Clinical Prize Papers - Wednesday Vascular access surveillance - does transonic ﬂow measurement improve ﬁstula longevity? I Shapey, M Savage, L Williams, R Chandrasekar Wirral University Teaching Hospitals Vascular access flow surveillance has a reported sensitivity of >90% to predict 50% stenosis. However, there is conflicting evidence that pre-emptive intervention following a reduction in flow rate results in an extended fistula lifetime. This study evaluated the impact of our transonic flow monitoring (TFM) surveillance programme upon AVF outcome. Data was prospectively collected from all AVFs performed between 1997 and 2013. A flow rate reduction of 15% over 3 consecutive readings was considered indicative of stenosis. The primary endpoint was fistula lifetime defined as fistula days. Subsequent successful percutaneous transluminal angioplasty (PTA) and the resulting change in fistula lifetime were considered secondary endpoints. 741 patients underwent 1379 fistula related surgical procedures (999 primary cases) during the study period. 238 AVFs failed due to thrombosis, of which 151 (63.4%) had undergone TFM. The mean age was 59.7 years. No differences of gender (p = 0.55) nor diabetic status (p = 0.28) existed between the two groups. Total fistula days were 60,318 and 19,278 in the TFM and non-TFM groups respectively. AVFs which underwent surveillance had a significantly longer (57%) mean lifetime (405 versus 232 fistula days, p < 0.05). PTA was prompted by TFM on 53 occasions resulting in 774 fistula days gained per PTA. TFM extends the mean fistula lifetime considerably with important ramifications for the dialysis-dependent population. Whilst TFM prompts more endovascular interventions, the morbidity associated with further surgical fistula formation as well as the risks of temporary central-venous catheterisation is reduced. Early implementation of dual antiplatelet therapy reduces recurrent neurological events prior to surgery without increasing peri-operative bleeding complications AJ Batchelder, J Hunter, V Cairns, A Munshi, AR Naylor University Hospitals of Leicester NHS Trust A daily Rapid-Access TIA Service was introduced in 2008. Symptomatic patients were given 75 mg Aspirin +40 mg Simvastatin by the referring doctor and were seen in the TIA Clinic by a stroke physician as soon as possible thereafter. Patients with 50-99% stenoses were transferred to the Vascular Unit for urgent carotid endarterectomy (CEA). In previous audits (n = 212 patients), the median delay between symptoms and CEA was 9 days. The median delay from admission to CEA was 2 days, during which time 28/212 patients (13%) suffered recurrent neurological events (26 TIA/AFX; 2 strokes). In order to prevent recurrent neurological events prior to CEA, the ’best medical therapy’ protocol was amended so that 75 mg Clopidogrel was started in the TIA Clinic (once cerebral haemorrhage was excluded on CT) and dual antiplatelet therapy was continued throughout the peri-operative period. Prospective audit of 100 recently symptomatic patients. Median delay for patients (M:F 1.7; mean age 73.8) from symptoms to CEA was 8 days (IQR 5-15). Median delay between admission and CEA was 3 days (IQR 2-5), during which time, two patients (2%) suffered recurrent TIAs (but no strokes). This represents a significant reduction on the 13% rate observed previously (OR 7.45 (95%CI 1.74-31.9), p = 0.0068). 30-day death/stroke after CEA was 1% (haemorrhagic transformation of ischaemic infarct). Two patients suffered significant bleeding complications (pretibial haematoma, neck haematoma requiring re-exploration). Early implementation of dual antiplatelet therapy was associated with a significant reduction in recurrent neurological events prior to CEA without any increase in peri-operative bleeding complications.
