VENUM (Vascular Education iN Undergraduate Medicine): a multicentre evaluation of undergraduate vascular education in the UK.

INTRODUCTION: Vascular surgery is a recognised surgical subspecialty covering an array of circulatory conditions predominately affecting geriatric and diabetic patients. As such, a wide breadth of clinicians will see patients with vascular pathologies, but it is unclear how detailed their knowledge base is. Key to this is the education of medical students, which has been poorly documented during undergraduate training in the UK. VENUM aimed to establish students' perceptions of vascular surgery and their confidence in performing vascular objective structured clinical examination (OCSE) skills. METHODS: During the academic year of 2022/2023, final-year medical students were invited to complete a JISC survey (collaborative authorship). Seventy-seven research leads were recruited to disseminate the survey. Quantitative and thematic analysis was used to assess the data. RESULTS: In total, 240 final-year medical students completed the survey (54% female; 26 medical schools represented). Forty-five per cent of students reported never having had a vascular placement, 24% had never completed a vascular-focused clinical examination and 26% reported low confidence in performing ankle brachial pressure index measurement. An assessment of peripheral arterial disease morbidity was answered correctly in 17% of respondents compared with 92% for angina (chi-square test p<0.001). Students perceived the specialty to be non-inclusive and that early exposure to vascular surgery was required for better engagement with the specialty. CONCLUSION: Students have experienced little exposure to vascular surgery. This may affect future recruitment to vascular surgery and overall knowledge of vascular conditions in UK-trained doctors, which may affect long-term patient management.

Arterial Complications following Total Knee Arthroplasty (TKA): A Systematic Review and Proposal for Improved Monitoring.

Introduction: Total knee arthroplasty (TKA) is a common operation and is becoming more common due to population aging and increasing BMI. TKA provides excellent improvement in quality of life but carries risk of arterial complications in the perioperative period. This systematic review aims to provide a greater understanding of the incidence of such complications, and time taken to diagnose arterial injury. Materials and methods: PubMed, Medline, Ovid SP and EMBASE databases were searched with the following MeSH keywords: 'complication', 'vascular injury', 'ischaemia', 'spasm', 'thrombosis', 'pseudoaneurysm', 'transection', 'pulse', 'ABPI OR ABI', 'Doppler', 'amputation'. All arterial vascular events in the perioperative state of the total knee replacement were included. Records were independently screened by two reviewers, and data was extracted according to a pre-determined proforma. Overall incidence and time to diagnosis was calculated for complications. Systematic review registration PROSPERO: CRD42018086643. No funding was received. Results: Twelve studies were selected for inclusion. A total of 3325 cases of arterial complications were recorded across all studies, and were divided into three categories, pseudoaneurysms (0.06%); ischaemia and thrombosis (0.17%); haemorrhage and arterial transections (0.07%). Time taken to reach the diagnosis for each complication was longest in the ischaemia and thrombosis group (6.8 days), followed by pseudoaneurysm (3.5 days) and haemorrhage and transections (3.0 days). Conclusion: TKA post-operative vascular complications are rare, but when they do occur they lead to limb and life threatening complications. This should be discussed with patients during the consent process. Current times to diagnosis represent missed opportunities to recognise arterial injury and facilitate rapid treatment of the complication. A very low threshold for seeking specialist input should be adopted, and any concern for vascular injury, such as unexplained perioperative bleeding, absent lower limb pulses in the post-operative period or unexplained severe pain should warrant immediate review by a vascular surgeon, and in centres where this is not possible, immediate blue-light transfer to the closest vascular centre.

