Joint Annual Scientific Meeting of The Irish Association of Vascular Surgeons and The Northern Ireland Vascular Society in May 2014 IAVS & NIVASC
CONFERENCE PROGRAMME Disclosure text Joint Annual Scientific Meeting of The Irish Association of Vascular Surgeons and The Northern Ireland Vascular Society in May 2014 is funded with the support of commercial bodies. These bodies are Aquilant Medical, BARD, Baxter, Cook Medical, Covidien, Cryolife, Endosurgical, Fannin, Fleetwood Health Ltd., GORE, Grunenthal Pharma, Healthcare 21, J&J – Ethicon, KCI Medical, Le Maitre, M3 Medical, MED Surgical, Medtronic, PEI, Tekno-Surgical.
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Ir J Med Sci (2014) 183 (Suppl 6):S263–S268 DOI 10.1007/s11845-014-1169-1 Ó Royal Academy of Medicine in Ireland 2014
1. Desferrioxamine as a pro-angiogenic in critical limb ischaemia Caroline Herron1, 4, Hugh O’Neill1, 2, 3, 4, Conn Hastings1, 4, Adolfo Lopez-Noreiga1, 2, 4, Fergal O’ Brien1, 3, 4, Ciara´n McDonnell 5, Garry Duffy1, 3, 4 (1) Tissue Engineering Research Group, Dept. of Anatomy, RCSI; (2) School of Pharmacy, RCSI; (3) Trinity Centre for Bioengineering, Trinity College Dublin; (4) Advanced Materials and Bioengineering Research (AMBER) Centre, RCSI and TCD; (5) Department of Vascular Surgery, Mater Misericordiae University Hospital Background: Chronic, critical limb ischaemia (CLI) represents a severe manifestation of peripheral arterial disease. Revascularisation procedures are invasive, carry significant risk of morbidity and all unsuitable for all patients. Therapeutic angiogenesis may be a potential alternative. In order to mimic the complexity of the angiogenic process, treatments must be given in a manner that allows for multimodal and controllable release. We aimed to use a chitosan based hydrogel as a delivery vehicle for a pro-angiogenic therapy. Further control of drug delivery was achieved using thermosensitive liposomes. Methods: Initial studies involved injecting desferrioxamine (DFO), a pro-angiogenic agent; within a chitosan gel into ischaemic hind limbs of an athymic mouse model. Collateral circulation was measured using laser Doppler imaging (LDI) and CD31 staining for endothelial cells. In the liposome study; thermosensitive liposomes were encapsulated with 100 lM of DFO. The liposome/DFO complexes were loaded into a 2 % w/v chitosan, 7 % w/v b-glycerophosphate (b-GP) gel, which acts as a biological depot. The same concentration of free DFO was free-loaded into the gel. Dual release of DFO was possible via the diffusion of the free loaded drug through the hydrogel and secondly via the application of a hyperthermic pulse to disrupt the liposomes and release encapsulated DFO. Results: Both LDI and immunohistochemical staining for endothelial cells revealed increased blood vessels in ischaemic limbs treated with DFO when compared to control.In the liposome study, approximately 90 % of the free loaded DFO was released from the gel over the first 4 days. Following a heat pulse to 42 °C a second peak of drug release was possible via disruption of the liposomes and release of their DFO. This corresponded to a 15–30 % increase in DFO release at all of the pulse time points (mean ± SD, n = 3). In gels containing liposomal DFO alone we illustrated an ability to control and bring about a 15 % increase in drug release as late as day 12. Conclusions: We have illustrated the potential of DFO to act as a proangiogenic agent, which we propose as an adjunct in the treatment of CLI.
2. Effects of neck radiation therapy on extra-cranial carotid arteries atherosclerosis disease progression: systematic review and a meta-analysis Bashar K1, Kheirelseid E. A. H1, Healy D1, Clarke-Moloney M1, Burke PE1, Kavanagh EG1, Walsh SR2 (1) Department of Vascular Surgery University Hospital Limerick, Limerick, Ireland; (2) Department of surgery, National University of Ireland, Galway Introduction: Radiation arteritis following neck irradiation as a treatment for head and neck malignancy has been well documented. The long-term sequelae of radiation exposure of the carotid arteries may take years to manifest clinically, and extra-cranial carotid artery
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(ECCA) stenosis is a well-recognised vascular complication. These carotid lesions should not be regarded as benign and should be treated in the same manner as standard carotid stenosis. Previous studies have noted increased cerebrovascular events such as stroke in this cohort of patients because of high-grade symptomatic carotid stenosis resulting in emboli. Method: Online search for case–control studies and randomised clinical trials that reported on stenosis in extra-cranial carotid arteries in patients with neck malignancies who received radiation therapy (RT) comparing them to patients with neck malignancies who did not receive RT. Results: Eight studies were included in the final analysis with total of 1,070 patients–596 received RT compared to 474 in the control group. There was statistically significant difference in overall stenosis rate in all eight studies [Pooled risk ratio = 4.08 (1.70, 9.78), p = 0.002] and high grade ([70 %) stenosis in six studies [Pooled risk ratio = 8.82 (3.46, 22.52), p = 0.00001], both being higher in the RT group. Pooled analysis of the five studies that reported on low grade (\70 %) stenosis did not show significant difference [Pooled risk ratio = 2.38 (0.77, 7.34), p = 0.13]. Conclusion: Severe ECCA stenosis is higher among patients who received RT for neck malignancies. Those patients should be closely monitored and screening programs should be considered in all patients who receive neck RT.
