STRIPPING AND LIGATION Today, vascular surgeons and interventionists can perform most vein-related procedures on an outpatient basis, like this varicose vein stripping.

Are outpatient settings suitable for most vein-related procedures? From venograms and venoplasty to angiograms and angioplasty, the answer is an emphatic yes. With the right training, the right equipment, the right staff and the right space, vascular surgeons and interventionists — especially those trained in the last 10 or 15 years — should be able to handle the vast majority of vein-related procedures without ever needing to hospitalize patients. And thanks to many specially focused fellowships and residencies, the number of practitioners with the needed skill set is growing.

At the Vascular Institute of Michigan, which my partner and I opened in 2016, we're doing twice as many procedures as we were able to do in the hospital, and doing most of them on an outpatient basis. We practice all facets of vascular surgery, including lower extremity angiograms and venograms, laser ablation, micro phlebectomy, dialysis access and maintenance, catheter placement and mediport insertion. The only procedures we always do in the hospital are carotid stenting and aortic aneurysm endovascular repair (EVAR).

Along with being a fantastic arrangement for us, patient satisfaction has greatly increased as a result. Of course, we didn't just lease a building, haul in some equipment, throw open the doors and start treating patients. Planning was essential.

We actually started from scratch with a building that had to be gutted and rebuilt from the ground up. But before we opened, my partner and I made several site visits all over the country to other facilities that specialize in vascular procedures. We had a vision, but we wanted to make sure we knew what pitfalls to watch out for. We learned a lot.

1 The right space. If all you're doing is pain intervention, you don't need much space. You'll be using either radiofrequency ablation or laser ablation, and both machines are very small. Nor will you need a lot of room for personnel, because those procedures require only an anesthesia provider and a nurse, in addition to the surgeon.

SUITABLE SETTING Dr. Margni and his partner practice all facets of vascular surgery in their surgical center. Only a small number of procedures need to be done in hospitals.

But if you're doing procedures that require more sophisticated imaging and C-arms — such as lower extremity angiograms and interventions — you're talking about bigger tables, bigger shelves for equipment, more wires and more people. In short, you're going to need a sizable room.

Our plan from the start was to have a setup that was bigger and better than what we had at the hospital. At the center of it all, we have an ergonomic boom that was a major expenditure, but which has made our lives easier and improved our outcomes. Instead of struggling to see the small screen that comes with the C-arm, we see everything clearly on large, movable screens. That helps minimize the strain on our eyes, necks and backs, especially when we're wearing heavy lead for long periods. And the improved visualization is virtually essential for anyone doing these kinds of complex procedures. If you don't see a lesion, you can't treat it.

The procedure room is also large enough to provide needed storage, because we don't want people leaving to get supplies and equipment while procedures are going on. If we have excessive bleeding or some other emergency, we can't afford to wait to get it under control. And of course when you open the door to the OR, radiation can leak and sterility can be compromised. So our policy is to open the door only twice — once when the patient comes in and once when the patient leaves. In addition to safety and sterility, it's also a matter of convenience and privacy.

When we made our site visits, we asked everyone what, if anything, they'd do differently if they were starting over. They all said the same thing — they'd do a better job of planning for future expansion. So we planned ahead and made sure we have enough space to expand to 2 ORs in case our practice grows to 4 or 6 surgeons.

2 The right equipment. We invested heavily in the latest portable ultrasound devices and we use them for every single access. If you're doing an angiogram and trying to access the common femoral artery through the groin, there's a safe zone of about 3 centimeters. It's very unsafe to go in blindly, no matter how good you are, because every anatomy is different.

Having cutting-edge ultrasound may add costs initially, but it's a great investment, because it will minimize, if not eliminate, complications. One of the most frequent — sometimes even fatal — complications is access bleeding. Thanks to ultrasound, we haven't had any major hematomas that required us to transfer patients to the hospital.

An added convenience, and one I highly recommend, is that our ultrasound syncs with our EMR. Most insurance companies want proof that you used ultrasound for certain procedures. In the past we needed to print a hard copy record, but the syncing feature automates the process.

I also strongly recommend having a mobile surgical table. The alternative is to have to repeatedly move the C-arm. That not only wastes time and radiation, it's so heavy, you'll likely need several people to do it. That can be exhausting by the end of the day. A mobile table provides flexibility, and makes it easy to quickly and precisely focus the C-arm where you want. It also frees up personnel to perform other tasks while just one person moves the table.

We also use an intravascular ultrasound imaging system (IVUS), which greatly augments our images, especially for complex procedures. It's almost like having a camera inside the vessel. The IVUS also helps us with patients who have poor renal function, since they can't be given conventional dye. For those patients, we use CO₂ angiography. But the CO₂ image is not as precise, especially below the knee, so the IVUS helps improve visualization.

3 The right anesthesia providers. We use conscious sedation, and we contract with an anesthesia group that handles its own billing separately. That way we can concentrate on the complexity of the procedure without having to worry about the patient's vital signs and level of comfort. We know those are being taken care of by a provider who's more qualified than we are in that regard, and we know patient satisfaction, which is immensely important, will be higher as a result.

4 The right staff. An advantage to having worked for years in the hospital is that we were able to get to know who the best people were. Those were the people we brought with us. We wanted the folks who had the best work ethics, the most passion, the best social skills and the best bedside manner. It's a win-win. We all get to do the job we love, but with fixed hours, no late-night phone calls and weekends free. It's a huge lifestyle improvement for them, and the more satisfied employees are, the more productive they are. And the more satisfied patients end up being.

5 The right environment. Consumers are smart and discerning. Choosing a facility is like choosing a restaurant. It's not just the food; they also want a nice environment. So we worked with an architect to design the space, and we prioritized comfort and quality — nice furniture, soft lighting and a pleasant all-round customer experience.

6 The needed support. Obviously, our equipment is essential, so we conducted an extensive search before choosing a vendor we knew could provide both high-quality imaging and terrific support. We've had machines malfunction on a couple of occasions. But we chose the vendor we did in part because there are 5 engineers within a 15-20 mile radius, so we always know we'll be able to get somebody on the same day, if necessary, and won't need to cancel procedures scheduled for the next day. The longest it's ever taken to get the fix we needed was about 6 hours. That's a crucial consideration. OSM