Consultant Vascular Surgeons Research Articles

Evaluating the Effectiveness of an Online Targeted Education Programme on Vascular Surgery Aimed at Early Postgraduate Doctors.

Introduction Mind The Bleep (MTB) is a junior doctor-led online education organisation that produces free open-access medical education (FOAMed) resources. This paper describes MTB vascular surgery online education programme. The target audience was early postgraduate doctors completing a rotation in vascular surgery. The aims were to increase participant confidence in basic vascular surgery topics and better prepare them for their role in vascular surgery. Methods Speakers included foundation doctors, vascular speciality registrars, consultant vascular surgeons, and a vascular nurse specialist. Post-webinar feedback surveys presented as a five-point Likert scale were used to assess the effectiveness of the course. Wilcoxon signed-rank tests were used to analyse the data. Results Over three months, from March to June 2022, nine one-hour targeted education sessions were conducted, with a total of 564 participants. Post-session feedback was obtained from 364 participants (64.6%). There was a significant increase in the participants' level of confidence in the topic seen across all sessions (p <0.05). The participants rated webinars highly in the domains of engagement (mean 4.31), helpfulness of the content (mean 4.50), and interest (mean 4.39). From the cohort, 200 participants provided feedback on whether attending the webinar better prepared them for a vascular surgery rotation, with 66.5% (n = 133) reporting yes. Conclusion The MTB vascular surgery online education program successfully increased participants' confidence and their preparedness for a role in vascular surgery. As a result, it is a useful adjunct to undergraduate surgical education.

REPAIRS Delphi: A UK and Ireland Consensus Statement on the Management of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use

Consensus guidelines on the optimal management of infected arterial pseudoaneurysms secondary to groin injecting drug use are lacking. This pathology is a problem in the UK and globally, and operative management options remain contentious. This study was designed to establish consensus to promote better management of these patients, drawing on the expert experience of those in a location with a high prevalence of illicit drug use. A three round modified Delphi was undertaken, systematically surveying consultant vascular surgeons in the UK and Ireland using an online platform. Seventy five vascular surgery units were invited to participate, with one consultant providing the unit consensus practice. Round one responses were thematically analysed to generate statements for round two. These statements were evaluated by participants using a five point Likert scale. Consensus was achieved at a threshold of 70% or more agreement or disagreement. Those statements not reaching consensus were assessed and modified for round three. The results of the Delphi process constituted the consensus statement. Round one received 64 (86%) responses, round two 59 (79%) responses, and round three 62 (83%) responses; 73 out of 75 (97%) units contributed. Round two comprised 150 statements and round three 24 statements. Ninety one statements achieved consensus agreement and 15 consensus disagreement. The Delphi statements covered sequential management of these patients from diagnosis and imaging, antibiotics and microbiology, surgical approach, wound management, follow up, and additional considerations. Pre-operative imaging achieved consensus agreement (97%), with computerised tomography angiogram being the modality of choice (97%). Ligation and debridement without arterial reconstruction was the preferred approach at initial surgical intervention (89%). Multidisciplinary management, ensuring holistic care and access to substance use services, also gained consensus agreement. This comprehensive consensus statement provides a strong insight into the standard of care for these patients.

Prescriber decision-making on antithrombotic therapy after endovascular intervention for peripheral artery disease: a protocol for a discrete choice experiment

IntroductionPeripheral artery disease (PAD) is a major risk factor for cardiovascular morbidity and mortality, despite surgical and endovascular treatments. Emerging evidence supports the use of immediate antithrombotic medications after endovascular...