3. The influence of geography on vascular surgery outcomes: a systematic review Stuart J Fergusson1, Catriona Semple2, Sheila Fisken3, Ewen M Harrison1 (1) Clinical Surgery, The University of Edinburgh, Royal Infirmary, 51 Little France Crescent, Edinburgh, EH16 4SB; (2) Royal Victoria Hospital, 274 Grosvenor Road, Belfast, BT12 6BA; (3) The University of Edinburgh, College of Medicine and Veterinary Medicine, 49 Little France Crescent. Edinburgh. EH16 4SB Background: Geographical factors are thought to influence access to healthcare services and are important for rural service provision. This study aims to establish whether outcomes following vascular surgery are influenced by rurality, travel-time or distance travelled to hospital. Methods: A search strategy was applied to Medline, Embase, CINAHL, Web of Science, the Cochrane Library, and ProQuest Dissertations & Theses. Quality assessment was conducted using a modified Newcastle-Ottawa scale (NOS). This study forms part of a larger review, PROSPERO registration no.: 42013005846. Results: 5,938 unique records were identified and 13 vascular surgery papers were eligible for inclusion, representing a total of 31,922 patients undergoing operations between 1960–2010. Studies had good methodological quality (median NOS score: 6 out of 8, range 6–8). Nine studies reported mortality rates following urgent or ruptured abdominal aortic aneurysm (AAA) repairs, and only one of these studies demonstrated a significant difference in mortality according to geographic factors [odds ratio (OR) of mortality 0.28 for patients travelling from [180 km distant]. (1) study of non-ruptured AAA repairs showed that patients living in a rural area had superior outcomes than urban patients (OR 0.69 for mortality). (1) study each for carotid endarterectomy and embolectomy for pulmonary embolism both compared mortality by hospital urban– rural characteristics and no relationship was seen. (1) study
Ir J Med Sci (2014) 183 (Suppl 6):S263–S268 compared–by home distance from hospital-readmission rates following lower extremity vascular bypass surgery, and no difference was seen. Conclusion: Geography is not a clear or consistent influence in outcomes following vascular surgery.
S265 Methods: Data was collected from a prospectively held vascular database and patient demographics, indications for surgery and 30 day outcome were analysed. Results: Our results are presented in Table 1 Table 1 Stroke Unit Era Pre Stroke Unit (Nov 08–Nov 13) Era (Nov 03–Oct 08)
4. Demographic trends in the surgical management of abdominal aortic aneurysm Ms L Darragh, Mr SA Badger, Mr RC Baker Vascular Surgery Department, Royal Victoria Hospital, Belfast Introduction: The demographic shift is towards an older population. The Department of Health implemented a ban on age discrimination in 2012, however the Royal College of Surgeons document, Access all Ages raises concerns that elderly patients are not being offered surgery appropriately. The study aim was to investigate the presenting age of patients for abdominal aortic aneurysm (AAA) surgery. Patients and methods: Data were collected from electronic and written theatre logbooks for the 12 months of both 1995 and 2012. All patients undergoing either elective or emergency aneurysm repairs were included. In 2012 both open and endovascular aneurysm repair (EVAR) were assessed. Age was expressed as mean (± SD) and inter-group comparison made using independent t test or Chi squared test as appropriate, with a p value of \0.05 considered statistically significant. Results: The total patient numbers increased between the two time periods (1995 n = 104, 2012 n = 226). Patients were older in 2012 (75.8 ± 7.3) than in 1995 (72.5 ± 7.9; p \ 0.0001) for the whole cohort. The proportion requiring emergency surgery was higher in 1995 (48/104 vs. 62/226; p = 0.001). The age of elective cases increased significantly (1995: 70.3 ± 6.8; 2012: 75.1 ± 7.3; p \ 0.0001). Although emergency patients were also older, this was not significant (1995: 75.1 ± 8.5; 2012: 77.8 ± 6.9; p = 0.072). In 2012 the patients undergoing EVAR (n = 83) were older (78.6 ± 6.0 vs. 74.2 ± 7.4; p \ 0.0001) than those who had open repair (n = 143). Conclusions: Patients with AAA are undergoing surgery later in life, indicating that age discrimination is not occurring in this unit. This may be partly due to the introduction of endovascular repair to the surgeon’s armamentarium.
5. Evolution of carotid surgical practice in the last 10 years L Hanrahan1, C Canning1, O Abdulrahim1, S O’Neill1, P Madhavan1, MP Colgan1, Z Martin1 (1) Departments of Vascular Surgery, St James’s Hospital, Dublin; (2) Stroke Medicine, St James’s Hospital, Dublin Background: Stroke units provide immediate care, close monitoring of, and appropriate intervention in the evolving stroke. Prompt treatment reduces mortality from acute stroke and disability levels amongst survivors. The aim of this study was to review the practice of carotid endarterectomy (CEA) over the 5-year period since a stroke unit was established in St. James’s Hospital and to compare results to the 5-year period prior to this.
Number of CEA’s
229
263
Male:female ratio
168:61 (73 % male)
191:72 (73 % male)
Number of patients \65years 69
83
Number of patients [80years 28
24
Number of symptomatic patients
179/229 (78 %)
139/263 (53 %)
Number of symptomatic patients with 50–69 % stenosis
42/179 (23 %)
25/139 (18 %)
Mortality rate
3/229 (1.3 %)
1/263 (\1 %)
Stroke rate
2/229 (\1 %)
5/263 (1.9 %)
Number of cranial nerve injuries Number of MI’s
4/229(1.75 %)
8/263 (3 %)
2/229 (\1 %)
2/263 (\1 %)
Conclusions: Since the introduction of the Stroke Unit, there has been a slight decrease in the overall number of CEA’s performed with a 25 % increase in the proportion of endarterectomies performed for symptomatic disease. Despite the reduction in surgery for asymptomatic disease the overall 30 days stroke and death rate remains excellent at 2 %.
6. Imaging of lower limb peripheral arterial disease in a regional referral centre Dr Matthew Arneill, Dr Paul Karayiannis, Dr Peter Kennedy, Mr Paul Blair1 Royal Victoria Hospital, Belfast Trust Background: In January 2014 NICE updated guidelines on the management of lower limb peripheral arterial disease. This study aimed to assess imaging practice in a regional referral centre. Method: Tertiary centre study of vascular imaging of 174 patients undergoing infra-inguinal angioplasty or bypass surgery for critical ischemia (CI) or intermittent Claudication (IC) between May and October 2013. Retrospective collection of data from TMS, electronic care record NI and radiology systems. Results: Total of 174 patients underwent intervention, 24 were excluded as intervention was not for CI or IC. Mean age 67.5 years, 103 males and 48 females. Included 68 bypass surgery patients and 73 angioplasty patients; with 34 inpatients and 117 outpatients. CT angiography was the last form of imaging in 81 % of patients with CI and 58 % with IC. Mean inpatient waiting time for CT angiography was 2.0 and 2.5 days for MR angiography. Mean outpatient waiting time for CT angiography was 39.0 days for CI and 77.5 days for IC. Average outpatient waiting time for MR Angiography was 46 days for CI and 74 days for IC.
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S266 54 % of patients with imaging in the Belfast Trust reside outside the Belfast Trust. Of the Inpatients transfers, only 50 % had vascular imaging performed in admitting hospital. Conclusion: Current practice relies disproportionally on the use of CT Angiography. The implementation of NICE imaging recommendations requires a regional radiological approach to service the demand of a regional vascular service. Local guidelines must be created and implemented for vascular imaging in patients with IC or CI.
