1. Objectives At the end of last century health cost-effectiveness balance caught on with the purpose of optimizing resources and improving care level quality at the same time. Kehlet (1) and Carli (2) were among the pioneers of new school of thought about all-accomplished patient management, that is multimodal approach. Showing encouraging results in colon-rectal surgery, the second step was the question of feasibility in other surgical specialties. Taking on this challenge our Vascular Team has been tried to apply a fast-track protocol as clinical as managerial in major vascular surgery during last 11 years. Material and Methods The Vascular Team, established by surgeons and anesthetists, decided to plan specific fast-track protocol in aortic abdominal surgery at the beginning of 2000. Then a retrospective study was performed, examining major clinical outcomes as morbidity, length of stay and mortality. Following literature and team experience the patient and his pathology were studied, analyzing the pathway from first visit to follow-up as later summarized in the ERAS Items (3) (see Table 1). Vascular surgeons decided to apply minimally invasive surgery: Left sub-costal incision, involving less dermatomes (4) no evisceration, reducing water loss due to perspiration avoidance or limited use of curare drug, ameliorating perioperative respiratory performance no insertion of nasogastric tube, useless to surgeon as well as to anesthesiologist no insertion of drainage at the end of surgery, making intraoperative good homeostasis limited oral bowel preparation, reducing preoperative dehydration Vascular anesthetists tried to reduce invasive manners and improve perioperative pain control: inserting thoracic epidural catheter just before operation, followed by gradual 15-20 ml of Levobupivacaine 0,5% administration to obtain preoperative analgesia between T2 and L1l levels using double seal laryngeal mask to decrease airway invasiveness, being as safe as orotracheal tube and low anesthetic gas amount (Sevoflurane MAC 0.7%) avoiding central venous catheter and capitalizing two large peripheral cannulae (16G and/or 14G), enough for fluid and blood products infusions managing fluid administration avoiding hypovolemia and hyperidratation at the same time with rational use of colloids (euvolemia) following hemodynamic intraoperative performance by delta-up/delta-down analysis of radial artery catheter and, if necessary, by transoesophageal echocardiography for particular cases optimizing postoperative analgesia after intensive nurse training Moreover the Team agreed to: assess whole preoperative care pathway in outpatient regimen reduce perioperative laboratory and instrumental tests following literature indications use intraoperative blood rescue avoiding autologous blood infusion when possible avoid postoperative care unit and transfer patient directly to the vascular ward, basing on Ramsey Scale, ameliorating patient comfort enhance rehabilitation based on early oral feeding and early ambulation in vascular ward periodical updating with surgeons, anesthetists, nurses and other specialists as cardiologists, physiotherapists, dietitians, diabetologists and so on. Results Since May 2000 to November 2011, 931 patients were treated for elective aortic disease, 758 by open surgical technique and fast-track program. Mean age was 70 years old (SD ± 8,3) ASA 2 16,5%, ASA 3 55,1% and ASA 4 28,3%. Surgical time was 154 minutes (SD ± 50,9) with 36 suprarenal clamping. Intraoperative blood losses were 741 ml (SD ± 607,9) and mean autotransfusion after intraoperative blood rescue use was 323 ml (SD ± 327). 10 patients (1.32%) required admission in ICU within two days after surgery. Discharge at home was 3.86 days after surgery with a median of 3 days (range 2-23). Mortality rate was 1.98% (15 patients) because of multiple organ failure (5), massive gastric bleeding in 1 haepatopatic patient, haemorrhage in 1 another haepatopatic patient, surgical complications (5) and heart complications (3). Morbidity 6.59% (50 patients) was related to surgical complications (17), remarkable serum creatinine increase (15) whereof 3 patients needed transitional dialysis, heart complications (9) and other adverse events (9) as shown in table 2. Only 13 readmissions within 30 days after discharge were recorded (1,72%), related to lymphorrea (4), wound dehiscence (5), haemoperitoneum by anticoagulant drugs (1), vomiting flu-related (1), gastritis (1) and peripheral infection.. Discussion & Conclusion Apart from seriousness of pathology, the surgical act seems only the epiphenomenon of a complex condition as perioperative disease is. This is due to surgical incision, catheter insertions, dread for operation, having a feeling to be a patient and no more a person, so that psycho-physical balance became impaired. The aim of fast-track philosophy is limiting -as better as possible- the perioperative stress, related to adverse effects as ileus, nausea, vomiting, insulin-resistance and so on. Obtaining good results isn't easy because often technical difficulties, struggle against medical and administrative dogma and personnel turn-over have to be faced. Drawing up a protocol needs time, learning by successes and mistakes. In our experience applying aortic fast-track required few years, challenging fears and scepticism. Nevertheless the results were comfortable, considering an high risk surgery like abdominal aortic one. References 1) Kehlet H. Multimodal approach to control postoperative pathophisiology and rehabilitation. Br J Anaesth 1997; 78: 606-17 2) Carli F. Perioperative medicine. Are the anesthesiologists ready? Minerva Anestesiol. 2001; 67 (4): 252-255 3) Lassen K. et al.: Consensus review of optimal perioperative care in colorectal surgery: ERAS Group recommendation. Arch Surg 2009; 144: 961-9 4) Brustia P. et al.: Left sub-costal minilaparotomy in aortic surgery. Minerva Cardioangiol.2001; 49: 91-7 Items for colorectal surgery 3 Grade of evidenc e Similar items for open aortic surgery? Feasible to open aortic surgery? 1Preadmission information and counselling-yes 2Preoperative bowel preparationAyes 3 Preoperative fasting and carbohydrate loading Ayes 4Preanaesthetic medicationAyes 5Prophylaxis against thromboembolismAyes 6Antimicrobial prophylaxisAyes 7Standard anesthetic protocolAyes 8 Preventing and treating postoperative nausea and vomiting -yes 9Laparoscopy-assisted surgeryAno 10Surgical incision-yes 11Nasogastric intubationAyes 12Preventing intraoperative hypotermiaAyes 13Perioperative fluid managementAyes 14Drainage of peritoneal cavityAyes 15Urinary drainageAyes 16Prevention of postoperative ileusAyes 17Postoperative analgesiaAyes 18Postoperative nutritional careAyes 19Early mobilization-yes 20audit-yes? Table 1 : ERAS Items adaptable to vascular surgery modified by Lassen K Table 2 : data related to fast track in open aortic surgery Pts treated n° 758 Mortality n° 15 M.O.F.5 haemorrhage2 surgical complications5 cardiac complications3 Morbidity n°50 surgical 17 renal15 cardiac9 other9 Readmission n°13 lymphorrea4 wound dehiscence5 haemoperitoneum1 other3 Figure 1 : patient assisted ambulation 2,5 hours after end of surgery