Patients with asymptomatic carotid stenosis can join ACST-2, an HTA funded trial, when carotid endarterectomy (CEA) and carotid stenting (CAS) are both possible, but where there is uncertainty as to which procedure is best. By July 2014, over 1500 patients had been recruited from nearly 100 centres worldwide. As predicted 20% of patients have come from the United Kingdom, the second highest recruiting country in the trial. Eligible patients have significant carotid artery stenosis requiring intervention, but no recent ipsilateral carotid territory symptoms, and no anatomic obstacle to CEA or CAS. Patients should have an expected lifespan of >5 good-quality years. Baseline data are available for 1330 patients (912 men, 418 women) whose median age was 72 yrs (SD+/-8.1). One-third were diabetic, most (96%) had ipsilateral stenosis of 70-99% (median 80%) with a contralateral stenosis of 50-99% in 30% patients and contralateral occlusion in 8%. Patients were on appropriate medical treatment at randomisation and at 1-month follow-up (86% anti-hypertensive, 85% lipid-lowering, 99% anti-thrombotic in both CEA and CAS groups). For 1078 patients undergoing intervention with at least 1 month follow-up and Rankin Scoring at 6 months for any stroke, the overall serious cardiovascular event rate (ie, disabling stroke, fatal myocardial infarction and death) at 30 days was 1.0%. This compares favourably with results from ACST-1 (peri-operative risk = 1.7%). The blinded rate of serious peri-procedural complications in ACST-2 is low. ACST-2 aims to randomise >3600 patients to assess the short-term risks and long-term efficacy of CEA and CAS. The shortfall in cardiovascular risk management in screen detected abdominal aortic aneurysms RA Benson, S Murray, BA Ozdemir, F D’Abate, IM Loftus St George’s Vascular Institute, St. George’s Hospital NHS Trust, London The National Abdominal Aortic Aneurysm Screening Programme (NAAASP) has been rolled out across the UK based on evidence indicating significant survival benefit in pilot centres. Despite this prevalence remains lower than predicted. Known risk factors for aneurysm disease make identification of abdominal aortic aneurysm (AAA) an important opportunity to address and manage these factors. It also has implications for a more targeted screening strategy. Risk profile and medical optimisation of screen detected aneurysm patients in a cohort of the NAAASP was analysed to identify improvements in patient management. Data from 24,851 men screened during the 5 year period from 1st April 200916th October 2013 was analysed for risk factors and treatment optimisation during follow-up. AAA prevalence was 1.18%. It correlated strongly with current or past smoking (50% and 40% respectively) and hypertension (54%), a history of dyslipidaemia (34%), ischaemic heart disease (21%) and positive family history (11%). Only 7 men were identified from non-smokers without hypertension or family history (2.4%). Post-screening follow-up identified a significant shortfall in statin and anti-platelet use (61% and 49% respectively) as well as management of hypertension (51%) despite primary care notification. As expected, patients with screen detected AAA have a high prevalence of cardiovascular risk factors and established atherosclerotic disease. There is a significant shortfall in the opportunity to undertake effective primary and secondary prevention in those with screen detected AAA, as well as an opportunity for increase education in higher risk populations. Randomised controlled trial of preoperative supervised exercise in patients undergoing elective abdominal aortic aneurysm repair H Barakat, J Khan, Y Shahin, P McCollum, I Chetter
ACST-2 Update: Over 1500 asymptomatic patients randomised to CEA vs CAS, with a low rate of major peri-procedural complications The ACST-2 Collaborative Group University of Oxford
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Academic Vascular Surgical Unit, Hull York Medical School The aim was to assess whether a period of preoperative medically supervised exercise improves clinical outcomes following elective abdominal aortic aneurysm (AAA) repair.
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Patients scheduled for open or endovascular (EVAR) repair were randomised to either six weeks of supervised exercise or standard treatment. The primary outcome measure was the occurrence of postoperative complications (A composite end point of cardiac, pulmonary and renal complications). Secondary outcome measures were: Thirty-day mortality, lengths of hospital and critical care stay, APACHE II scores recorded at critical care admission, re-operation and postoperative bleeding. Patients were followed up for three months. A total of 124 patients (62 in each group) were included (111 men, mean (s.d.) age 73 (7) years) of which 46 patients underwent EVAR (23 in each group). 14 patients (22.6 per cent) sustained postoperative complications in the exercise group, compared to 26 (41.9 per cent) in the non-exercise group (P = 0.021). Four patients (3.2 per cent, 2 in each group) died within 30 days postoperatively. Patients in the exercise group stayed less in hospital [median (IQR) 7 (5-9) days vs 8 (6.0 -12.3) days] (P = 0.025). There were no significant differences in the length of critical care stay (P = 0.845), APACHE II scores (P = 0.256), incidence of re-operations (P = 1.000) and postoperative bleeding (P = 0.343). A period of preoperative supervised exercise training reduces postoperative cardiac, respiratory and renal complications and length of hospital stay in patients undergoing elective AAA repair.
identified from the waveform. The machine makes a diagnosis independent of the operator, displaying a blue indicator for a normal limb and red for significant arterial disease. A Duplex study was then immediately carried out. This involved recording waveforms at six points and scanning for occlusions and any colour flow aliasing, then calculating PSVR from the waveform data sampled at and immediately upstream of that location. A routine Duplex report was generated for each patient. 135 limbs were assessed. The machine failed to make a diagnosis on 7 limbs and gave equivocal results on 3 limbs leaving 125 limbs in the study. Criteria for significant disease was total occlusion or a stenosis PSVR >3 (50%). Sensitivity, Specificity and Accuracy were 95, 98 and 97% respectively. D_A_V_E puts diagnostic power into the hands of specialist nursing staff at the point of initial patient contact, either in the home or the GP surgery. This is a truly disruptive innovation that will permit new treatment pathways to be explored for this challenging and often neglected branch of vascular surgery.