A 13 year experience with Botox treatment for axillary hyperhidrosis: cost effectiveness and quality of life analysis John P Gibbons, Emmeline Nugent, Nollaig O’Donohoe, Bridget Egan, Martin Feeley, Sean Tierney Deptartment of Vascular Surgery, Adelaide and Meath National Childrens Hospital, Tallaght, Dublin 24, Ireland Background: Hyperhidrosis is a chronic autonomic disorder that can be debilitating and can lead to reduced quality of life (QoL). The use of botox has provided a non-surgical option for the treatment of this disease and carries no major risks to the patient when compared to sympathectomy. This study investigates the cost effectiveness of Botox therapy as a function of QoL in a centre with 13 years’ experience. Methods: Cost analysis was performed using the costs incurred in a single treatment for axillary hyperhydrosis. Data was collected on patients (n = 44) that have attended the clinic since 2001. The average duration between treatments was used for life cycle analysis for 1 year. Validated Dermatology QoL Index was used to measure improvement in QoL (range 0–30) for patients before and greater than 4 weeks after treatment. Results: Cost analysis shows that the average 1 year cost for treatment is €852.85. The average duration of cessation of effects is 5 weeks. For those with recurrence of symptoms, the improvement in QoL showed a mean 14.4 (r = 4.98) point increase in QoL. Analysis of the individual questions reveals that the most significant improvements were in patient’s self-image with the least effect upon intimacy. Conclusions: Using the costs for 1 year and the validated QoL survey we calculated that the cost per point of improved QoL is €59.13 per year which is very reasonable considering the lack of significant complications when compared to the surgical treatment.
8. Role of far infra-red therapy in dialysis arteriovenous fistula maturation and survival: systematic review and meta-analysis Bashar K1, Healy D 1, Leonard D. Browne2, Kheirelseid E.A.H1, Michael T. Walsh2, Clarke – Moloney M 1, Burke PE1, Kavanagh EG1, Walsh SR3 (1) Department of vascular surgery, University Hospital Limerick, Limerick, Ireland; (2) Centre for Applied Biomedical Engineering Research (CABER),Department of Mechanical, Aeronautical and Biomedical Engineering, Materials and Surface Science Institute, University of Limerick, Limerick, Ireland; (3) Department of surgery, National University of Ireland, Galway Introduction: A well-functioning arteriovenous fistula (AVF) is the best modality for vascular access in patients with end-stage renal disease (ESRD) requiring haemodialysis (HD). However, AVFs’
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Ir J Med Sci (2014) 183 (Suppl 6):S263–S268 main disadvantage is the high rate of maturation failure, with approximately one-third (20–50 %) not maturing into useful access. This review examine the use of Far-Infra Red therapy in an attempt to enhance both primary (unassisted) and secondary (assisted) patency rates for AVF in dialysis and pre-dialysis patients. Method: We performed an online search for observational studies and randomised controlled trials (RCTs) that evaluated FIR in patients with AVF. Eligible studies compared FIR with control treatment and reported at least one outcome measure relating to access survival. Primary patency and secondary patency rates were the main outcomes of interest. Results: Four RCTs (666 patients) were included. Unassisted patency assessed in 610 patients, and was significantly better among those who received FIR (228/311) compared to (185/299) controls [pooled risk ratio of 1.23(1.12–1.35), = 0.00001]. In addition, the two studies that reported secondary patency rates showed significant difference in favour of FIR therapy–160/168 patients—compared to 140/163 controls [pooled risk ratio of 1.11(1.04-1.19], p = 0.003). Conclusion: FIR therapy positively influences the complex process of AVF maturation increasing both primary and secondary patency rates.
9. An ‘angioplasty first’ policy for severe infra-popliteal disease in critical limb ischaemia is feasible and effective: Outcomes from a single surgical unit Donal O’Connor, Ronan Doyle, Mohammed Farraz Khan, Bridget Egan, Martin Feeley, Sean Tierney Deptartment of Vascular Surgery, AMNCH, Tallaght Hospital, Dublin 24 Background: Critical limb ischaemia (CLI) is associated with high rates of major amputation and mortality. Revascularisation of infrapopliteal disease is particularly challenging. Distal bypass is usually not feasible due to patients’ co-morbidities or lack of suitable conduit/ distal target. Technical advances have allowed infra-popliteal angioplasty (IPA) to be adopted for such patients but published outcomes for severe infra-popliteal disease are very limited. This study reviews an ‘IPA first’ policy for complex lesions (TASC-D) in patients with CLI in a surgical unit. Methods: All cases of primary IPA for CLI between January 2010 and June 2013 were retrieved from a prospectively maintained vascular surgery database. Infra-popliteal disease was classified by TransAtlantic Inter-society Consensus class (TASC A-D) based on formal angiography. Disease severity was assessed independently by two surgeons. Primary outcome measures were technical success, freedom from re-intervention, major amputation and survival. Results were analysed on an intention to treat basis Results: IPA was performed in 61 limbs of 53 patients (41/53 male, 36/53 diabetic, median age 73). All patients had Rutherford class 4–6 CLI (rest pain or tissue loss). All limbs had absence of straight-line inflow to the foot and at least 2 cm occlusions in one or more infrapopliteal arteries (TASC D). Technical success rate was 81.3 % (49/61 limbs). Mean follow up was 17 months (1–42). Twelve patients required re-intervention (8: repeat IPA, 4: distal bypass). Major amputation rate was 9.8 % (6/61 limbs). Overall survival was 81 and 72 % at one and 3 years. Amputation free survival was 64 % at 3 years. On multivariate analysis, chronic kidney disease stage 4–5 was an independent risk factor for survival (p \ 0.05). Conclusion: An IPA first policy for CLI is technically feasible and achieves comparable limb salvage to published distal bypass outcomes. Long term survival remains limited by patients’ co-morbidities.