A feasibility survey to inform trial design investigating surgical site infection prevention in vascular surgery

Introduction: Current surgical site infection (SSI) prevention guidance indicates low-quality evidence supporting many of their recommendations. Subsequently, there is substantial variation in practice and often implementation of unsubstantiated interventions. There is therefore a need to rapidly evaluate best practices to prevent SSI. This survey aimed to evaluate current practice in the prevention of SSI and equipoise regarding potential interventions to reduce SSI rates in major lower limb amputation (MLLA) and groin incisions. Methods: A cross-sectional national survey was developed from current international guidelines to prevent SSI, following CHERRIES and CROSS checklists. A study steering committee directed internal validation prior to dissemination via single stage sampling of the membership of the Vascular Society of Great Britain and Ireland. Results: The survey received 58 responses from clinicians across 38 NHS trusts. Most respondents were consultant vascular surgeons (91%; 53/58). Preoperatively, there was variable practice in the use of preoperative bathing, surgical site preparation, antibiotic prophylaxis duration and the use of incise drapes for both MLLA and groin incisions. Intraoperatively there was little consensus for wound irrigation, drain insertion, changing gloves and instruments prior to skin closure, skin closure technique, and the use of dressings for both MLLA and groin incisions. The majority of respondents were willing to randomise patients to most interventions. Nearly three-quarters (72%; 42/58) of respondents agreed or strongly agreed that a combined outcome measure of SSI and wound dehiscence would be the ideal primary outcome in a trial investigating SSI prevention in MLLA. Conclusions: Despite significant heterogeneity in practice to prevent SSI, the majority of surgeons surveyed showed they would be willing to randomise to interventions in a randomised controlled trial. This key finding is important in the design of future studies.

Determination of skill and knowledge requirements of an instrument nurse working in major vascular surgery for the development of a virtual reality training tool

BackgroundAn open abdominal aortic aneurysm (AAA) repair is a complex high-risk procedure, with limited opportunities for an instrument nurse to gain experience and develop the necessary skills to assist the surgeon in caring for the patient during surgery. The aim of the study was to inform the content for a virtual reality (VR) training tool to develop the skills of an instrument nurse when working in major vascular surgery. MethodsAn exploratory, descriptive qualitative design using focus groups and semistructured interviews was selected for this study to explore and understand the perceptions of consultant vascular surgeons and expert vascular instrument nurses about the skills required by an instrument nurse when caring for a patient undergoing major vascular surgery. Expert vascular instrument nurses (n = 9) and consultant vascular surgeon (n = 4) were recruited via the Australian College of Perioperative Nurses (ACORN) and the Australian and New Zealand Society for Vascular Surgery (ANZSVS), respectively. ResultsData were analyzed using thematic analysis (Braun & Clarke, 2012). Four themes emerged from the data analysis. These were: preparation for surgery, essential psychomotor skills, nontechnical skills, and the virtual reality training tool design and content. ConclusionExpert vascular instrument nurses and consultant vascular surgeons provided a detailed compilation of the knowledge and skills required by an instrument nurse which will inform the content and design of the proposed virtual reality training tool. Whilst this study is based on open AAA repair, it also provides a valuable insight into what surgeons and nurses consider important for an instrument nurse when assisting with a surgical procedure.

887 Design and Implementation of a Standardised Protocol to Assess the Pre-Operative Prophylactic Antimicrobial Guidelines in Vascular Surgery – a Trust-Wide Experience

Abstract Aim The project's aim was to design and implement a replicable protocol in order to assess the pre-operative prophylactic antimicrobial prescribing that could be universally applied to all patients undergoing major vascular surgery. Method A retrospective audit was undertaken to establish existing guidelines in circulation and current practice trends at Worcestershire Acute Hospitals NHS Trust. Multiple theoretical models to stratify procedure and infection risks were designed including clean verses dirty site surgery, procedure specific surgery, procedures with or without utilisation of prosthesis, universal one size fits all guidelines. A panel consisting of consultant vascular surgeons, the antimicrobial stewardship lead consultant microbiologist, and a core surgical trainee co-ordinating the project appraised the results. Criteria included ease of implementation minimising prescribing errors, anaphylaxis, and the need for a tailored guideline for different major vascular procedures to determine suitability of the guideline. Results The initial audit signified a need to standardised guidelines in order to provide patients with a standardised care pathway that utilises best practice. In this instance an anatomical approach to the pre-operative prophylactic antimicrobial guideline for major vascular surgery was adopted and implemented at Trust level. Conclusions A replicable protocol has been established in order to appraise, design, and implement antimicrobial guidelines that can be transferable between departments and trusts alike.

