D.C. Berridge

Percutaneous transluminal angioplasty for intermittent claudication: Evidence on which to base the medicine

OBJECTIVES This study aims to assess the impact of PTA on the quality of life (QoL) of claudicants and to analyse which patients and which arterial lesions derive the most benefit. DESIGN A prospective observational study. MATERIALS One hundred and seventeen claudicants undergoing PTA were studied; 35 patients had bilateral disease, whilst 82 had unilateral disease and underwent PTA to a solitary iliac lesion, solitary superficial femoral or a iliac lesion above a diseased superficial femoral artery in 24, 39 and 19 cases, respectively. METHODS Patients completed the Short Form 36 (SF36) and EuroQol (EQ) QoL assessment instruments prior to and at 1, 3, 6, and 12 months following intervention. The SF36 produces a QoL profile, whilst the EQ produces two QoL indices. RESULTS Claudication has a deleterious effect on QoL, especially in patients with multi-segment disease. PTA results in an immediate and lasting improvement in the QoL of claudicants. Unilateral claudicants undergoing PTA to a solitary iliac lesion demonstrate the most marked QoL benefits and 12 months post PTA report a QoL approaching that of an age-matched population. Patients with bilateral claudication undergoing unilateral PTA and unilateral claudicants undergoing PTA to a solitary SFA lesion demonstrate some QoL benefits, but at 12 months post PTA do not approach the QoL scores of an age-matched population. Unilateral claudicants undergoing iliac PTA above a diseased SFA demonstrate minimal QoL changes. CONCLUSIONS These results should influence decision making in the management of claudication and it may be possible to prioritise PTA waiting lists to ensure patients with greatest potential benefit are treated with most urgency.

Randomized clinical trial of intraoperative autotransfusion in surgery for abdominal aortic aneurysm.

Perioperative homologous blood transfusion (HBT) is associated with adverse reactions and risks transmission of infection. It has also been implicated as an immunosuppressive agent. Intraoperative autotransfusion (IAT) is a potential method of autologous transfusion.

Outcome following saphenopopliteal surgery: a prospective observational study

Objectives High recurrence rates following small saphenous varicose vein surgery have been reported. The aim of this study was to ascertain initial success rates following saphenopopliteal junction (SPJ) surgery using pre- and postoperative duplex scanning. Methods A prospective study was performed on patients with ultrasound-proven SPJ reflux. Patients underwent preoperative duplex skin marking and a postoperative quality assurance scan. Results Ninety procedures were performed in 88 patients. The SPJ was successfully ligated in 87 (96.7%) cases. Reflux was completely abolished in 51 (56.7%) cases, but persisted solely in the small saphenous vein (SSV) in 32.2%. Subsequently, 10 consecutive patients underwent 11 SPJ ligations with stripping of the SSV. Follow-up ultrasound scan demonstrated successful ligation of the SPJ and elimination of superficial venous reflux. Conclusion This study demonstrates that preoperative duplex SPJ marking results in a high percentage of successful ligation. Given that residual persistent reflux was avoided in patients who underwent stripping of the SSV, we propose that patients who require SPJ surgery undergo duplex marking along with specific consideration with regard to treatment of the residual SSV.

The relationship between the saphenopopliteal junction and the common peroneal nerve: a cada-veric study

Objectives The variable anatomy of the short saphenous vein (SSV) and the potential failure to identify the saphenopopliteal junction (SPJ) contribute to an increased risk of damage to the common peroneal nerve (CPN) during surgical exploration. The aim of the present study was to determine the variation of the SPJ, its relationship to the CPN, and the relationship of both SPJ and CPN to defined anatomical landmarks. Methods Measurements of the distance between the SPJ and CPN, and the defined anatomical landmarks (fibula head, lateral joint space, lateral femoral epicondyle), were undertaken on 30 cadaveric limbs following careful dissection of the popliteal fossa. Results The level of SPJ termination was classified as low (below), normal (within 100 mm above) and high (more than 100 mm above), the lateral femoral epicondyle. Of the 30 limbs dissected, 70% of SPJs were normal, 23% low and 7% high. Direct measurement from the SPJ to anatomical landmarks showed a higher interquartile range (IQR) in low compared with normal terminations; however, the vertical distance from the SPJ to the fibula head showed an increase in IQR from low to normal terminations (7.1–14.2). The mean distances between the SPJ and CPN in low and normal terminations were 23.3 and 16.7 mm, respectively. Comparison of the IQR showed values very similar to low terminations having a slightly higher IQR compared with normal terminations (7.15–6.0). Conclusion Significant anatomic variation was observed in the termination of the SSV, with 67% located within 66 mm above the lateral femoral epicondyle. The risk of damaging the CPN during saphenopopliteal ligation may be higher for SPJs located above the lateral femoral epicondyle because of the proximity of the two structures and variability of SPJ.

The Problem with Big Data: Operating on Smaller Datasets to Bridge the Implementation Gap

Big datasets have the potential to revolutionize public health. However, there is a mismatch between the political and scientific optimism surrounding big data and the public’s perception of its benefit. We suggest a systematic and concerted emphasis on developing models derived from smaller datasets to illustrate to the public how big data can produce tangible benefits in the long term. In order to highlight the immediate value of a small data approach, we produced a proof-of-concept model predicting hospital length of stay. The results demonstrate that existing small datasets can be used to create models that generate a reasonable prediction, facilitating health-care delivery. We propose that greater attention (and funding) needs to be directed toward the utilization of existing information resources in parallel with current efforts to create and exploit “big data.”