Ir J Med Sci (2014) 183 (Suppl 6):S263–S268
10. Explanting the failed EVAR—predictors of poor outcome McManus C, McKinley A, Blair PH, Harkin DW Belfast Vascular Unit, Royal Victoria Hospital 274 Grosvenor Road Belfast BT12 6BA Background: Delayed secondary open conversion post placement of EVAR stent-graft may be necessary in a small cohort of patients due to the development of adverse consequences such as infection, endoleak and graft migration. This study aim was to evaluate if this procedure can be performed safely and try to identify poor prognostic factors of patient outcome Methods: Details of patients who underwent EVAR and subsequent explantation of their device at the Belfast Vascular Unit were identified using the endovascular database. Type of initial procedure, patient age, lifespan of EVAR, reason for explantation and 30 day mortality were recorded. Results: From the database, 33 patients were identified with 28 being used for analysis (20 elective). Mean age at initial procedure was 72 years with 46 months as a mean duration of implant. Reasons for explantation included graft migration (five patients), endoleak with sac expansion (type 1 endoleak: five patients, type 2 endoleak six patients, type 4 endoleak : one patient), sac expansion with no obvious cause (four patients), infection (four patients), juxtarenal aneurismal change and stent-graft fracture (one patient each). A 30 day mortality rate of 21 % was noted, however, a mortality rate of 75 % existed for those requiring explantation secondary to infection. All of the patients who had an explantation secondary to infection had their initial EVAR performed on an emergency basis. Conclusions: This study demonstrates that explantation of EVAR carries significant risk especially for those with an infected stent-graft. This further highlights the need for appropriate patient selection, particularly in the emergency setting.
11. The economic burden of diabetic foot complications presenting to a university hospital in the Republic of Ireland I Robertson, M Majeed, E Ibrahim, D Mehigan, S Sheehan, M Barry Department of Vascular Surgery St Vincent’s University Hospital Elm Park Dublin 4 Introduction: The impact of diabetic foot complications on the Irish health service is significant. Despite a multidisciplinary approach, the number of admissions for diabetic foot complications continues to rise. The aim of this study was to assess the economic burden of diabetic foot complications presenting to a vascular surgery service in a large university hospital in the Republic of Ireland. Methods: A prospectively maintained database containing all admissions for diabetic foot complications was interrogated. The financial impact of overall hospital stay, including costs per each operative procedure performed was estimated using detailed procedure estimates provided by the hospital finance department. Results: Forty-seven admissions with diabetic foot complications were recorded over a 9-month period. Of the 47, six had more than one admission (range 2–5). Eleven patients had type-1 diabetes and 16 of those with type-2 diabetes were on daily insulin. The average length of stay was 27 days (range 1–375 days). The overall total number of bed days was 1,262, which represents a cost to the hospital
S267 of €1,388,200. There were 23 debridements, eight toe amputations, six below knee amputations, two trans-metatarsal amputations and one femoral-popliteal bypass. The total cost for operative intervention was €32,311. Therefore, the combined cost of hospital stay and operative intervention for a nine-month period was €1,420,511. Conclusion: The increase in prevalence of diabetes has resulted in a huge economic burden to vascular surgery services throughout the Republic of Ireland. This requires further education for patients and healthcare professionals to ensure expeditious referral to specialist services and early aggressive treatment.
12. Mid to long term results of endovenous laser ablation versus conventional surgery in patients with great saphenous varicose veins in a tertiary referral centre N Hamada, L Higgins, BY Chua, M Alawy, S Sultan Western Vascular Institute, Galway city, Ireland Background: Many randomised controlled trials were carried out in the last decade to study the short term outcome of endovenous laser ablation (EVLA), conventional surgery (CS) and other modalities of treatment. There are very few studies took into consideration the mid to long term outcome of these procedures. Objective: To compare the clinical and radiological success rate, patient satisfaction and complication rate of EVLA versus CS (high ligation and short stripping to knee level) after 5 years follow up. Methods: A total of 130 limbs were treated either with EVLA or CS from April 2004 till June 2006. We were able to reassess 104 limbs out of these 130 limbs after 5 years of treatment. Primary endpoint was recurrence defined by non-obliteration or reformation of the treated vein segment in ultrasound examination. Secondary endpoints were complication rate & change of Venous Clinical Severity Score (VCSS) Results: More than 88 % of the cohort of our patients was classified as C2 or C3 venous disease. Their VCSS was of average of 3.6 in EVLA group & 4.3 in CS group. We have followed our patients for 5.3 years in average (range from 3.42 to 8.75 years) The recurrence rate by duplex was 54.76 % in EVLA group while it was 32.26 % in CS group (P value of 0.027) Early –within 90 days of treatment minor complications rate excluding pain in EVLA group was 21.43 % while it was 12.9 % in CS group (P value of 0.287). Both groups showed a significant improvement of VCSS with a higher improvement in CS group. Conclusion: After 5 years of follow up, EVLA is associated with higher long term recurrence of the treated great saphenous vein segment in ultrasound duplex in comparison to CS. Both modalities are effective in improving VCSS.
13. Could absolute toe pressure measurements be substituted with TcPO2 in our vascular unit? N. O’ Donohoe, E. Nugent, V. McDonald,J.Gibbons, B. Egan, M. Feeley, S. Tierney Vascular Unit, Tallaght Hospital,Dublin Aims: TcPO2 measurement has been postulated as a useful tool in deciding on surgical intervention, determining the amputation level and
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S268 predicting skin healing. We aimed to evaluate whether TcPO2 could, not only assist, but substitute the measurement of absolute toe pressures. Method: A retrospective audit was performed. Data on age, gender, smoking status, co-morbidities, toe pressures, TcPO2 measurements, revascularisation and amputation status was collected. The main objective was to determine if TcPO2 measurements correlate with absolute toe pressures. Results: Data on 106 patients was collected (male = 70, Ulcer patients = 23 %; Smokers = 56 %). We looked at co-morbidities which could affect TcPO2 results. (CRF = 25 %, IHD = 71 %, COPD = 16 %, Diabetes = 65 %. A negative correlation (r2 = 0.318) was found between absolute toe pressures and TcPO2. There was a significant difference in Tcpo2 measurements in those patients who had revascularisation procedures (mean = 28.12) compared with those who didn’t (mean = 41.33)
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Ir J Med Sci (2014) 183 (Suppl 6):S263–S268 This was also found to be the case in men (mean = 33.53) compared with women (45.84), Smokers (mean = 32.63) compared with non-smokers (mean = 42.30 and patients who had amputations (mean = 45.41) versus those who had limbs preserved (mean = 69.01) There was no statistical difference found in diabetes, CRF, COPD nor anaemia. Conclusion: TcPO2 correlates relatively poorly with absolute toe pressures in our unit and appears to measure a different aspect of tissue perfusion. In combination with toe pressure and other data, it may yield clinically useful information but it is not a substitute for absolute toe pressures. Further work is required to determine if TcPO2 can be utilised as a reliable adjunct to inform clinical decision making in predicting those patients who require surgical intervention.