Predictors of percutaneous access-related complications in aortic endovascular procedures: 'real-world' insights and a comparison to open access.

Percutaneous endovascular aneurysm repair (PEVAR) is becoming increasingly popular due to fewer access-related complications, shorter procedural times and length of stay (LOS). Our aim was to explore factors associated with access-related complications and their impact on procedural time and LOS. We retrospectively analyzed consecutive aorto-iliac endovascular procedures in a tertiary hub comprising 2 institutions and 18 consultant vascular surgeons and interventional radiologists between 2016-2017. Access-related complications were defined as: bleeding requiring cutdown or return to theatre, acute limb ischemia or common femoral artery (CFA) pseudoaneurysm requiring intervention and wound infection or dehiscence needing hospitalization. Of 511 patients, 354 (69%) had a percutaneous approach via 589 CFA access sites. In this percutaneous group, access-related complications occurred in 11% of sites (65/589); Their rate varied with procedure type ranging between 3.6% to 17.6%. The most common complication was bleeding due to closure device failure in 8.5% (50/589) of access sites. When uncomplicated, percutaneous interventions were faster compared to open surgical access (P<0.0001). Operation time and median LOS (3 vs. 2 days) were longer for elective standard EVAR patients experiencing access-related complications (P=0.033). In the percutaneous group, multivariate regression analysis demonstrated significant associations between access-related complications and eGFR (odds ratio (OR) 0.984 [0.972-0.997], P=0.014), CFA depth (OR 1.026 [1.008-1.045], P=0.005), device used (Prostar vs. Proglide (OR 2.177 [1.236-3.832], P=0.007) and procedural type (complex vs. standard EVAR) (OR 2.017 [1.122-3.627], P=0.019). We developed a risk score which had reasonably good predictive power (C-statistic 0.716 [0.646-0.787], P<0.0001) for avoiding access complications. Physiological (low eGFR level), anatomical (increased CFA depth) and technical factors (choice of device and complex procedures) were identified as predictors of access-related complications in this large retrospective series. These are important for safe selection of patients that would benefit from percutaneous access.

What is the current practice for managing patients with chronic limb-threatening ischaemia in vascular surgery services? A survey of UK vascular surgeons.

The Vascular Society of Great Britain and Ireland (VSGBI) Peripheral Arterial Disease Quality Improvement Framework (PAD QIF) stipulates targets for managing patients with chronic limb-threatening ischaemia (CLTI); however, it is unknown whether these are achievable. This survey aims to evaluate contemporary practice for managing CLTI in the UK. A questionnaire was developed in conjunction with the VSGBI to survey the management of CLTI and canvass opinions on the PAD QIF. The survey was distributed to all consultant members of the VSGBI and through a targeted social media campaign. Forty-seven consultant vascular surgeons based at 36 arterial centres across the UK responded (response rate from arterial centres = 46%). Only 14.3% of centres provided outpatient consultation within the target of seven days from referral, with only one centre providing revascularisation within the target of seven days from consultation. For inpatient management, 31.6% provided surgical and 23.8% endovascular revascularisation within the target of three days from assessment. While 60% of participants believe the PAD QIF's 5-day 'admitted care' pathway is achievable, only 28.6% thought the 14-day 'non-admitted care' pathway was feasible. Challenges to meeting these targets include the availability of theatre space and angiography lists, and availability of outpatient appointments for patient assessment. The opinion of UK vascular surgeons indicates that achieving the targets of the PAD QIF represents a major challenge based upon current services. Adapting existing services with a greater focus on providing an 'urgent' model of care may help to potentially overcome these challenges.