Arterial Complications following Total Knee Arthroplasty (TKA): A Systematic Review and Proposal for Improved Monitoring

@#Introduction: Total knee arthroplasty (TKA) is a common operation and is becoming more common due to population aging and increasing BMI. TKA provides excellent improvement in quality of life but carries risk of arterial complications in the perioperative period. This systematic review aims to provide a greater understanding of the incidence of such complications, and time taken to diagnose arterial injury. Materials and methods: PubMed, Medline, Ovid SP and EMBASE databases were searched with the following MeSH keywords: ‘complication’, ‘vascular injury’, ‘ischaemia’, ‘spasm’, ‘thrombosis’, ‘pseudoaneurysm’, ‘transection’, ‘pulse’, ‘ABPI OR ABI’, ‘Doppler’, ‘amputation’. All arterial vascular events in the perioperative state of the total knee replacement were included. Records were independently screened by two reviewers, and data was extracted according to a pre-determined proforma. Overall incidence and time to diagnosis was calculated for complications. Systematic review registration PROSPERO: CRD42018086643. No funding was received. Results: Twelve studies were selected for inclusion. A total of 3325 cases of arterial complications were recorded across all studies, and were divided into three categories, pseudoaneurysms (0.06%); ischaemia and thrombosis (0.17%); haemorrhage and arterial transections (0.07%). Time taken to reach the diagnosis for each complication was longest in the ischaemia and thrombosis group (6.8 days), followed by pseudoaneurysm (3.5 days) and haemorrhage and transections (3.0 days). Conclusion: TKA post-operative vascular complications are rare, but when they do occur they lead to limb and life threatening complications. This should be discussed with patients during the consent process. Current times to diagnosis represent missed opportunities to recognise arterial injury and facilitate rapid treatment of the complication. A very low threshold for seeking specialist input should be adopted, and any concern for vascular injury, such as unexplained perioperative bleeding, absent lower limb pulses in the post-operative period or unexplained severe pain should warrant immediate review by a vascular surgeon, and in centres where this is not possible, immediate bluelight transfer to the closest vascular centre

How to Write a High Quality Multiple Choice Question (MCQ): A Guide for Clinicians.

Despite the variety of assessment tools available, multiple choice questions (MCQs) still play an integral part in examinations at both a national and speciality board level. MCQs have a number of methodological advantages yet their strength is related to the quality of the question posed. Specifically, there has been a move towards the MCQ testing a taxonomically higher order concept of integration-interpretation and problem solving. This paper focuses on question development and the potential pitfalls to avoid.

Weekend effect in non-elective abdominal aortic aneurysm repair.

BACKGROUND: The 'weekend effect' describes the phenomenon where patient outcomes appear worse for those admitted at the weekend. It has been used recently to justify significant changes in UK health policy. Recent evidence has suggested that the effect may be due to a combination of inadequate correction for confounding factors and inaccurate coding. The effects of these factors were investigated in patients with acute abdominal aortic aneurysm (AAA). METHODS: Patients undergoing non-elective AAA repair entered into the UK National Vascular Registry from January 2013 until December 2015 were included in a case-control study. The patients were divided according to whether they were treated during the week (Monday 08.00 hours to Friday 17.00 hours) or at the weekend. Data extracted included demographics, co-morbidities, preoperative medications and baseline blood test results, as well as outcomes. Coding issues were investigated by looking at patients treated for ruptured, symptomatic or asymptomatic AAA within the non-elective cohort. The primary outcome was in-hospital mortality. Secondary outcomes included length of inpatient stay, and cardiac, respiratory and renal complications. RESULTS: The mortality rate appeared to be higher at the weekend (odds ratio (OR) 1·69, 95 per cent c.i. 1·47 to 1·94; P < 0·001), but this effect disappeared when confounding factors and coding issues were corrected for (corrected OR for ruptured AAA 1·09, 0·92 to 1·29; P = 0·330). Differences in outcomes were similar for prolonged length of hospital stay (uncorrected OR 1·21, 95 per cent c.i. 1·06 to 1·37, P = 0·005; corrected OR for ruptured AAA 1·06, 0·91 to 1·10, P = 0·478), and morbidity outcomes. CONCLUSION: After appropriate correction for confounding factors and coding effects, there was no evidence of a significant weekend effect in the treatment of non-elective AAA in the UK.

Systematic review and meta-analysis of the association between frailty and outcome in surgical patients.

