Marked variation in venous thromboprophylaxis management for abdominal aortic aneurysm repair; results of survey amongst vascular surgeons in the United Kingdom

Objectives: We aimed to survey the current management of venous thromboprophylaxis in patients undergoing elective surgery for abdominal aortic aneurysm (AAA) by vascular surgeons in the United Kingdom. Design: A questionnaire was designed to investigate anticoagulation strategies in the perioperative period of elective AAA repair, both open and endovascular. This included both chemical and mechanical prophylaxis. A total of 395 questionnaires was posted to the members of the Vascular Society of Great Britain and Ireland. Results: One hundred and seventy-two (44%) valid responses were received. Half of the respondents administered pre-operative chemical prophylaxis at a mean of 13 h prior to AAA surgery. There was a high level of concordance in administration of heparin during surgery and in thromboprophylaxis post-operatively, with 97% giving some form of thromboprophylaxis. However there was a variation in the dose and timing, if administered, of chemical and mechanical prophylaxis. Conclusion: The survey revealed diversity in perioperative thromboprophylaxis strategies among vascular surgeons. This suggests that standardisation of pre-operative and post-operative mechanical and chemical thromboprophylaxis may be required which could potentially improve the outcomes in elective management of AAA in the UK

Risk stratification by pre-operative cardiopulmonary exercise testing improves outcomes following elective abdominal aortic aneurysm surgery : a cohort study

Background: In 2009, the NHS evidence adoption center and National Institute for Health and Care Excellence (NICE) published a review of the use of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). They recommended the development of a risk-assessment tool to help identify AAA patients with greater or lesser risk of operative mortality and to contribute to mortality prediction. A low anaerobic threshold (AT), which is a reliable, objective measure of pre-operative cardiorespiratory fitness, as determined by pre-operative cardiopulmonary exercise testing (CPET) is associated with poor surgical outcomes for major abdominal surgery. We aimed to assess the impact of a CPET-based risk-stratification strategy upon perioperative mortality, length of stay and non-operative costs for elective (open and endovascular) infra-renal AAA patients. Methods: A retrospective cohort study was undertaken. Pre-operative CPET-based selection for elective surgical intervention was introduced in 2007. An anonymized cohort of 230 consecutive infra-renal AAA patients (2007 to 2011) was studied. A historical control group of 128 consecutive infra-renal AAA patients (2003 to 2007) was identified for comparison. Comparative analysis of demographic and outcome data for CPET-pass (AT ≥ 11 ml/kg/min), CPET-fail (AT < 11 ml/kg/min) and CPET-submaximal (no AT generated) subgroups with control subjects was performed. Primary outcomes included 30-day mortality, survival and length of stay (LOS); secondary outcomes were non-operative inpatient costs. Results: Of 230 subjects, 188 underwent CPET: CPET-pass n = 131, CPET-fail n = 35 and CPET-submaximal n = 22. When compared to the controls, CPET-pass patients exhibited reduced median total LOS (10 vs 13 days for open surgery, n = 74, P < 0.01 and 4 vs 6 days for EVAR, n = 29, P < 0.05), intensive therapy unit requirement (3 vs 4 days for open repair only, P < 0.001), non-operative costs (£5,387 vs £9,634 for open repair, P < 0.001) and perioperative mortality (2.7% vs 12.6% (odds ratio: 0.19) for open repair only, P < 0.05). CPET-stratified (open/endovascular) patients exhibited a mid-term survival benefit (P < 0.05). Conclusion: In this retrospective cohort study, a pre-operative AT > 11 ml/kg/min was associated with reduced perioperative mortality (open cases only), LOS, survival and inpatient costs (open and endovascular repair) for elective infra-renal AAA surgery

The risk of harm whilst waiting for varicose veins procedure.

INTRODUCTION: Varicose veins (VV) negatively impact quality of life (QoL) and have risks of major complications including bleeding, ulceration and phlebitis. During the COVID-19 pandemic, the VSGBI (Vascular Society of Great Britain and Ireland) and GIRFT (Get It Right First Time) classified VVs as lowest priority for intervention. OBJECTIVE: This study aims to determine harm caused and the impact on the QoL on patients waiting for their VVs procedures for more than 1 year. METHODS: This was a prospective study conducted at the Norfolk and Norwich University Hospital (NNUH). Patients with VVs awaiting intervention for >1 year were included in the study. Patients with CEAP C6 disease were considered to be too high risk to be invited for treatment during the Covid-19 pandemic. Patients were sent QoL questionnaires and underwent a telephone consultation to assess harm. Both generic (EQ-VAS and EQ-5D) and disease-specific (AVVQ and CIVIQ-14) instruments were utilised. There were no control groups available for comparison. RESULTS: 275 patients were identified (37.1% male) with median time on waiting list of 60 weeks (IQR 56-65). 19 patients (6.9%) came to major harm, including phlebitis (3.6%), bleeding (1.8%) and ulceration (1.8%). Fifty-two patients (18.9%) had minor harm, including worsening pain (12.7%) and swelling (6.2%). 6.9% reported psychological harm. Rising CEAP stage was also associated with worsening level of harm in patients with C5-6 disease (p < 0.0001). Only 8.7% stated they would decline surgery during the pandemic. 104 QoL questionnaires were returned. Median EQ-VAS and EQ-5D was 75 (IQR: 60-85) and 0.685 (0.566-0.761), respectively. Median AVVQ score was 23.2 (14.9-31.0) and CIVIQ-14 score was 33 (21-44).ConclusionsThis study highlights the impact of delaying VVs surgery during a pandemic. A significant rate of both major and minor as well as psychological harm was reported. In addition, VVs had a significant detriment to quality of life