Vascular Access Training for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Placement: A Feasibility Study in Emergency Physicians

Background: Training vascular access skills for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to emergency physicians (EPs) could contribute to better outcomes in patients with non-compressible truncal hemorrhage. This study aimed to determine whether a concise training program could train EPs to recognize anatomical structures and correctly visualize and identify the puncture site for percuta­neous REBOA catheter placement. Methods: Our training program included basic anatomy and training in access materials for REBOA. Participants underwent expert-guided practice on each other and were then tested on key skills: the identification of anatomical structures, anatomy knowledge, technical skills for vascular access imaging with a handheld ultrasound, and time to identify adequate puncture site of the common femoral artery (CFA). Consultant vascular surgeons functioned as expert controls. Results: Eleven EPs participated. They had a median overall technical skills score of 32.5 (27.0–35.0) and median time to identify the CFA puncture site of 52.9 s (35.6–63.7), which improved to 34.0 s (21.2–44.7) at the post-test (Z = –2.756, P = 0.006). Consultant vascular surgeons were significantly faster (P = 0.000). Conclusions: EPs are capable of visualizing the femoral artery and vein within 1 min. This speed improved rapidly after repetition. Our concise training program proved useful regardless of prior endovascular experience. This program, as a component of an expanded Endovascular Resuscitation and Trauma Management curriculum, in combination with realistic task training models (simulator, perfused cadaver, or live tissue) has the potential to provide effective training of the skills required to competently perform REBOA.

Categorisation of tibial artery disease on computer tomography angiography according to the TASC II classification.

Purpose Computer tomography angiography is used to assess peripheral arterial disease. Its preference over other imaging modalities is based upon its rapid acquisition and high spatial resolution, along with ease of access. TASC II have recently updated their vascular lesion classification to include infrapopliteal lesions, and our aim is to assess the reproducibility of TASC II on infrapopliteal disease when using computer tomography angiography. Methods A retrospective analysis of a series of consecutive computer tomography angiographies was performed by seven assessors (three consultant radiologists, two consultant vascular surgeons and two vascular specialty trainees). Each assessor was asked to classify the target vessel based on the TASC II classification. Statistical analysis was performed using Cohen's weighted kappa. Results Seven assessors analysed 48 target vessels in 25 patients (20 men), with a mean age of 72.9 years. Twenty posterior tibial, 27 anterior tibial and one peroneal artery were analysed. Poor agreement was demonstrated between the two vascular consultants, with a kappa of 0.094. Weak agreement was demonstrated among the radiologists, with a kappa of 0.547. The total group of assessors had a kappa of 0.176. Conclusion This study showed poor agreement between assessors when applying the TASC II classification to infrapopliteal lesions on computer tomography angiography. TASC II should not be used to classify lesions, for clinical or research purposes, with this image modality.

Postoperative CT Evaluation After EVAR

Purpose: To compare the postoperative computed tomography angiography (CTA) assessment made by vascular surgeons and interventional radiologists after endovascular aneurysm repair (EVAR) at a tertiary vascular clinic to an outside core review facility. Methods: One hundred patients (mean age 78.7 years, range 88–55; 84 men) with consecutive, elective, routine CTA controls after EVAR were retrospectively studied. Consultant vascular surgeons or radiologists had evaluated all original scans and written the original report. All scans were then reevaluated by an independent core clinic. Findings were classified as vascular or extravascular and stratified as clinically significant or clinically nonsignificant by an independent external reviewer. Results: The number of vascular findings detected by the vascular clinic was 72 vs 69 by the core clinic. The vascular clinic reported more clinically significant findings (primarily stent compression or kinks) as well as endoleaks and their origin. The core clinic reported more pseudoaneurysms (24 vs 12). None of the patients with puncture complications needed reintervention. Interrater analysis of all findings between the 2 clinics showed good agreement when comparing endoleaks overall (without subclassification) and moderate agreement when assessing aneurysm growth. The core clinic reported extravascular findings in 58 patients; 37 of these were classified as clinically significant. The vascular clinic reported extravascular findings in 23 patients; 7 of these were clinically significant. The core clinic also reported 2 cases of suspected malignancies, which had not been reported by the vascular clinic. Conclusion: During routine CTA follow-up after EVAR, a significant number of vascular and nonvascular findings are detected. Whereas a highly dedicated vascular clinic identifies most vascular findings regardless of the specialty of the reader, some extravascular findings are missed. However, the frequency of clinically significant findings or findings that might warrant reintervention was low in this study.

Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?

BackgroundVascular surgery became a new independent surgical specialty in the United Kingdom (UK) in 2013. In this matter for debate we discuss the question, is there a “shortage of vascular surgeons in the United Kingdom?” Materials and methodsWe used data derived from the “Vascular Surgery United Kingdom Workforce Survey 2014”, NHS Employers Electronic Staff Records (ESR), and the National Vascular Registry (NVR) surgeon-level public report to estimate current and predict future workforce requirements. ResultsWe estimate there are approximately 458 Consultant Vascular Surgeons for the current UK population of 63 million, or 1 per 137,000 population. In several UK Regions there are a large number of relatively small teams (3 or less) of vascular surgeons working in separate NHS Trusts in close geographical proximity. In developed countries, both the number and complexity of vascular surgery procedures (open and endovascular) per capita population is increasing, and concerns have been raised that demand cannot be met without a significant expansion in numbers of vascular surgeons. Additional workforce demand arises from the impact of population growth and changes in surgical work-patterns with respect to gender, working-life-balance and 7-day services. ConclusionsWe predict a future shortage of Consultant Vascular Surgeons in the UK and recommend an increase in training numbers and an expansion in the UK Consultant Vascular Surgeon workforce to accommodate population growth, facilitate changes in work-patterns and to create safe sustainable services.

Clinicians’ perceptions of prescribing antibiotics for infections in the diabetic foot

Responsible use of antibiotics is high on the public health agenda. The management of infection within the diabetic foot is variable, partly due to a lack of consensus and evidence to guide management choices. Study aims: To explore and describe experiences and views regarding the clinical management of diabetic foot infections among specialist secondary care clinicians involved in the management of diabetic foot infections; to explore perceptions and awareness of antibiotic resistance; to explore whether there are any unknown factors that may contribute to the ‘non-pharmacological’ prescribing of antibiotics. Study design and methods: A phenomenological approach was used, with data collected in face to face interviews with specialist hospital clinicians including Consultant Physicians, Specialist Registrars, Consultant Microbiologist, Specialist Podiatrists and Consultant Vascular Surgeons within two acute hospital foundation trusts in the south of England.

The Vascular Surgery Workforce: A Survey of Consultant Vascular Surgeons in the UK, 2014

The purpose of this study was to describe the demographics, training, and practice characteristics of consultant vascular surgeons across the UK to provide an assessment of current, and inform future prediction of workforce needs. A questionnaire was developed using a modified Delphi process to generate questionnaire items. The questionnaire was emailed to all consultant vascular surgeons (n=450) in the UK who were members of the Vascular Society of Great Britain & Ireland. 352 consultant vascular surgeons from 95 hospital trusts across the UK completed the survey (78%response rate). The mean age was 50.6 years old, the majority (62%) were mid-career, but 24% were above the age of 55. Currently, 92% are men and only 8% women. 93% work full-time, with 60% working >50 hours, and 21% working >60 hours per week. The average team was 5 to 6 (range 2-10) vascular surgeons, with 23% working in a large team of ≥8. 17% still work in small teams of ≤3. Over 90% of consultant vascular surgeons perform the major index vascular surgery procedures (aneurysm repair, carotid endarterectomy, infra-inguinal bypass, amputation). While 84% perform standard endovascular abdominal aortic aneurysm repair (EVAR), <50% perform more complex endovascular aortic therapy. The majority of vascular surgeons "like their job" (85%) and are "satisfied" (69%) with their job. 34% of consultant vascular surgeons indicated they were "extremely likely" to retire within the next 10 years. This study provides the first detailed analysis of the new specialty of vascular surgery as practiced in the UK. There is a need to plan for a significant expansion in the consultant vascular surgeon workforce in the UK over the next 10 years to maintain the status quo.

