Is continued inpatient care necessary for a patient with PVD s/p right common femoral artery focal endarterectomy and bypass, stable on Xarelto (rivaroxaban) for PAD?

Continued Inpatient Stay is NOT Medically Necessary

This patient should be discharged home as planned and does not require continued inpatient hospitalization. The clinical scenario describes a stable post-operative patient following peripheral arterial revascularization who has already met all standard discharge criteria.

Clinical Status Assessment

The patient demonstrates clear readiness for discharge based on the following:

• Hemodynamic stability with vital signs stable (VSS) 1
• Successful ambulation with physical therapy in the hallway, indicating adequate functional recovery 1
• Normal voiding function without urinary retention 1
• Intact surgical incision on right leg without bleeding or signs of infection 1
• Adequate distal perfusion with warm right foot and palpable dorsalis pedis and posterior tibial signals 1
• Appropriate anticoagulation initiated with Xarelto (rivaroxaban) for PAD 2, 3

Evidence-Based Discharge Criteria

According to ACC/AHA guidelines for peripheral arterial disease management, patients may be discharged when they are clinically stable, have achieved acceptable glycemic control, can manage at home (with or without assistance), have had any urgently needed surgery performed, and have a well-defined discharge plan including appropriate anticoagulation 1. This patient meets all these criteria.

Post-operative monitoring requirements after lower extremity bypass do not mandate continued hospitalization but rather periodic outpatient follow-up with pulse examination, symptom assessment, and graft surveillance 1.

Anticoagulation Management Post-Discharge

The patient has been appropriately started on rivaroxaban for PAD, which is evidence-based therapy:

• Rivaroxaban 2.5 mg twice daily plus aspirin significantly reduces major adverse cardiovascular and limb events after lower extremity revascularization, including a 33% reduction in acute limb ischemia (HR 0.67,95% CI 0.55-0.82) 4
• This benefit is consistent regardless of surgical versus endovascular approach and appears early after revascularization 4
• For patients undergoing surgical bypass, rivaroxaban reduces the primary composite outcome (HR 0.78,95% CI 0.62-0.98) with benefits seen in both venous and prosthetic conduit bypasses 2, 3

The FDA-approved dosing for rivaroxaban in PAD is 2.5 mg twice daily with aspirin, which can be safely initiated and continued in the outpatient setting 5.

Absence of Complications Requiring Hospitalization

There are no documented complications that would necessitate continued inpatient care:

• No bleeding complications from the surgical site 1
• No signs of graft thrombosis (warm foot with palpable pulses) 1
• No infection (intact incision) 1
• No hemodynamic instability 1
• No acute limb ischemia 1

Outpatient Management Plan

The patient has received appropriate discharge education:

• Incisional care instructions have been reviewed 1
• Discharge instructions have been provided 1
• Anticoagulation therapy has been initiated 2

Post-discharge, the patient should have outpatient follow-up that includes pulse examination of proximal, graft, and outflow vessels, with consideration for duplex imaging surveillance of the bypass graft within the first 2 years 1.

Common Pitfall to Avoid

Do not confuse the need for close post-operative monitoring with the need for continued hospitalization. Patients who are hemodynamically stable, ambulatory, and without complications can be safely monitored in the outpatient setting with appropriate follow-up arrangements 1. The initiation of rivaroxaban does not require inpatient monitoring, as this medication has rapid onset and does not require INR monitoring like warfarin 5.