Systematic Reviews of the Literature Are Not Always Either Useful Or the Best Way To Add To Science

Systematic reviews are becoming more popular as a way of doing research; however, not all systematic reviews are clinically useful and sometimes another type of review (scoping, topical, or critical) would be of greater value to the clinical and scientific community. The different types of review and their use are described, illustrated by examples relevant to vascular surgery

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) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease

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Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm

Background: The aim of this study was to develop a 48-h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C-statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48-h mortality in the IMPROVE data was reasonable (C-statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C-statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life-saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non-intervention rates, while respecting the wishes of the patient and family

Protocol for a prospective, longitudinal cohort study on the effect of arterial disease level on the outcomes of supervised exercise in intermittent claudication: the ELECT Registry

textabstractIntroduction Despite guideline recommendations advocating conservative management before invasive treatment in intermittent claudication, early revascularisation remains widespread in patients with favourable anatomy. The aim of the Effect of Disease Level on Outcomes of Supervised Exercise in Intermittent Claudication Registry is to determine the effect of the location of stenosis on the outcomes of supervised exercise in patients with intermittent claudication due to peripheral arterial disease. Methods and analysis This multicentre prospective cohort study aims to enrol 320 patients in 10 vascular centres across the Netherlands. All patients diagnosed with intermittent claudication (peripheral arterial disease: Fontaine II/Rutherford 1–3), who are considered candidates for supervised exercise therapy by their own physicians are appropriate to participate. Participants will receive standard care, meaning supervised exercise therapy first, with endovascular or open revascularisation in case of insufficient effect (at the discretion of patient and vascular surgeon). For the primary objectives, patients are grouped according to anatomical characteristics of disease (aortoiliac, femoropopliteal or multilevel disease) as apparent on the preferred imaging modality in the participating centre (either duplex, CT angiography or magnetic resonance angiography). Changes in walking performance (treadmill tests, 6min walk test) and quality of life (QoL; Vascular QoL Questionnaire-6, WHO QoL Questionnaire-Bref) will be compared between groups, after multivariate adjustment for possible confounders. Freedom from revascularisation and major adverse cardiovascular disease events, and attainment of the treatment goal between anatomical groups will be compared using Kaplan-Meier survival curves. Ethics and dissemination This study has been exempted from formal medical ethical approval by the Medical Research Ethics Committees United ‘MEC-U’ (W17.071). Results are intended for publication in peer-reviewed journals and for presentation to stakeholders nationally and internationally. Trial registration number NTR7332; Pre-results

Clinical cardiovascular imaging

Medical imaging has revolutionised the practice of diagnostic medicine since Wilhelm Röntgen’s discovery of X-rays in 1895. The profound impact of conventional medical imaging on diagnostic medicine is currently being replicated in the domain of clinical research, where quantitative imaging methods provide a powerful and versatile tool for the investigation of disease aetiology, measurement of disease progression and assessment of response to therapy/intervention. Quantitative imaging also holds immense promise as a method for risk assessment, prognosis and treatment stratification. Cardiovascular imaging in particular is a vast and still rapidly evolving field, with a seemingly endless number of methods and applications. Imaging has become central not only to the diagnosis, management and monitoring of cardiovascular disease but is also the basis of many life-saving interventions. Cardiovascular diseases affect all parts of the body, and their evaluation can necessitate imaging of large organs such as the heart and aorta down to the microcirculation where imaging of the microvasculature in the form of tissue perfusion can be crucial. Specialist imaging techniques aimed at investigating every part of the cardiovascular system have been developed and refined, but there is no single modality that comprehensively evaluates all aspects of vascular disease in all body regions. The aim of this chapter is to present the reader with a general introduction to imaging and a roadmap that can be used to explore this field more fully, guided by particular clinical and research interests. For a comprehensive overview of cardiovascular imaging techniques and applications, the reader is directed to The European Society of Cardiology Textbook of Cardiovascular Imaging (Zamorano et al. The ESC textbook of cardiovascular imaging. Oxford University Press; 2015.). A brief overview of selected cardiovascular imaging techniques is presented to illustrate the range of available methods and applications and is not intended to be exhaustive or comprehensive. A section on cardiovascular applications of magnetic resonance imaging (MRI) is preceded by a short primer on the basic technical and practical aspects of MRI