CONFERENCE PROGRAMME Disclosure text Joint Annual Scientific Meeting of The Irish Association of Vascular Surgeons and The Northern Ireland Vascular Society in May 2014 is funded with the support of commercial bodies. These bodies are Aquilant Medical, BARD, Baxter, Cook Medical, Covidien, Cryolife, Endosurgical, Fannin, Fleetwood Health Ltd., GORE, Grunenthal Pharma, Healthcare 21, J&J – Ethicon, KCI Medical, Le Maitre, M3 Medical, MED Surgical, Medtronic, PEI, Tekno-Surgical.
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Ir J Med Sci (2014) 183 (Suppl 6):S263–S268 DOI 10.1007/s11845-014-1169-1 Ó Royal Academy of Medicine in Ireland 2014
1. Desferrioxamine as a pro-angiogenic in critical limb ischaemia Caroline Herron1, 4, Hugh O’Neill1, 2, 3, 4, Conn Hastings1, 4, Adolfo Lopez-Noreiga1, 2, 4, Fergal O’ Brien1, 3, 4, Ciara´n McDonnell 5, Garry Duffy1, 3, 4 (1) Tissue Engineering Research Group, Dept. of Anatomy, RCSI; (2) School of Pharmacy, RCSI; (3) Trinity Centre for Bioengineering, Trinity College Dublin; (4) Advanced Materials and Bioengineering Research (AMBER) Centre, RCSI and TCD; (5) Department of Vascular Surgery, Mater Misericordiae University Hospital Background: Chronic, critical limb ischaemia (CLI) represents a severe manifestation of peripheral arterial disease. Revascularisation procedures are invasive, carry significant risk of morbidity and all unsuitable for all patients. Therapeutic angiogenesis may be a potential alternative. In order to mimic the complexity of the angiogenic process, treatments must be given in a manner that allows for multimodal and controllable release. We aimed to use a chitosan based hydrogel as a delivery vehicle for a pro-angiogenic therapy. Further control of drug delivery was achieved using thermosensitive liposomes. Methods: Initial studies involved injecting desferrioxamine (DFO), a pro-angiogenic agent; within a chitosan gel into ischaemic hind limbs of an athymic mouse model. Collateral circulation was measured using laser Doppler imaging (LDI) and CD31 staining for endothelial cells. In the liposome study; thermosensitive liposomes were encapsulated with 100 lM of DFO. The liposome/DFO complexes were loaded into a 2 % w/v chitosan, 7 % w/v b-glycerophosphate (b-GP) gel, which acts as a biological depot. The same concentration of free DFO was free-loaded into the gel. Dual release of DFO was possible via the diffusion of the free loaded drug through the hydrogel and secondly via the application of a hyperthermic pulse to disrupt the liposomes and release encapsulated DFO. Results: Both LDI and immunohistochemical staining for endothelial cells revealed increased blood vessels in ischaemic limbs treated with DFO when compared to control.In the liposome study, approximately 90 % of the free loaded DFO was released from the gel over the first 4 days. Following a heat pulse to 42 °C a second peak of drug release was possible via disruption of the liposomes and release of their DFO. This corresponded to a 15–30 % increase in DFO release at all of the pulse time points (mean ± SD, n = 3). In gels containing liposomal DFO alone we illustrated an ability to control and bring about a 15 % increase in drug release as late as day 12. Conclusions: We have illustrated the potential of DFO to act as a proangiogenic agent, which we propose as an adjunct in the treatment of CLI.
2. Effects of neck radiation therapy on extra-cranial carotid arteries atherosclerosis disease progression: systematic review and a meta-analysis Bashar K1, Kheirelseid E. A. H1, Healy D1, Clarke-Moloney M1, Burke PE1, Kavanagh EG1, Walsh SR2 (1) Department of Vascular Surgery University Hospital Limerick, Limerick, Ireland; (2) Department of surgery, National University of Ireland, Galway Introduction: Radiation arteritis following neck irradiation as a treatment for head and neck malignancy has been well documented. The long-term sequelae of radiation exposure of the carotid arteries may take years to manifest clinically, and extra-cranial carotid artery
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(ECCA) stenosis is a well-recognised vascular complication. These carotid lesions should not be regarded as benign and should be treated in the same manner as standard carotid stenosis. Previous studies have noted increased cerebrovascular events such as stroke in this cohort of patients because of high-grade symptomatic carotid stenosis resulting in emboli. Method: Online search for case–control studies and randomised clinical trials that reported on stenosis in extra-cranial carotid arteries in patients with neck malignancies who received radiation therapy (RT) comparing them to patients with neck malignancies who did not receive RT. Results: Eight studies were included in the final analysis with total of 1,070 patients–596 received RT compared to 474 in the control group. There was statistically significant difference in overall stenosis rate in all eight studies [Pooled risk ratio = 4.08 (1.70, 9.78), p = 0.002] and high grade ([70 %) stenosis in six studies [Pooled risk ratio = 8.82 (3.46, 22.52), p = 0.00001], both being higher in the RT group. Pooled analysis of the five studies that reported on low grade (\70 %) stenosis did not show significant difference [Pooled risk ratio = 2.38 (0.77, 7.34), p = 0.13]. Conclusion: Severe ECCA stenosis is higher among patients who received RT for neck malignancies. Those patients should be closely monitored and screening programs should be considered in all patients who receive neck RT.
3. The influence of geography on vascular surgery outcomes: a systematic review Stuart J Fergusson1, Catriona Semple2, Sheila Fisken3, Ewen M Harrison1 (1) Clinical Surgery, The University of Edinburgh, Royal Infirmary, 51 Little France Crescent, Edinburgh, EH16 4SB; (2) Royal Victoria Hospital, 274 Grosvenor Road, Belfast, BT12 6BA; (3) The University of Edinburgh, College of Medicine and Veterinary Medicine, 49 Little France Crescent. Edinburgh. EH16 4SB Background: Geographical factors are thought to influence access to healthcare services and are important for rural service provision. This study aims to establish whether outcomes following vascular surgery are influenced by rurality, travel-time or distance travelled to hospital. Methods: A search strategy was applied to Medline, Embase, CINAHL, Web of Science, the Cochrane Library, and ProQuest Dissertations & Theses. Quality assessment was conducted using a modified Newcastle-Ottawa scale (NOS). This study forms part of a larger review, PROSPERO registration no.: 42013005846. Results: 5,938 unique records were identified and 13 vascular surgery papers were eligible for inclusion, representing a total of 31,922 patients undergoing operations between 1960–2010. Studies had good methodological quality (median NOS score: 6 out of 8, range 6–8). Nine studies reported mortality rates following urgent or ruptured abdominal aortic aneurysm (AAA) repairs, and only one of these studies demonstrated a significant difference in mortality according to geographic factors [odds ratio (OR) of mortality 0.28 for patients travelling from [180 km distant]. (1) study of non-ruptured AAA repairs showed that patients living in a rural area had superior outcomes than urban patients (OR 0.69 for mortality). (1) study each for carotid endarterectomy and embolectomy for pulmonary embolism both compared mortality by hospital urban– rural characteristics and no relationship was seen. (1) study
Ir J Med Sci (2014) 183 (Suppl 6):S263–S268 compared–by home distance from hospital-readmission rates following lower extremity vascular bypass surgery, and no difference was seen. Conclusion: Geography is not a clear or consistent influence in outcomes following vascular surgery.