INTRODUCTION: Frailty is becoming increasingly prevalent in the elderly population although a lack of consensus regarding a clinical definition hampers comparison of clinical studies. More elderly patients are being assessed for surgical intervention but the effect of frailty on surgical related outcomes is still not clear. METHODS: A systematic literature search for studies prospectively reporting frailty and postoperative outcomes in patients undergoing surgical intervention was performed with data collated from a total of 12 studies. Random effects meta-analysis modelling was undertaken to estimate the association between frailty and mortality rates (in-hospital and one-year), length of hospital stay and the need for step-down care for further rehabilitation/nursing home placement. RESULTS: Frailty was associated with a higher in-hospital mortality rate (pooled odds ratio [OR]: 2.77, 95% confidence interval [CI]: 1.62-4.73), a higher one-year mortality rate (pooled OR: 1.99, 95% CI: 1.49-2.66), a longer hospital stay (pooled mean difference: 1.05 days, 95% CI: 0.02-2.07 days) and a higher discharge rate to further rehabilitation/step-down care (pooled OR: 5.71, 95% CI: 3.41-9.55). CONCLUSIONS: The presence of frailty in patients undergoing surgical intervention is associated with poorer outcomes with regard to mortality and return to independence. Further in-depth studies are required to identify factors that can be optimised to reduce the burden of frailty in surgical patients.

A Novel Combined Hybrid Approach to Enable Revascularisation of a Trauma-Induced Subclavian Artery Injury.

INTRODUCTION: This case highlights the complexity of upper limb revascularization after a subclavian artery traumatic injury and strengthens the role of a hybrid/multi-disciplinary approach to such injuries. REPORT: A 45-year-old male patient presented with an acute right upper limb following a traumatic injury to the right subclavian artery due to a motor vehicle accident (MVA). Associated injuries included an unstable cervical spine injury, a large open right clavicular injury, and a brain injury, which limited the potential revascularisation options available. The arm was revascularised using a hybrid endovascular/open surgical approach, namely embolization of the proximal subclavian artery (just distal to vertebral artery) and a right common femoral artery to distal axillary artery bypass using prosthetic material. DISCUSSION: Blunt injuries to the subclavian artery are often high impact, complex and associated with multiple injuries to surrounding structures, which limit the role of standard procedures used in the elective setting. This case highlights the role of multidisciplinary team involvement, using a hybrid approach and a novel distal inflow site to restore upper limb perfusion.

Incidence and Outcomes of Severe Renal Impairment Following Ruptured Abdominal Aortic Aneurysm Repair.

INTRODUCTION: Acute kidney injury (AKI) following ruptured abdominal aortic aneurysm (rAAA) repair is common and multifactorial. A standard definition of AKI after endovascular repair (EVAR), the Aneurysm Renal Injury Score (ARISe), has been proposed to facilitate standardised reporting and thus improve understanding of this issue. METHODS: Data were collected retrospectively on AKI in a prospectively maintained database of all patients treated for rAAA in a single tertiary referral centre since the availability of routine out of hours emergency EVAR. The ARISe score was used to describe the degree of AKI and factors which correlated with poor renal outcomes were assessed. RESULTS: Two-hundred and five patients were treated between January 2006 and April 2014. Of these, 125 were treated with open repair (OSR) and 80 were treated with EVAR. Severe AKI (defined as ARISe score ≥3) occurred in 36% of patients. After correction for confounders, patients treated with OSR were significantly more likely to develop severe AKI (43% vs. 26%, p = .02). There was no significant difference in preoperative serum creatinine between groups, but increased preoperative serum creatinine was strongly associated with severe AKI postoperatively (p < .001). Age, sex, endograft type, and preoperative CT scanning were not associated with differences in renal outcomes. Clamp position above renal arteries was predictive of severe AKI in patients treated with OSR (p < .01). Patients suffering severe AKI had significantly higher mortality at 30 days and 12 months (28% vs. 5% and 44% vs. 13%, p < .001 for both comparisons). CONCLUSION: Severe AKI is common following successful repair of rAAA. In this large case series of high-risk patients, OSR was associated with significantly higher rates of severe AKI compared with EVAR, despite the increased dose of contrast involved in EVAR and the older age of these patients. In turn, severe AKI was associated with higher mortality rates.

Antithrombotic treatment for acute extracranial carotid artery dissections: a meta-analysis.