Regular duplex ultrasound surveillance is required to maintain stent patency following deep venous reconstruction for acute and chronic thrombotic disease P Saha1,2 , N Karunanithy3,4 , RE Bell2 , K Breen5 , B Modarai1,2 , S Black2
International Validation of a Risk Score for Complications and Re-interventions after Endovascular Aneurysm Repair (EVAR): An Evidence Base for Endograft Surveillance A Karthikesalingam, BO Patterson, JL De Bruin, A Vidal-Diez, PJE Holt, RJ Hinchliffe, MM Thompson Department of Outcomes Research, St George’s Vascular Institute, London Lifelong surveillance is considered mandatory after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA), in order to detect endograft complications and prevent aneurysm rupture. Current protocols are not cost-effective or clinically-effective. We examined the international validity of the "St George’s Vascular Institute (SGVI) score" for EVAR complications, which might inform surveillance and influence patient selection. The ENGAGE registry (Endurant Stent Graft Natural Selection Global Postmarket Registry) recruited patients undergoing EVAR at 79 centres in 30 countries. Re-interventions and endograft complications were recorded up to three years after surgery. Pre-operative aneurysm morphology was extracted from the registry database, and used to predict whether patients would be at low- or high-risk of complications after EVAR by employing a published risk score (the SGVI [St George’s Vascular Institute] score). Kaplan-Meier analysis was used to compare the incidence of endograft complications and re-interventions in patients predicted to be at low risk, versus those predicted to be at high risk. 1207 patients underwent EVAR, with follow-up of up to 3 years. The SGVI Score accurately discriminated freedom from re-interventions (89.9% vs 79.3% in low-risk versus high-risk patients, p < 0.001), freedom from endograft complications (77.6% vs. 69.6% in low-risk vs high-risk patients, p = 0.015) and freedom from a composite outcome measure of re-interventions or endograft complications (74.7% vs 66.1% in low-risk vs. high-risk patients, p = 0.008) during mid-term follow-up. This study presents international validation of a morphological risk score that predicts mid-term re-interventions and endograft complications. The results may enable risk-stratified surveillance after EVAR.
1 Academic Department of Surgery, Cardiovascular Division, BHF Centre of Excellence, King’s College London and NIHR Biomedical Research Centre at Guy’s and St. Thomas’ NHS Foundation Trust, London; 2 Department of Vascular Surgery, Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health Partners, London; 3 Division of Imaging Sciences, Cardiovascular Division, BHF Centre of Excellence, King’s College London and NIHR Biomedical Research Centre at Guy’s and St. Thomas’ NHS Foundation Trust, London; 4 Department of Interventional Radiology, Guy’s and St. Thomas’ NHS Foundation Trust, London; 5 Department of Thrombosis and Thrombophilia, Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health Partners, London
There is uncertainty regarding the appropriate surveillance intervals following endovascular deep venous reconstruction. In this study we report the initial outcomes of venous stenting in both the acute and chronic setting treated at two tertiary referral centres using a dedicated ultrasound surveillance programme. A prospective database of elective and urgent patients who underwent percutaneous deep venous reconstruction (2012-2014) was analysed. Patients were assessed using duplex ultrasound immediately following intervention and at two weeks, six weeks and six monthly intervals. Imaging was reviewed for stent patency and the need for adjunctive procedures recorded. 209 venous stents were placed in 85pts (median age 38 yrs) with a median follow-up of 8mths (range 1-27mths). 23pts had a documented thrombophilia and all patients received therapeutic anticoagulation following surgery. 46pts had stenting of a residual stenosis following catheter-directed-thrombolysis of acute iliofemoral deep vein thrombosis. Of these patients, 9pts (20%) required further procedures at a median time of 2wks following stent insertion (range 1-8wks). The overall stent patency in this group was 96%. In patients with chronic venous disease (n = 39), 16pts (41%) required further intervention. The median time for re-intervention was 2wks (range 1-16wks) and the overall stent patency in patients treated for chronic venous disease was 85%. Regular duplex ultrasound surveillance is required to maintain stent patency following deep venous reconstruction in both the acute and chronic setting. Re-intervention is most common in the first two weeks following surgery.