S265 Methods: Data was collected from a prospectively held vascular database and patient demographics, indications for surgery and 30 day outcome were analysed. Results: Our results are presented in Table 1 Table 1 Stroke Unit Era Pre Stroke Unit (Nov 08–Nov 13) Era (Nov 03–Oct 08)
4. Demographic trends in the surgical management of abdominal aortic aneurysm Ms L Darragh, Mr SA Badger, Mr RC Baker Vascular Surgery Department, Royal Victoria Hospital, Belfast Introduction: The demographic shift is towards an older population. The Department of Health implemented a ban on age discrimination in 2012, however the Royal College of Surgeons document, Access all Ages raises concerns that elderly patients are not being offered surgery appropriately. The study aim was to investigate the presenting age of patients for abdominal aortic aneurysm (AAA) surgery. Patients and methods: Data were collected from electronic and written theatre logbooks for the 12 months of both 1995 and 2012. All patients undergoing either elective or emergency aneurysm repairs were included. In 2012 both open and endovascular aneurysm repair (EVAR) were assessed. Age was expressed as mean (± SD) and inter-group comparison made using independent t test or Chi squared test as appropriate, with a p value of \0.05 considered statistically significant. Results: The total patient numbers increased between the two time periods (1995 n = 104, 2012 n = 226). Patients were older in 2012 (75.8 ± 7.3) than in 1995 (72.5 ± 7.9; p \ 0.0001) for the whole cohort. The proportion requiring emergency surgery was higher in 1995 (48/104 vs. 62/226; p = 0.001). The age of elective cases increased significantly (1995: 70.3 ± 6.8; 2012: 75.1 ± 7.3; p \ 0.0001). Although emergency patients were also older, this was not significant (1995: 75.1 ± 8.5; 2012: 77.8 ± 6.9; p = 0.072). In 2012 the patients undergoing EVAR (n = 83) were older (78.6 ± 6.0 vs. 74.2 ± 7.4; p \ 0.0001) than those who had open repair (n = 143). Conclusions: Patients with AAA are undergoing surgery later in life, indicating that age discrimination is not occurring in this unit. This may be partly due to the introduction of endovascular repair to the surgeon’s armamentarium.
5. Evolution of carotid surgical practice in the last 10 years L Hanrahan1, C Canning1, O Abdulrahim1, S O’Neill1, P Madhavan1, MP Colgan1, Z Martin1 (1) Departments of Vascular Surgery, St James’s Hospital, Dublin; (2) Stroke Medicine, St James’s Hospital, Dublin Background: Stroke units provide immediate care, close monitoring of, and appropriate intervention in the evolving stroke. Prompt treatment reduces mortality from acute stroke and disability levels amongst survivors. The aim of this study was to review the practice of carotid endarterectomy (CEA) over the 5-year period since a stroke unit was established in St. James’s Hospital and to compare results to the 5-year period prior to this.
Number of CEA’s
229
263
Male:female ratio
168:61 (73 % male)
191:72 (73 % male)
Number of patients \65years 69
83
Number of patients [80years 28
24
Number of symptomatic patients
179/229 (78 %)
139/263 (53 %)
Number of symptomatic patients with 50–69 % stenosis
42/179 (23 %)
25/139 (18 %)
Mortality rate
3/229 (1.3 %)
1/263 (\1 %)
Stroke rate
2/229 (\1 %)
5/263 (1.9 %)
Number of cranial nerve injuries Number of MI’s
4/229(1.75 %)
8/263 (3 %)
2/229 (\1 %)
2/263 (\1 %)
Conclusions: Since the introduction of the Stroke Unit, there has been a slight decrease in the overall number of CEA’s performed with a 25 % increase in the proportion of endarterectomies performed for symptomatic disease. Despite the reduction in surgery for asymptomatic disease the overall 30 days stroke and death rate remains excellent at 2 %.
6. Imaging of lower limb peripheral arterial disease in a regional referral centre Dr Matthew Arneill, Dr Paul Karayiannis, Dr Peter Kennedy, Mr Paul Blair1 Royal Victoria Hospital, Belfast Trust Background: In January 2014 NICE updated guidelines on the management of lower limb peripheral arterial disease. This study aimed to assess imaging practice in a regional referral centre. Method: Tertiary centre study of vascular imaging of 174 patients undergoing infra-inguinal angioplasty or bypass surgery for critical ischemia (CI) or intermittent Claudication (IC) between May and October 2013. Retrospective collection of data from TMS, electronic care record NI and radiology systems. Results: Total of 174 patients underwent intervention, 24 were excluded as intervention was not for CI or IC. Mean age 67.5 years, 103 males and 48 females. Included 68 bypass surgery patients and 73 angioplasty patients; with 34 inpatients and 117 outpatients. CT angiography was the last form of imaging in 81 % of patients with CI and 58 % with IC. Mean inpatient waiting time for CT angiography was 2.0 and 2.5 days for MR angiography. Mean outpatient waiting time for CT angiography was 39.0 days for CI and 77.5 days for IC. Average outpatient waiting time for MR Angiography was 46 days for CI and 74 days for IC.
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S266 54 % of patients with imaging in the Belfast Trust reside outside the Belfast Trust. Of the Inpatients transfers, only 50 % had vascular imaging performed in admitting hospital. Conclusion: Current practice relies disproportionally on the use of CT Angiography. The implementation of NICE imaging recommendations requires a regional radiological approach to service the demand of a regional vascular service. Local guidelines must be created and implemented for vascular imaging in patients with IC or CI.