INTRODUCTION: Carotid artery dissection is a leading cause of stroke in younger patients, with an associated prevalence of 2.6-3.0 per 100,000 population. This meta-analysis aims to determine whether in patients managed medically, treatment with anticoagulants or antiplatelet agents was associated with a better outcome with respect to mortality, ischaemic stroke, and major bleeding episodes. PATIENTS AND METHODS: A comprehensive search strategy was employed of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to March 2015), and EMBASE (January 1980 to March 2015) databases. Primary outcomes were death (all causes) or disability. Secondary outcomes were ischaemic stroke, symptomatic intracranial haemorrhage, and major extracranial haemorrhage during the reported follow-up period. RESULTS: No completed randomized trials were found. Comparing antiplatelets with anticoagulants across 38 studies (1,398 patients), there were no significant differences in the odds of death (effects size, ES, -0.007, p = .871), nor in the death and disability comparison or across any secondary outcomes. CONCLUSION: There were no randomised trials comparing either anticoagulants or antiplatelets with control, thus there is no level 1 evidence to support their routine use for the treatment of carotid artery dissection. Also, there were no randomised trials that directly compared anticoagulants with antiplatelet drugs, and the reported non-randomised studies did not show any evidence of a significant difference between the two.

Effect of frailty on short- and mid-term outcomes in vascular surgical patients.

BACKGROUND: Frailty is a multidimensional vulnerability resulting from age-associated decline. The impact of frailty on outcomes was assessed in a cohort of vascular surgical patients. METHODS: The study included patients aged over 65 years with length of hospital stay (LOS) greater than 2 days, who were admitted to a tertiary vascular unit over a single calendar year. Demographics, mode of admission, diagnosis, mortality, LOS and discharge destination were recorded, as well as a variety of frailty-specific characteristics. The impact of frailty on LOS, discharge destination, survival and readmission rate was assessed using multivariable regression techniques. The ability of the models to predict these outcomes was also assessed. RESULTS: In total, 413 patients of median age 77 years were followed for a median of 18 (range 12-24) months. The in-hospital, 3- and 12-month mortality rates were 3·6, 8·5 and 13·8 per cent respectively. Receiver operating characteristic (ROC) curve analysis revealed that frailty-based regression models were excellent predictors of 12-month mortality (area under the ROC curve (AUC) = 0·81), prolonged LOS (AUC = 0·79) and discharge to a care institution (AUC = 0·84). A simple additive frailty score using six key features retained strong predictive power for 12-month mortality (AUC = 0·83), discharge to a care institution (AUC = 0·78) and prolonged LOS (AUC = 0·74). This frailty score was also strongly associated with readmission rates (P < 0·001). CONCLUSION: Frailty in vascular surgery patients predicts a multiplicity of poorer outcomes. Optimal management should include identification of at-risk patients and treatment of modifiable risk factors.

Survival following ruptured abdominal aortic aneurysm before and during the IMPROVE Trial: a single-centre series.

OBJECTIVES: The first large-scale randomised trial (Immediate Management of the Patient with Rupture: Open Versus Endovascular repair [IMPROVE]) for endovascular repair of ruptured abdominal aortic aneurysm (rEVAR) has recently finished recruiting patients. The aim of this study was to examine the impact on survival after rEVAR when the IMPROVE protocol was initiated in a high volume abdominal aortic aneurysm (AAA) centre previously performing rEVAR. METHODS: One hundred and sixty-nine patients requiring emergency infrarenal AAA repair from January 2006 to April 2013 were included. Eighty-four patients were treated before (38 rEVAR, 46 open) and 85 (31 rEVAR, 54 open) were treated during the trial period. A retrospective analysis was performed. RESULTS: Before the trial, there was a significant survival benefit for rEVAR over open repair (90-day mortality 13% vs. 30%, p = .04, difference remained significant up to 2 years postoperatively). This survival benefit was lost after starting randomisation (90-day mortality 35% vs. 33%, p = .93). There was an increase in overall 30-day mortality from 15% to 31% (p = .02), while there was no change for open repair (p = .438). There was a significant decrease in general anaesthetic use (p = .002) for patients treated during the trial. Randomised patients had shorter hospital and intensive treatment unit stays (p = .006 and p = .03 respectively). CONCLUSIONS: The change in survival seen during the IMROVE trial highlights the need for randomised rather than cohort data to eliminate selection bias. These results from a single centre reinforce those recently reported in IMPROVE.