Doppler Assisted Vascular Expert: Smart Triaging with D_A_V_E D H King1 , M G Taylor2 , D M Nott3 , M Al-Qaisi1 , Y Panayiotopoulos1 , R J Hinchcliffe4 , T Browne1 Hospital, Chelmsford, Essex; 2 Kings College, London; 3 Imperial College, London; 4 St Georges Hospital, London
Put pre-established vascular diagnostic criteria into an operator independent machine BlueDopTM aimed at triaging the diabetic foot Cuff free ABPI and automatic detection of a diastolic notch have been combined in a single application. ABPI is computed using arm BP and a peripheral blood flow waveform. The presence of a diastolic notch (normal limb) is also
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Intra-procedural pain score in a randomised controlled trial comparing mechanochemical ablation to radiofrequency ablation: the Multicentre VeneﬁtTM versus ClariVein® for Varicose Veins (VVCVV) trial R Bootun1 , TRA Lane1 , B Dharmarajah1 , CS Lim1 , M Najem2 , S Renton2 , K Sritharan1 , AH Davies1 1 Academic
Section of Vascular Surgery, Imperial College London; 2 Department of Vascular Surgery, North West London Hospitals NHS Trust Endovenous techniques are currently the recommended choice for truncal vein treatment. However, thermal techniques require tumescent anaesthesia, which
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can be uncomfortable during administration. Non-tumescent non-thermal techniques would therefore have potential benefits. This randomised controlled trial is being carried out to compare the degree of pain patients experience while receiving mechanochemical ablation (MOCA) or radiofrequency ablation (RFA). Patients attending for primary varicose vein treatment were randomised to receive MOCA (ClariVein®) or RFA (Covidien® Venefit™). The most symptomatic limb was randomised. The primary outcome measure was intra-procedural pain using a validated visual analogue scale. Secondary outcome measures were change in quality of life and clinical scores, time to return to normal activities as well as the occlusion rate. One hundred and seventy patients have been randomised (51% in the MOCA group). Baseline characteristics were similar. Maximum pain score was significantly lower in the MOCA group (23.5 mm ± 22 mm) compared to the RFA group (34.8 mm ± 24 mm; P = 0.004). Average pain score was, however, similar in the MOCA group (17.4 mm ± 21 mm) and the RFA group (23.6 mm ± 17.5 mm; P = 0.057). Fifty-nine percent attended follow-up at one month and the complete or proximal occlusion rates was 94% for the MOCA group and 92% for the RFA group. At 1 month, the clinical and quality of life scores for both groups had similar improvements. Early results show that MOCA is less painful than RFA procedure. Clinical and quality of life scores were similarly improved at 1 month. The long-term data including occlusion rates at 6 months and quality of life scores is being collected.
© 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
University of Texas diabetic ulcer classiﬁcation identiﬁes the limbs at risk from presentation to a diabetic foot clinic K Hussey1 , B Kennon2 , WP Stuart1 1 Department
of Vascular Surgery, Western Infirmary, Glasgow; 2 Department of Diabetes, Southern General Hospital, Glasgow University of Texas (UoT) scoring is widely used to classify diabetic foot ulcers (a number indicates the ulcer depth and a letter describes the presence of sepsis and/or ischaemia). It has been validated as a predictor of outcome for ulcer episodes. We examined our database to establish the utility of this tool to predict the outcome for a limb (ulcer duration, major amputations and salvage procedures). The date were analysed by limb. Between 2005 and 2013 there were 971 ulcer episodes affecting 515 limbs (388 patients). UoT score implied peripheral arterial occlusive disease (PAOD) in 44.6% (UoT clinical groups C and D). Median duration of ulceration per limb was 4 months (range 1 to 63 months), significantly higher in the PAOD cohort compared with the non-arterial groups (A and B). There was also a significantly higher risk of major amputation (13.5% versus 4%) and 21% of the PAOD limbs underwent salvage procedures (of which 31% still had a subsequent amputation), significantly more than in the non-PAOD group (2%). In only 12 limbs was the PAOD status upgraded from presentation. UoT scoring robustly identifies the highest risk foot ulcers indicating patients requiring intervention and those at highest risk of amputation. This may be a valuable tool for communication within the healthcare team.
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