Is there a continuing role for traditional surgery

Despite recent NICE guidance there remains a definite role for surgery in the management of varicose veins. A lot of the available evidence that has driven the transformation of care towards endovenous treatments is of good quality yet published by enthusiasts. No endovenous studies have reported long term results as far out from intervention as the open studies, yet in the meta-analysis from Murad et al, the authors suggested from their results that when surgery was compared with all endoluminal ablation therapies, surgery was associated with a non-significant reduction in the risk of varicose vein recurrence (RR0.63; 95%CI 0.37--1.07). Much of the longer-term data on recurrence following open surgery for primary varicose veins dates back well over 15 years ago. This is prior to the inclusion of routine duplex assessment and sub-specialty designation. The recent Cochrane review (13 randomised controlled studies, 3081 patients). The overall conclusion was that UGFS, EVLT and RFA were at least as effective as surgery in the treatment of the LSV. This meta-analysis did not include the CLASS (Comparison of LAser, Surgery and foam Sclerotherapy as a treatment for varicose veins) trial in whichmeasures of clinical success were similar among the groups. Only 48% of the patients screened were eligible for the CLASS study and of these, only 24% of the eligible patients agreed to take part in the study. Similarly in the study by Carradice out of a total of 772 patients assessed for suitability, 442 did not meet the inclusion criteria. There is no doubt that endovenous surgery will increasingly become first line treatment for patients with symptomatic superficial venous reflux specifically in patients with SSV reflux. However, given the device related limitations with endothermal techniques specifically with regard to adverse anatomical features allied to the poorer results of UGFS within the treatment of LSV reflux, there is without doubt still a role for more traditional open surgical techniques that can be delivered with good short and long term outcomes and still being delivered in a cost effective manner.

Primary care trust commissioning of varicose vein intervention – New guidance needed?:

Objectives In light of evidence of national variability in service commissioning of varicose vein intervention, our aim was to evaluate the current state of primary care trust commissioning for all forms of varicose vein intervention in England. We also sought to clarify the extent to which access to endovenous and surgical varicose vein services is being restricted. Methods Under the Freedom of Information Act (2001), a structured email survey was sent to 108 primary care trusts in England. Trusts were asked how many elective endovenous laser therapy and open procedures were commissioned from 2008 to 2011 and they were asked to submit their commissioning policy for analysis. The ‘qualifying criteria’ expressed in each policy were analysed by theme and geographical region. Results Of 108 surveys, 95 (88%) were completed and returned. Of these, 91 (96%) stated that varicose vein interventions were actively commissioned. Eighty-eight (97%) of primary care trusts that commissioned varicose vein interventions stated that access was restricted. Qualifying criteria varied considerably between regions. Conclusions Access to varicose vein intervention appears to be restricted, with national variation in commissioning across England. This might have an impact on patient care and surgical training. We propose that a national decision be made about which varicose vein patients should be offered funding for treatment on the National Health Service.

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.

A Pilot Study Comparing the Use of Below-Knee and Above-Knee Graduated Stockings in Patients with Superficial Venous Incompetence

Objective: Investigation of the effects of high- and low-ankle-pressure, above- and below-knee compression stockings on the haemodynamics of normal and superficially incompetent venous systems. Design: Prospective duplex study of a normal group and a venous incompetence group randomised to high- or low-pressure stockings. Setting: Vascular services of a University Hospital. Subjects: Six subjects with normal venous haemodynamics (12 limbs) and 12 patients with superficial venous incompetence (20 limbs). Methods: Subjects wore below-knee and then above-knee stockings for 1 week each. Duplex scans were performed at the outset and end of the study and on fitting and after wearing each stocking type. Main outcome measures: Duplex-derived femoral and popliteal venous velocities were measured and indexed against the initial velocity. Results: Below-knee stockings produced only minor changes. Above-knee stockings produced increased velocities in normal subjects. Similar changes were only seen with higher-pressure stockings in patients with incompetence. Conclusion: Above-knee, high-ankle-pressure stockings produce increased deep venous flow velocities.

Accuracy of centrally recorded OPCS codes for vascular surgery in the United Kingdom

AIM Centrally recorded OPCS codes are based upon district returns. The aim of this study is to determine the accuracy of this system with regard to vascular surgery. METHODS Prospectively recorded audit data for vascular and endovascular procedures were compared with those obtained from the Department of Health and Welsh Office. Five U.K. hospitals were involved in the study. Data were obtained for the twelve months, 1 April 1994-30 March 1995 (these being the most up to date figures available). RESULTS The total number of arterial reconstructions based on audit data was 1082. Those recorded by the OPCS codes were 743. This represents a discrepancy of -31.3% (range for the five hospitals: -13.1% to -63.8%). When examining specific codes similar discrepancies were seen. For example, in one hospital 38 AAA repairs were carried out but only two were centrally recorded. However, examination of ICD9 codes (relating to hospital admissions) for that hospital showed that 38 patients with AAA were admitted. A similar wide variation was seen when examining iliac and superficial femoral artery endovascular procedures. Despite the discrepancies of audit and OPCS data, the codes for reconstructions did reflect relative workload of the different hospitals. CONCLUSION This study shows that there is a marked underestimate of vascular workload when comparing central recorded data with that obtained from local audit. Marked variation is seen in the accuracy of data submitted from different hospitals.