The Abdominal Aortic Aneurysm Statistically Corrected Operative Risk Evaluation (AAA SCORE) for predicting mortality after open and endovascular interventions

BackgroundAccurate adjustment of surgical outcome data for risk is vital in an era of surgeon-level reporting. Current risk prediction models for abdominal aortic aneurysm (AAA) repair are suboptimal. We aimed to develop a reliable risk model for in-hospital mortality after intervention for AAA, using rigorous contemporary statistical techniques to handle missing data.MethodsUsing data collected during a 15-month period in the United Kingdom National Vascular Database, we applied multiple imputation methodology together with stepwise model selection to generate preoperative and perioperative models of in-hospital mortality after AAA repair, using two thirds of the available data. Model performance was then assessed on the remaining third of the data by receiver operating characteristic curve analysis and compared with existing risk prediction models. Model calibration was assessed by Hosmer-Lemeshow analysis.ResultsA total of 8088 AAA repair operations were recorded in the National Vascular Database during the study period, of which 5870 (72.6%) were elective procedures. Both preoperative and perioperative models showed excellent discrimination, with areas under the receiver operating characteristic curve of .89 and .92, respectively. This was significantly better than any of the existing models (area under the receiver operating characteristic curve for best comparator model, .84 and .88; P < .001 and P = .001, respectively). Discrimination remained excellent when only elective procedures were considered. There was no evidence of miscalibration by Hosmer-Lemeshow analysis.ConclusionsWe have developed accurate models to assess risk of in-hospital mortality after AAA repair. These models were carefully developed with rigorous statistical methodology and significantly outperform existing methods for both elective cases and overall AAA mortality. These models will be invaluable for both preoperative patient counseling and accurate risk adjustment of published outcome data

National Vascular Registry: 2014 Progress Report.

The National Vascular Registry is commissioned by the Healthcare Quality Improvement Partnership (HQIP) to measure the quality and outcomes of care for patients who undergo major vascular surgery in NHS hospitals in England and Wales. It aims to provide comparative information on the performance of NHS hospitals and thereby support local quality improvement as well as inform patients about the care delivered in the NHS. As such, all NHS hospitals in England, Wales, Scotland and Northern Ireland are encouraged to participate in the Registry. The measures used to describe the patterns and outcomes of care are drawn from various national guidelines including: the “2014 The Provision of Services for Patients with Vascular Disease” and the Quality Improvement Frameworks published by the Vascular Society, and the National Institute for Health and Care Excellence (NICE) guidelines on stroke and peripheral arterial disease. In 2014, the Registry published NHS trust and surgeon-level information for elective infrarenal Abdominal Aortic Aneurysm (AAA) repair and carotid endarterectomy on the Registry website. From 28 October, information on both procedures has been available on the www.vsqip.org.uk website for all UK NHS trusts that currently perform them. For English NHS trusts, the same information was published for individual consultants, as part of NHS England’s “Everyone Counts: Planning for Patients 2013/4” initiative. Consultant-level information was also published for NHS hospitals in Wales, Scotland and Northern Ireland for consenting surgeons. This progress report aims to complement that information by (1) providing an overview of care delivered by the NHS at a national level, and (2) describing various developments within the National Vascular Registry. The Registry will publish its next annual report on major vascular surgery in November 2015

National Vascular Registry: 2015 Annual Report.

The National Vascular Registry is commissioned by the Healthcare Quality Improvement Partnership (HQIP) to measure the quality and outcomes of care for patients who undergo major vascular surgery in NHS hospitals in England and Wales. It aims to provide comparative information on the performance of NHS vascular units and thereby support local quality improvement as well as inform patients about major vascular interventions delivered in the NHS. As such, all NHS hospitals in England, Wales, Scotland and Northern Ireland are encouraged to participate in the Registry. The measures used to describe the patterns and outcomes of care are drawn from various national guidelines including: the “Provision of Services for Patients with Vascular Disease” document and the Quality Improvement Frameworks published by the Vascular Society, and the National Institute for Health and Care Excellence (NICE) guidelines on stroke and peripheral arterial disease. This report provides a description of the care provided by NHS vascular units, and contains information on the process and outcomes of care for: (i) patients undergoing abdominal aortic aneurysm (AAA) repair, (ii) patients undergoing carotid endarterectomy, (iii) patients undergoing a revascularisation procedure (angioplasty/stent or bypass) or major amputation for lower-limb peripheral arterial disease (PAD). In addition, the report presents the findings of an organisational audit conducted in August 2015

Infection in prosthetic material

Surgical site infection (SSI) occurs when a wound created as part of a surgical procedure becomes infected. SSI is one of the most common healthcare-associated infections and occurs in approximately 5% of patients undergoing a surgical procedure. SSI may lead to patients suffering considerable morbidity or mortality and have significant cost implications. The aetiology involves the interplay of host, environmental and pathogen factors all of which should be addressed in seeking to reduce the risk of developing an infection. The presence of prosthetic material reduces the number of bacteria necessary for an infection to develop and can give rise to treatment and diagnostic difficulties. The responsible organisms are most commonly Staphylococcus aureus and S. epidermidis. Diagnosis is frequently problematic and antibiotic treatment alone is often ineffective due to biofilm formation necessitating removal of prosthesis in many cases. Prevention of infection is by far the most important aspect of prosthetic implant surgery. Patient optimization is equally important as the cutting edge research into biological prostheses in reducing the incidence of prosthetic infection in future practice