RESEARCH LETTER Peri-operative Fast Track Management in Open Abdominal Aortic Aneurysm Repair Enrico Giustiniano a,* , Fulvio Nisi a , Efrem Civilini b a Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy b Department of Biomedical Sciences, Humanitas University, Milan, Italy Open surgical repair (OSR) of an abdominal aortic aneurysm (AAA) exposes the patient to the risk of post-operative complications, due both to the operation per se and the comorbidities that they may suffer from. Enhanced recovery after surgery (ERAS) protocols 1 have improved surgical outcomes in several specialties. Despite the recent release of specific guidelines, 2,3 their application in the vascular field appears limited. Owing to the lack of specific guidelines, an institutional protocol for open surgery enhanced recovery (OSER) has been implemented for patients undergoing OSR of AAA at our institution since 2015. 4 The OSER protocol consists of: (1) moderate physical exercise, control or limitation of risk factors, and lifestyle modification at least three weeks before surgery; (2) an anaesthetic strategy based on short acting drugs; (3) 800 mL of 12.5% maltodextrin containing clear drink on the pre- ceding evening, followed by an additional 400 mL up to two hours before anaesthesia; (4) reduced invasiveness (naso- gastric tube and urinary catheter removed at the end of surgery and no central venous catheter); (5) goal directed fluid therapy guided by haemodynamic monitoring; (6) no routine post-operative intensive care unit (ICU) admission; (7) multimodal post-operative pain control by suprafascial continuous analgesia with ropivacaine 0.4% (no post- operative opiate administration), pregabalin 50 e 75 mg in the evening, paracetamol 1 g every six hours intravenous and ketoprofen 100 mg intravenous as rescue drug if nu- merical rating scale > 4, no more than twice a day; and (8) early mobilisation and feeding (sitting up after 4 hours and drinking a cup of tea; standing and walking after 6 e 8 hours). When the protocol was first introduced in 2016, the ERAS Society had still not provided guidelines for vascular surgery, which have been issued in recent years. The main differences between the ERAS protocol for open AAA 3 and this local OSER protocol are items 4, 5, 6, and 7, e.g., use of mini-invasive haemodynamic monitoring (pulse contour analysis for invasive blood pressure and cardiac output monitoring;) and adoption of a defined haemodynamic optimisation strategy, avoidance of central venous line placement, avoidance of routine ICU admission, and fully opioid free pain management, avoiding neuraxial anaesthesia. To enhance adherence to the OSER protocol, pre- operative counselling is of paramount importance. Exten- sive patient counselling with a trained nurse starts three weeks pre-operatively. During the in hospital stay, a vascular surgery resident is in charge of ensuring adherence to the fast track bundle with a 24 hours duty. Our institution’s database of elective AAA cases was analysed retrospectively, and data from January 2011 and November 2023 were collected. Only elective OSR of infrarenal AAAs, pararenal AAAs, and type IV thoraco- abdominal aortic aneurysms were included. Ruptured or symptomatic AAA, interventions with concomitant repair of any other organ, patients with previous OSR for AAA, and aortic surgery for occlusive disease were excluded. Data before and after implementation of the OSER were compared and analysed. Statistical analysis was performed using Student’s t test for parametric data and Manne Whitney U test for non-parametric data. Hospital length of stay was the primary outcome. Secondary outcomes were systemic complications, including renal, cardiac, and respi- ratory adverse events. The main results are summarised in Table 1. After systematic application of the OSER protocol for OSR of AAA, a statistically non-significant reduction in duration of hospitalisation (median 8 days before imple- mentation vs. three days after implementation; p ¼ .075) and a statistically significant reduction in complications (12.8% after implementation vs. 25.6% before imple- mentation of OSER; p ¼ .004) was observed. The ICU admission rate did not change over the years (11.6% vs. 10.2%; p ¼ .66) even though patients appeared to be sicker (number of patients with American Society of Anesthesiol- ogists [ASA] class 3 increased over time). Patients were not routinely admitted to the ICU, but only based on physician’s judgement or due to unpredictable complications such as intra-operative bleeding. Both in hospital and 30 day mor- tality rates in this cohort were considerably low. A limitation of this study was that data were gathered retrospectively, resulting in missing data before 2015, which may have caused bias in data interpretation. Furthermore, adherence to the OSER was not collected. * Corresponding author. Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy. E-mail address: enrico.giustiniano@humanitas.it (Enrico Giustiniano). Please cite this article as: Giustiniano E et al., Peri-operative Fast Track Management in Open Abdominal Aortic Aneurysm Repair, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.06.010 Eur J Vasc Endovasc Surg (xxxx) xxx, xxx