A 13 year experience with Botox treatment for axillary hyperhidrosis: cost effectiveness and quality of life analysis John P Gibbons, Emmeline Nugent, Nollaig O’Donohoe, Bridget Egan, Martin Feeley, Sean Tierney Deptartment of Vascular Surgery, Adelaide and Meath National Childrens Hospital, Tallaght, Dublin 24, Ireland Background: Hyperhidrosis is a chronic autonomic disorder that can be debilitating and can lead to reduced quality of life (QoL). The use of botox has provided a non-surgical option for the treatment of this disease and carries no major risks to the patient when compared to sympathectomy. This study investigates the cost effectiveness of Botox therapy as a function of QoL in a centre with 13 years’ experience. Methods: Cost analysis was performed using the costs incurred in a single treatment for axillary hyperhydrosis. Data was collected on patients (n = 44) that have attended the clinic since 2001. The average duration between treatments was used for life cycle analysis for 1 year. Validated Dermatology QoL Index was used to measure improvement in QoL (range 0–30) for patients before and greater than 4 weeks after treatment. Results: Cost analysis shows that the average 1 year cost for treatment is €852.85. The average duration of cessation of effects is 5 weeks. For those with recurrence of symptoms, the improvement in QoL showed a mean 14.4 (r = 4.98) point increase in QoL. Analysis of the individual questions reveals that the most significant improvements were in patient’s self-image with the least effect upon intimacy. Conclusions: Using the costs for 1 year and the validated QoL survey we calculated that the cost per point of improved QoL is €59.13 per year which is very reasonable considering the lack of significant complications when compared to the surgical treatment.
8. Role of far infra-red therapy in dialysis arteriovenous fistula maturation and survival: systematic review and meta-analysis Bashar K1, Healy D 1, Leonard D. Browne2, Kheirelseid E.A.H1, Michael T. Walsh2, Clarke – Moloney M 1, Burke PE1, Kavanagh EG1, Walsh SR3 (1) Department of vascular surgery, University Hospital Limerick, Limerick, Ireland; (2) Centre for Applied Biomedical Engineering Research (CABER),Department of Mechanical, Aeronautical and Biomedical Engineering, Materials and Surface Science Institute, University of Limerick, Limerick, Ireland; (3) Department of surgery, National University of Ireland, Galway Introduction: A well-functioning arteriovenous fistula (AVF) is the best modality for vascular access in patients with end-stage renal disease (ESRD) requiring haemodialysis (HD). However, AVFs’
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Ir J Med Sci (2014) 183 (Suppl 6):S263–S268 main disadvantage is the high rate of maturation failure, with approximately one-third (20–50 %) not maturing into useful access. This review examine the use of Far-Infra Red therapy in an attempt to enhance both primary (unassisted) and secondary (assisted) patency rates for AVF in dialysis and pre-dialysis patients. Method: We performed an online search for observational studies and randomised controlled trials (RCTs) that evaluated FIR in patients with AVF. Eligible studies compared FIR with control treatment and reported at least one outcome measure relating to access survival. Primary patency and secondary patency rates were the main outcomes of interest. Results: Four RCTs (666 patients) were included. Unassisted patency assessed in 610 patients, and was significantly better among those who received FIR (228/311) compared to (185/299) controls [pooled risk ratio of 1.23(1.12–1.35), = 0.00001]. In addition, the two studies that reported secondary patency rates showed significant difference in favour of FIR therapy–160/168 patients—compared to 140/163 controls [pooled risk ratio of 1.11(1.04-1.19], p = 0.003). Conclusion: FIR therapy positively influences the complex process of AVF maturation increasing both primary and secondary patency rates.
9. An ‘angioplasty first’ policy for severe infra-popliteal disease in critical limb ischaemia is feasible and effective: Outcomes from a single surgical unit Donal O’Connor, Ronan Doyle, Mohammed Farraz Khan, Bridget Egan, Martin Feeley, Sean Tierney Deptartment of Vascular Surgery, AMNCH, Tallaght Hospital, Dublin 24 Background: Critical limb ischaemia (CLI) is associated with high rates of major amputation and mortality. Revascularisation of infrapopliteal disease is particularly challenging. Distal bypass is usually not feasible due to patients’ co-morbidities or lack of suitable conduit/ distal target. Technical advances have allowed infra-popliteal angioplasty (IPA) to be adopted for such patients but published outcomes for severe infra-popliteal disease are very limited. This study reviews an ‘IPA first’ policy for complex lesions (TASC-D) in patients with CLI in a surgical unit. Methods: All cases of primary IPA for CLI between January 2010 and June 2013 were retrieved from a prospectively maintained vascular surgery database. Infra-popliteal disease was classified by TransAtlantic Inter-society Consensus class (TASC A-D) based on formal angiography. Disease severity was assessed independently by two surgeons. Primary outcome measures were technical success, freedom from re-intervention, major amputation and survival. Results were analysed on an intention to treat basis Results: IPA was performed in 61 limbs of 53 patients (41/53 male, 36/53 diabetic, median age 73). All patients had Rutherford class 4–6 CLI (rest pain or tissue loss). All limbs had absence of straight-line inflow to the foot and at least 2 cm occlusions in one or more infrapopliteal arteries (TASC D). Technical success rate was 81.3 % (49/61 limbs). Mean follow up was 17 months (1–42). Twelve patients required re-intervention (8: repeat IPA, 4: distal bypass). Major amputation rate was 9.8 % (6/61 limbs). Overall survival was 81 and 72 % at one and 3 years. Amputation free survival was 64 % at 3 years. On multivariate analysis, chronic kidney disease stage 4–5 was an independent risk factor for survival (p \ 0.05). Conclusion: An IPA first policy for CLI is technically feasible and achieves comparable limb salvage to published distal bypass outcomes. Long term survival remains limited by patients’ co-morbidities.
