Implementation of the National Health Service Abdominal Aortic Aneurysm Screening Program in England

The National Health Service Abdominal Aortic Aneurysm Screening Program (NAAASP) has been introduced after research and analysis of data from a number of randomized trials and existing local screening programs in England that showed a reduction in aneurysm-related mortality when men aged ≥65 years were offered ultrasound screening. The evidence was assessed by the United Kingdom National Screening Committee against a set of internationally recognized criteria that confirmed that screening all men aged ≥65 years saves lives. The introduction of abdominal aortic aneurysm (AAA) screening to men aged 65 years is estimated to reduce premature death from ruptured AAAs by up to 50% over the next 10 years. This article describes the AAA screening program in England, its ongoing implementation and current challenges, and outcomes in the first 150,000 men

Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

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Editor's choice : European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of acute limb ischaemia

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Causes of varicose vein recurrence: Late results of a randomized controlled trial of stripping the long saphenous vein

BackgroundThe purpose of this study was to investigate the long-term outcomes following stripping of the long saphenous vein during primary varicose vein surgery and to identify factors which may predict recurrence and the need for reoperation.MethodsThe original study was designed as a randomized trial of 100 patients (133 legs) who underwent saphenofemoral ligation with or without long saphenous vein stripping. After invitation 11 years later, 51 patients (74 legs) underwent clinical review and duplex imaging and completed an Aberdeen Varicose Vein Symptom Severity Score (AVVSSS). The hospital notes of the original cohort of patients were used to compile cumulative data and assess predictive factors.ResultsA cumulative total of 83 legs had developed clinically recurrent varicose veins by 11 years (62%). There was no statistically significant difference between the ligation-only and the stripping groups. Reoperation was required for 20 of 69 legs that underwent ligation alone compared with 7 of 64 legs that had additional long saphenous vein stripping (relative risk [RR], 2.65; 95% confidence interval, 1.20 to 5.84; P = .012). By life table analysis, freedom from reoperation at 11 years was 70% after ligation, compared with 86% after stripping (P = .01). The presence of neovascularization (RR, 2.88; P = .15) , an incompetent superficial vessel in the thigh (RR, 3.24; P = .03) or an incompetent saphenofemoral junction on duplex imaging at 2 years postoperatively (RR, 4.89; P = .0001) increased the risk of a patient's developing clinically recurrent veins. Patients with visible recurrent varicose veins had a significantly worse AVVSSS (P = .001).ConclusionStripping the long saphenous vein is recommended as part of routine varicose vein surgery as it reduced the risk of reoperation by 60% after 11 years, although it did not reduce the rate of visible recurrent veins

Outcomes in Men From the NHS Abdominal Aortic Aneurysm Screening Programme With a Large Aneurysm Referred for Intervention.

OBJECTIVE The NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP) has been implemented since 2013. Men with a large aneurysm >54 mm, either at first screen or during surveillance, are referred for intervention. The aim of the present study was to explore outcomes in these men and to see whether there was any regional variation in treatment rates and type of repair. METHODS The study cohort included all men referred to a vascular network with a large abdominal aortic aneurysm (AAA). Basic demographic information, nurse assessment details, as well as outcome data were extracted from the national NAAASP IT system, AAA SMaRT, for analysis. RESULTS Some 3 026 men were referred for possible intervention (48% first screen, 52% surveillance). Some 448 men (13.3%) either declined (63, 2.1%), or were turned down for early intervention for various reasons (385, 12.7%). Some 8% were declined for medical reasons (true turn down rate). Men referred from surveillance were older, and more likely not to have had elective surgery within three months (16.0 vs. 11.2%; HR 1.37, 95% CI 1.07-1.75, p = .011). Turn down rates did not vary among local programmes, when surveillance men were taken into account. Some 2 624 (87%) men had planned AAA repair, with a peri-operative mortality of 1.3%. Thirty day surgical mortality was lower after EVAR: 0.4% compared with 2.1% after open repair. The method of repair remained consistent year on year, with roughly equal numbers undergoing endovascular (50%) and open surgical repair (48%); 2% unknown. There was regional variation in the proportion treated by endovascular repair: from 20% to 97%. CONCLUSION The turn down rate after referral for treatment with a screen detected AAA was low, but there remains considerable regional variation in the proportion undergoing endovascular repair. Procedures were undertaken with low peri-operative mortality

Safety of Men With Small and Medium Abdominal Aortic Aneurysms Under Surveillance in the NAAASP.

BACKGROUND: Population screening for abdominal aortic aneurysm (AAA) has commenced in several countries, and has been shown to reduce AAA-related mortality by up to 50%. Most men who screen positive have an AAA <5.5 cm in diameter, the referral threshold for treatment, and are entered into an ultrasound surveillance program. This study aimed to determine the risk of ruptured AAA (rAAA) in men under surveillance. METHODS: Men in the National Health Service AAA Screening Programme who initially had a small (3-4.4 cm) or medium (4.5-5.4 cm) AAA were followed up. The screening program's database collected data on ultrasound AAA diameter measurements, dates of referral, and loss to follow-up. Local screening programs recorded adverse outcomes, including rAAA and death. Rupture and mortality rates were calculated by initial and final known AAA diameter. RESULTS: A total of 18 652 men were included (50 103 person-years of surveillance). Thirty-one men had rAAA during surveillance, of whom 29 died. Some 952 men died of other causes during surveillance, mainly cardiovascular complications (26.3%) and cancer (31.2%). The overall mortality rate was 1.96% per annum, similar for men with small and medium AAAs. The rAAA risk was 0.03% per annum (95% CI, 0.02%-0.05%) for men with small AAAs and 0.28% (0.17%-0.44%) for medium AAAs. The rAAA risk for men with AAAs just below the referral threshold (5.0-5.4 cm) was 0.40% (0.22%-0.73%). CONCLUSIONS: The risk of rAAA under surveillance is <0.5% per annum, even just below the present referral threshold of 5.5 cm, and only 0.4% of men under surveillance are estimated to rupture before referral. It can be concluded that men with small and medium screen-detected AAAs are safe provided they are enrolled in an intensive surveillance program, and that there is no evidence that the current referral threshold of 5.5 cm should be changed.This work was funded by the British Heart Foundation (RE/13/6/30180), and Homerton College, University of Cambridge. The NHS AAA Screening Programme, as part of Public Health England, is funded by the Department of Health