A Survey of Perioperative Management of Major Lower Limb Amputations: Current UK Practice

A Quality Improvement Framework has been formulated aiming to reduce the perioperative mortality of patients undergoing major lower limb amputations as this is unacceptably high. Surgical site infections (SSI) have a significant impact on the morbidity and mortality of this group of patients. This study aimed to establish whether consensus exists among UK consultant vascular surgeons regarding perioperative management of major lower limb amputations and review current evidence regarding the prevention of SSI. A postal questionnaire, which had previously been piloted, was sent to consultant members of the Vascular Society. It comprised 17 questions to establish their current perioperative practice and the estimated incidence of SSI within their patient cohort. The chi-squared test was used to establish the impact of skin preparation, dressings, and closure technique on infection rates. A total of 168 consultants responded to the questionnaire-a response rate of 37.2%. The median-reported infection rate was in the range of 6-10%. 95.8% of respondents always give antibiotics. The majority of respondents use aqueous betadine (44.6%). The majority of respondents close the skin with subcuticular continuous sutures (58.3%). The preferred dressing for both above- and below-knee amputations was a stump bandage (62.5% and 61.9%, respectively). No statistically significant difference was seen in the reported infection when examined in relation to skin preparation, closure method, or dressings used. It appears that there is currently little consensus on the perioperative management of patients undergoing major lower limb amputation. Further studies in the form of randomized control trials are required to facilitate decision making and optimize patient outcome.

The need for a National Service Framework for leg ulcers

Leg ulcers are common and costly to treat, and the quality of care provided to patients with this condition varies widely across the UK. The introduction of specialized community-based leg ulcer clinics in Gloucestershire has been associated with increased ulcer healing rates and decreased rates of ulcer recurrence, but this model of care has not been widely replicated. One way of ending this 'postcode lottery' is to produce a National Service Framework for leg ulcers, with the aim of delivering high-quality evidence-based care via such clinics under the supervision of local consultant vascular surgeons. Existing National Service Frameworks cover a range of common conditions that are, like leg ulceration, associated with significant morbidity, disability and resource use. These documents aim to raise quality and decrease regional variations in health care across the National Health Service, and leg ulceration fulfils all the necessary criteria for inclusion in a National Service Framework. Centrally defined standards of care for patients with leg ulceration, and the reorganization and restructuring of local services to allow the accurate assessment and treatment of such patients are required. Without a National Service Framework to drive up the quality of care across the country, the treatment of patients with leg ulcers will remain suboptimal for the majority of those who suffer from this common and debilitating condition.

Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: A description of the severity and extent of disease using the Bollinger angiogram scoring method and the TransAtlantic Inter-Society Consensus II classification

The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed in patients with severe lower limb ischemia (rest pain, tissue loss) who survive for 2 years after intervention that initial randomization to bypass surgery, compared with balloon angioplasty, was associated with an improvement in subsequent amputation-free survival and overall survival of about 6 and 7 months, respectively. The aim of this report is to describe the angiographic severity and extent of infrainguinal arterial disease in the BASIL trial cohort so that the trial outcomes can be appropriately generalized to other patient cohorts with similar anatomic (angiographic) patterns of disease. Preintervention angiograms were scored using the Bollinger method and the TransAtlantic Inter-Society Consensus (TASC) II classification system by three consultant interventional radiologists and two consultant vascular surgeons unaware of the treatment received or patient outcomes. As was to be expected from the randomization process, patients in the two trial arms were well matched in terms of angiographic severity and extent of disease as documented by Bollinger and TASC II. In patients with the least overall disease, it tended to be concentrated in the superficial femoral and popliteal arteries, which were the commonest sites of disease overall. The below knee arteries became increasingly involved as the overall severity of disease increased, but the disease in the above knee arteries did not tend to worsen. The posterior tibial artery was the most diseased crural artery, whereas the peroneal appeared relatively spared. There was less interobserver disagreement with the Bollinger method than with the TASC II classification system, which also appears inherently less sensitive to clinically important differences in infrapopliteal disease among patients with severe leg ischemia. Anatomic (angiographic) disease description in patients with severe leg ischemia requires a reproducible scoring system that is sensitive to differences in crural artery disease. The Bollinger system appears well suited for this purpose, but the TASC II classification system less so. We hope this detailed analysis will facilitate appropriate generalization of the BASIL trial data to other groups of patients affected by similar anatomic (angiographic) patterns of disease.