Ir J Med Sci (2014) 183 (Suppl 6):S263–S268
10. Explanting the failed EVAR—predictors of poor outcome McManus C, McKinley A, Blair PH, Harkin DW Belfast Vascular Unit, Royal Victoria Hospital 274 Grosvenor Road Belfast BT12 6BA Background: Delayed secondary open conversion post placement of EVAR stent-graft may be necessary in a small cohort of patients due to the development of adverse consequences such as infection, endoleak and graft migration. This study aim was to evaluate if this procedure can be performed safely and try to identify poor prognostic factors of patient outcome Methods: Details of patients who underwent EVAR and subsequent explantation of their device at the Belfast Vascular Unit were identified using the endovascular database. Type of initial procedure, patient age, lifespan of EVAR, reason for explantation and 30 day mortality were recorded. Results: From the database, 33 patients were identified with 28 being used for analysis (20 elective). Mean age at initial procedure was 72 years with 46 months as a mean duration of implant. Reasons for explantation included graft migration (five patients), endoleak with sac expansion (type 1 endoleak: five patients, type 2 endoleak six patients, type 4 endoleak : one patient), sac expansion with no obvious cause (four patients), infection (four patients), juxtarenal aneurismal change and stent-graft fracture (one patient each). A 30 day mortality rate of 21 % was noted, however, a mortality rate of 75 % existed for those requiring explantation secondary to infection. All of the patients who had an explantation secondary to infection had their initial EVAR performed on an emergency basis. Conclusions: This study demonstrates that explantation of EVAR carries significant risk especially for those with an infected stent-graft. This further highlights the need for appropriate patient selection, particularly in the emergency setting.
11. The economic burden of diabetic foot complications presenting to a university hospital in the Republic of Ireland I Robertson, M Majeed, E Ibrahim, D Mehigan, S Sheehan, M Barry Department of Vascular Surgery St Vincent’s University Hospital Elm Park Dublin 4 Introduction: The impact of diabetic foot complications on the Irish health service is significant. Despite a multidisciplinary approach, the number of admissions for diabetic foot complications continues to rise. The aim of this study was to assess the economic burden of diabetic foot complications presenting to a vascular surgery service in a large university hospital in the Republic of Ireland. Methods: A prospectively maintained database containing all admissions for diabetic foot complications was interrogated. The financial impact of overall hospital stay, including costs per each operative procedure performed was estimated using detailed procedure estimates provided by the hospital finance department. Results: Forty-seven admissions with diabetic foot complications were recorded over a 9-month period. Of the 47, six had more than one admission (range 2–5). Eleven patients had type-1 diabetes and 16 of those with type-2 diabetes were on daily insulin. The average length of stay was 27 days (range 1–375 days). The overall total number of bed days was 1,262, which represents a cost to the hospital
S267 of €1,388,200. There were 23 debridements, eight toe amputations, six below knee amputations, two trans-metatarsal amputations and one femoral-popliteal bypass. The total cost for operative intervention was €32,311. Therefore, the combined cost of hospital stay and operative intervention for a nine-month period was €1,420,511. Conclusion: The increase in prevalence of diabetes has resulted in a huge economic burden to vascular surgery services throughout the Republic of Ireland. This requires further education for patients and healthcare professionals to ensure expeditious referral to specialist services and early aggressive treatment.
12. Mid to long term results of endovenous laser ablation versus conventional surgery in patients with great saphenous varicose veins in a tertiary referral centre N Hamada, L Higgins, BY Chua, M Alawy, S Sultan Western Vascular Institute, Galway city, Ireland Background: Many randomised controlled trials were carried out in the last decade to study the short term outcome of endovenous laser ablation (EVLA), conventional surgery (CS) and other modalities of treatment. There are very few studies took into consideration the mid to long term outcome of these procedures. Objective: To compare the clinical and radiological success rate, patient satisfaction and complication rate of EVLA versus CS (high ligation and short stripping to knee level) after 5 years follow up. Methods: A total of 130 limbs were treated either with EVLA or CS from April 2004 till June 2006. We were able to reassess 104 limbs out of these 130 limbs after 5 years of treatment. Primary endpoint was recurrence defined by non-obliteration or reformation of the treated vein segment in ultrasound examination. Secondary endpoints were complication rate & change of Venous Clinical Severity Score (VCSS) Results: More than 88 % of the cohort of our patients was classified as C2 or C3 venous disease. Their VCSS was of average of 3.6 in EVLA group & 4.3 in CS group. We have followed our patients for 5.3 years in average (range from 3.42 to 8.75 years) The recurrence rate by duplex was 54.76 % in EVLA group while it was 32.26 % in CS group (P value of 0.027) Early –within 90 days of treatment minor complications rate excluding pain in EVLA group was 21.43 % while it was 12.9 % in CS group (P value of 0.287). Both groups showed a significant improvement of VCSS with a higher improvement in CS group. Conclusion: After 5 years of follow up, EVLA is associated with higher long term recurrence of the treated great saphenous vein segment in ultrasound duplex in comparison to CS. Both modalities are effective in improving VCSS.
13. Could absolute toe pressure measurements be substituted with TcPO2 in our vascular unit? N. O’ Donohoe, E. Nugent, V. McDonald,J.Gibbons, B. Egan, M. Feeley, S. Tierney Vascular Unit, Tallaght Hospital,Dublin Aims: TcPO2 measurement has been postulated as a useful tool in deciding on surgical intervention, determining the amputation level and
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S268 predicting skin healing. We aimed to evaluate whether TcPO2 could, not only assist, but substitute the measurement of absolute toe pressures. Method: A retrospective audit was performed. Data on age, gender, smoking status, co-morbidities, toe pressures, TcPO2 measurements, revascularisation and amputation status was collected. The main objective was to determine if TcPO2 measurements correlate with absolute toe pressures. Results: Data on 106 patients was collected (male = 70, Ulcer patients = 23 %; Smokers = 56 %). We looked at co-morbidities which could affect TcPO2 results. (CRF = 25 %, IHD = 71 %, COPD = 16 %, Diabetes = 65 %. A negative correlation (r2 = 0.318) was found between absolute toe pressures and TcPO2. There was a significant difference in Tcpo2 measurements in those patients who had revascularisation procedures (mean = 28.12) compared with those who didn’t (mean = 41.33)
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Ir J Med Sci (2014) 183 (Suppl 6):S263–S268 This was also found to be the case in men (mean = 33.53) compared with women (45.84), Smokers (mean = 32.63) compared with non-smokers (mean = 42.30 and patients who had amputations (mean = 45.41) versus those who had limbs preserved (mean = 69.01) There was no statistical difference found in diabetes, CRF, COPD nor anaemia. Conclusion: TcPO2 correlates relatively poorly with absolute toe pressures in our unit and appears to measure a different aspect of tissue perfusion. In combination with toe pressure and other data, it may yield clinically useful information but it is not a substitute for absolute toe pressures. Further work is required to determine if TcPO2 can be utilised as a reliable adjunct to inform clinical decision making in predicting those patients who require surgical intervention.