Effect of supervised exercise on physical function and balance in patients with intermittent claudication.

BACKGROUND: The aim of the study was to identify whether a standard supervised exercise programme (SEP) for patients with intermittent claudication improved specific measures of functional performance including balance. METHODS: A prospective observational study was performed at a single tertiary vascular centre. Patients with symptomatic intermittent claudication (Rutherford grades 1-3) were recruited to the study. Participants were assessed at baseline (before SEP) and 3, 6 and 12 months afterwards for markers of lower-limb ischaemia (treadmill walking distance and ankle : brachial pressure index), physical function (6-min walk, Timed Up and Go test, and Short Physical Performance Battery (SPPB) score), balance impairment using computerized dynamic posturography with the Sensory Organization Test (SOT), and quality of life (VascuQoL and Short Form 36). RESULTS: Fifty-one participants underwent SEP, which significantly improved initial treadmill walking distance (P = 0·001). Enrolment in a SEP also resulted in improvements in physical function as determined by 6-min maximum walking distance (P = 0·006), SPPB score (P < 0·001), and some domains of both generic (bodily pain, P = 0·025) and disease-specific (social domain, P = 0·039) quality of life. Significant improvements were also noted in balance, as determined by the SOT (P < 0·001). CONCLUSION: Supervised exercise improves both physical function and balance impairment.

Meta-analysis of contemporary short- and long-term mortality rates in patients diagnosed with critical leg ischaemia.

BACKGROUND: Critical leg ischaemia (CLI) has been associated with high mortality rates. There is a lack of contemporary data on both short- and long-term mortality rates in patients diagnosed with CLI. METHODS: This was a systematic literature search for studies prospectively reporting mortality in patients diagnosed with CLI. Meta-analysis and meta-regression models were developed to determine overall mortality rates and specific patient-related factors that were associated with death. RESULTS: A total of 50 studies were included in the analysis The estimated probability of all-cause mortality in patients with CLI was 3·7 per cent at 30 days, 17·5 per cent at 1 year, 35·1 per cent at 3 years and 46·2 per cent at 5 years. Men had a statistically significant survival benefit at 30 days and 3 years. The presence of ischaemic heart disease, tissue loss and older age resulted in a higher probability of death at 3 years. CONCLUSION: Early mortality rates in patients diagnosed with CLI have improved slightly compared with previous historical data, but long-term mortality rates are still high.

Early re-presentations and the potential role of catheter-directed thrombolysis in patients diagnosed with a lower limb deep vein thrombosis: a single-centre experience.

INTRODUCTION: Catheter-directed thrombolysis (CDT) for iliofemoral deep vein thrombosis (DVT) restores venous patency, reduces the risk of the post-thrombotic syndrome and may reduce longer term treatment costs. This study assessed the potential role of CDT in patients with DVT with regard to representation following the index event. METHODS: A retrospective review of all patients with a positive lower limb DVT scan. Potential suitability of each patient to undergo CDT was based on well-recognized inclusion/exclusion criteria. RESULTS: In total, 1689 patients underwent a DVT-specific lower limb venous duplex. A total of 269 were found to have a DVT. Fifty-three of these patients met the inclusion criteria for CDT (only 2 underwent CDT). Fifty-nine of the 269 patients with an index DVT re-presented to our institution with a venous thromboembolism-related clinical event. These patients were significantly younger than those who did not reattend. A higher proportion of patients who represented were deemed suitable for CDT for the index DVT compared with those who did not represent (17/59 versus 36/210; P = 0.04). CONCLUSION: This pragmatic study highlights the fact that significant number of patients return to secondary care with actual/perceived complications following initial diagnosis and treatment of a DVT which may have been amenable to CDT.

Meta-analysis of prospective trials determining the short- and mid-term effect of elective open and endovascular repair of abdominal aortic aneurysms on quality of life.

