The fast-track concept in treatment of critical ischemia of the extremities

Since its implementation the fast-track concept has proven to be successful in a variety of surgical disciplines but up to now it has only been applied in vascular surgery for open infrarenal aneurysm repair. Therefore, a model for interdisciplinary perioperative management in patients with peripheral arterial disease (PAD) was designed following fast-track principles. The main characteristics were extensive patient education, preoperative regional anesthesia, carbohydrate-rich beverages and shortened preoperative fasting times, preoperative and postoperative structured mobilization and electrical muscle stimulation (EMS). Patients aged 18-90 years with chronic critical or acute limb ischemia (Rutherford IV-VI) undergoing elective percutaneous transluminal angioplasty (PTA) or bypass operation were included. Sufficient patient compliance was mandatory. Patients with contraindications for mobilization or regional anesthesia were excluded. To ensure preoperative mobilization and improve perioperative pain management a distal sciatic nerve block was established. The primary endpoints were patient pain assessed by VAS (visual analogue scale) and quality of life (FLeQKI, SF-12 and HADS). Secondary outcome measures were walking distance, quantity of analgesic medication, perioperative complications, length of hospital stay, patency rate, 30-day mortality and laboratory parameters (myoglobin, CK, urea, creatinine, CRP and leukocytes). It was hypothesized that fast-track patients would suffer less pain and a have a higher quality of life compared to standard procedure patients. Moreover, a longer walking distance, less pain medication and a lower complication rate were expected and the length of hospital stay might be reduced.