longer operating times, and researchers theorized that communication was less effective among these personnel, which could increase misunderstandings and handover errors.6 According to the historical review article by Buckley and Buckley7 in this issue of AORN Journal, whether facility managers decide to use one team or multispecialty teams, a new education paradigm is necessary for vascular surgeons. This paradigm shift should ensure that manufacturers provide didactic and hands-on training and that they should supervise the surgeons who choose to use their devices in clinical practice. The article also indicates that, to learn new wire and catheter skills specific to endovascular aneurysm repair, perioperative nurses must be proficient in radiation safety and enhanced imaging techniques. LIFELONG LEARNING Regardless of whether a single or multispecialty approach to surgery is used, a perioperative nurse from several decades past walking into an AAA repair would find the OR of today to be almost unbelievable. Everything has changed. This is definitely not the OR I grew up in, and today’s OR will not be around in future decades. The dramatic changes emphasize the continual need for learning and upgrading one’s skills. Perioperative nurses
AORN Journal j 239
September 2014 Vol 100
must be lifelong learners and constantly update their knowledge and technical abilities by using all resources, including AORN, for education that affects their specialty areas. This AORN Journal issue only touches the surface of the changes in surgical endovascular procedures. Rapidly developing technology may enable better, faster, and less costly care in the near future. Endovascular procedures will continue to increase for every surgical specialty, and this method is now being used in specialties such as neurology, trauma, and other surgeries. This issue of AORN Journal reviews existing information and brings new ideas to the reader regarding endovascular surgery. Readers will find, in this issue, information and details on the history of endovascular surgery, managerial concerns for running an endovascular room, and details about endovascular AAA and aortoiliac aneurysm repair. I would like to thank the authors who took time from their very busy schedules to write these articles. I also would like to thank Editor-in-Chief Joy Don Baker, PhD, RN-BD, CNE, CNOR, NEA-BC, for her forward-thinking approach and encouragement to bring these exciting advances to our readers.
240 j AORN Journal
GUEST EDITORIAL
No 3
References 1. Gordon PA, Toursarkissian B. Treatment of abdominal aortic aneurysms: the role of endovascular repair. AORN J. 2014;100(3):241-259. 2. Beck AW, Goodney PP, Nolan BW, Likosky DS, EldrupJorgensen J, Cronenwett JL; Vascular Study Group of Northern New England. Predicting 1-year mortality after elective abdominal aortic aneurysm repair. J Vasc Surg. 2009;49(4):838-843. 3. Coselli JS, Green SY. Open aortic arch surgery: doomed to extinction? Tex Heart Inst J. 2012;39(6):836-837. 4. Hughes GC. Endovascular repair will be the best option for thoracoabdominal aortic aneurysm in 2020. Tex Heart Inst J. 2012;39(6):834-835. 5. Eder SP, Register JL. 10 management considerations for implementing an endovascular hybrid OR. AORN J. 2014; 100(3):260-270. 6. Mazer LM, Chiakof EL, Goodney PP, Edwards MS, Corriere MA. Single versus multi-specialty operative teams: association with perioperative mortality after endovascular abdominal aortic aneurysm repair. Am Surg. 2012;78(2):207-212. 7. Buckley SD, Buckley CJ. Advances in endovascular repair of aortoiliac aneurysmal disease: device design and nursing implications. AORN J. 2014;100(3):271-279.
Nancy J. Girard, PhD, RN, FAAN, is a consultant/owner of Nurse Collaborations, San Antonio, TX. Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.