Endovenous treatments for varicose veins – over-taking or over-rated?

A variety of endovenous therapies for the treatment of superficial venous incompetence are currently available. The aim of this study was to evaluate the prevalence of endovenous techniques used by consultant vascular surgeons in the United Kingdom. An anonymous online survey of 16 multiple choice questions relating to the nature and provision of treatment for varicose veins was devised. Consultant members of the Vascular Society of Great Britain and Ireland were invited to participate by email. A total of 108/352 (31%) surgeons completed the survey. The majority offered surgery as the first-line treatment for primary great saphenous vein (GSV) and small saphenous vein (SSV) incompetence (69% and 74%, respectively). Endovenous procedures were offered as first-line treatment by 32/108 (29.6%) for GSV reflux, 36/51 (70.6%) surgeons performed these under local anaesthetic and 21/51 (41.2%) were performed as an outpatient procedure. The most important factor influencing treatment decisions was considered to be patient preference by 77/108 (71.3%) surgeons, although 48/61 (78.7%) respondents were restricted by primary care trusts with regard to endovenous treatments, and 33/108 (30.6%) offered different treatments to private patients. Traditional surgery remains the most commonly offered treatment for patients with varicose veins. The provision of endovenous therapies varies greatly, and there are significant differences in local availability regarding these treatments.

Gaining Consent for Carotid Surgery: A Simulation-Based Study of Vascular Surgeons

Aim Despite no formal training in consenting patients, surgeons are assumed to be competent if they are able to perform an operation. We tested this assumption for carotid endarterectomy (CEA). Methods Thirty-two surgeons [Group 1: junior surgical trainees – performed 0 CEA's ( n = 11); 2: senior vascular trainees – 1–50 CEA's ( n = 11); 3: consultant vascular surgeons – > 50 CEA's ( n = 10)] consented two patients (trained actors) for a local anaesthetic CEA. The performance was assessed at post hoc video review by two independent assessors using a validated rating scale and checklist of risk factors. Results There was no difference in performance between the junior and senior trainees (1: median 91 range 64–121; 2: median 100.5 range 66–125; p = 0.118 1 vs. 2 Mann–Whitney). There was a significant improvement between senior trainees and consultant surgeons (3: median 120 range 89–1 142; p = 0.001 2 vs. 3). Few junior (1/11) and senior (2/11) trainees, and most (8/11) consultants, were competent. Inter-rater reliability was high ( α = 0.832). Consultant surgeons were significantly more likely to discuss cranial nerve injuries ( p < 0.0001 Chi-square test) as well as personal or hospital specific stroke risk ( p < 0.0001) than their junior counterparts. They were less likely to discuss infection ( p < 0.0001). Conclusion Senior trainees, despite being able to perform a CEA, were not competent in consent. The majority of consultant surgeons had developed competence in consenting even though they had no formal training.

Mortality of ruptured abdominal aortic aneurysm treated with open or endovascular repair

The study defined the selection criteria used for treatment of ruptured abdominal aortic aneurysms (RAAAs) and reviewed results during a 5-year period. From 2002 on, our tertiary referral center adopted a protocol of selective use of endovascular repair for RAAAs. The study included all patients with a proven RAAA who were admitted to our hospital from 2002 to 2006. The primary outcome measure was surgical mortality. A total of 187 patients were admitted with an acute AAA, and an RAAA was confirmed 135 (72%) by computed tomography scanning or at laparotomy, and 125 (93%) were treated, 89 by open means and 36 by endovascular means. The overall mortality rate was 24% and the mortality rate was 13.9% for endovascular repair. Endovascular repair was consistently used more often in patients with favorable anatomy and in patients who were hemodynamically more stable. There were considerable differences in approach between the four consultant vascular surgeons. The overall evaluation and inclusion for endovascular treatment increased during the study period. A strict protocol for admission, evaluation, and treatment of RAAA, with selective use of endovascular repair, resulted in low mortality rates in our center.