BACKGROUND: Repair of an abdominal aortic aneurysm (AAA) is undertaken to prevent rupture. Intervention is by either open repair (OR) or a more minimally invasive endovascular repair (EVAR). Quality-of-life (QoL) analysis is an important health outcome and a number of single studies have assessed QoL following OR and EVAR. This was a meta-analysis of published studies to assess the effect of an intervention on QoL in patients with an AAA. METHODS: A systematic literature search was undertaken for studies prospectively reporting QoL analysis in patients with an AAA undergoing elective intervention. A multivariable meta-analysis model was developed in which the outcomes were mean changes in QoL scores over time, both for all AAA repairs (OR and EVAR) and comparing OR with EVAR. RESULTS: Data were collated from 16 studies (14 OR, 12 EVAR). The results suggested that treating an AAA had an effect on patient-reported QoL, evident from the statistically significant changes predominantly in domains assessing physical ability and pain. QoL was affected most within the first 3 months after any form of intervention, and was more pronounced following OR. Furthermore, a deterioration in the Physical Component Summary score following an AAA repair (either OR or EVAR) was evident at 12 months after intervention. CONCLUSION: Treating an AAA deleteriously affects patient-reported QoL over the first year following intervention.

Implementation of a clinical prediction tool for pulmonary embolism diagnosis in a tertiary teaching hospital reduces the number of computed tomography pulmonary angiograms performed.

AIM: To evaluate the effect of implementing the Wells score clinical prediction tool (CPT) on rationalising the use of computed tomography pulmonary angiography (CTPA) for diagnosing pulmonary embolism (PE). METHODS: Within a tertiary teaching hospital, a retrospective study was conducted applying Wells score to all CTPA ordered in the first quarter of 2007. Subsequently, an algorithm including Wells score and d-dimer assay was developed to assist clinicians in rationalising their ordering of CTPA. A prospective study was performed from February to August 2009 to assess the impact of this algorithm. CTPA results, d-dimer levels, referral sources and dates were recorded. The number of CTPA performed over a 7-month period following implementation of the algorithm was compared with the same period during the previous year. PE prevalence within each risk category was compared with the published literature. RESULTS: Three hundred and thirty-three patients were investigated with CTPA in the prospective study period. Two hundred and sixty-eight patients (80.4% of cases) had complete data. The prevalence of PE in the present study was 13.8% with 57 (21.2%) patients stratified to low risk, 169 (63.0%) to intermediate risk and 42 (15.6%) to high risk. Subgroup prevalence was 8.8%, 11.8% and 23.8% respectively. Compared with the same period in 2008, 121 (26.6%) less CTPA were performed. CONCLUSION: Institutional implementation of a clinical prediction tool into the decision-making process is feasible and significantly reduces the number of CTPA being performed, with substantial cost savings and patient benefits.

Functional outcomes following revascularisation for critical limb ischaemia.

OBJECTIVES: More traditional outcome measures following lower limb bypass procedures are poor predictors of functional outcome. This paper aimed to review the effect of infrainguinal bypass surgery on residential and mobility status in patients with critical limb ischaemia. DESIGN: Review. METHODS: A Medline search up until April 2011 was undertaken of all studies involving patients with CLI undergoing ILLB and PTA. Studies were reviewed if they addressed the ambulatory/residential status of the patients pre- and post-operatively. Ambulatory status was defined as the ability to walk even with the help of a stick/frames. Independent residential status was defined as living at home with no help. RESULTS: A total of 10 studies on IILB were deemed suitable for inclusion in the review, reporting 3381 patients (2064 men). Median age ranged from 66 years to 84 years. Thirty day mortality ranged from 0% to 6.3%. Follow-up ranged from 30 days to 1 year. Three studies noted an improvement in ambulation status. No study reported any improvement in residential status after ILLB. Only one study reported on specific improvements in ambulatory status in patients with CLI after PTA. CONCLUSIONS: ILLB for patients with CLI is not without risk. Patients are not as independent or mobile following surgery. Further studies need to firstly identify the cause(s) of this and to determine optimal methods to return more patients to independence. Furthermore, CLI studies need to routinely report data on functionality.