Vascular And Endovascular Research Network Research Articles

Understanding the current acute aortic syndrome (AAS) pathways-The Collaborative Acute Aortic Syndrome Project (CAASP) protocol.

Acute aortic syndrome (AAS) is an emergency associated with high peri-hospital mortality rates. Variable clinical presentation makes timely diagnosis challenging and such delays in diagnosis directly impact patient outcomes. The aims of the Collaborative Acute Aortic Syndrome Project (CAASP) are to characterise and evaluate the current AAS pathways of a cohort of hospitals in the UK, USA and New Zealand to determine if patient outcomes are influenced by the AAS pathway (time to hospital admission, diagnosis and management plan) and demographic, social, geographic and patient-specific factors (clinical presentation and comorbidities). The objectives are to describe different AAS pathways and time duration between hospital admission to diagnosis and management plan instigation, and to compare patient outcomes between pathways. The study is a multicentre, retrospective service evaluation project of adult patients diagnosed on imaging with AAS. It will be coordinated by the UK National Interventional Radiology Trainee Research (UNITE) network and Vascular and Endovascular Research Network (VERN) in conjunction with The Aortic Dissection Charitable Trust (TADCT). All AAS cases diagnosed on imaging between 1st January 2018 to 1st June 2021 will be included and followed-up for 6 months. Eligibility criteria include aortic dissection (AD) Type A, Type B, non A/B, penetrating aortic ulcer, and intramural haematoma. Exclusion criteria are non-AAS pathology, acute on chronic AAS, and age<18. This project will evaluate patient demographics, timing of presentation, patient symptoms, risk factors for AD, physical examination findings, timing to imaging and treatment, hospital stay, and mortality. Univariate and multivariate analysis will be used to identify predictors associated with prolonged time to diagnosis or treatment and mortality at 30 days.

The FraiLTI (Frailty in chronic Limb-Threatening Ischaemia) Protocol

Background: Frailty, sarcopenia and multimorbidity are conditions commonly associated with the ageing process, and they are frequently observed in patients with chronic limb-threatening ischaemia (CLTI). Nevertheless, the extent to which these conditions are prevalent within the CLTI patient population has not been adequately examined in the UK. This proposed multicentre observational study aims to investigate the prevalence of these conditions in patients with CLTI and to assess their potential impact on important clinical outcomes including mortality, amputation and quality of life. Methods: FraiLTI (Frailty in chronic Limb-Threatening Ischaemia) is a multicentre prospective observational study in the UK that that aims to investigate the prevalence of frailty, sarcopenia and multimorbidity associated with CLTI. The secondary objective is to investigate potential correlations between frailty, sarcopenia and multimorbidity, with clinical outcomes such as amputation, mortality, major adverse cardiovascular events and readmission rates within a 90-day period. FraiLTI is led by Newcastle University, supported by the Vascular and Endovascular Research Network (VERN) and funded by the National Institute for Health Research (NIHR) and the Newcastle Hospital Charities. REDCap will be used to collect anonymised patient data. All hospitals with a dedicated vascular centre are eligible to participate. Full ethical approval (21/PR/0750) was granted on 13 July 2021. The study is registered on the International Standard Randomised Controlled Trial Number (ISRCTN) registry. Anticipated impact of the study: This study has the potential to address critical questions identified by the James–Lind Alliance (JLA) Priority Setting Partnership (PSP) in peripheral arterial disease. It is expected to make a substantial contribution to the creation of a prospective CLTI database, integrating essential data on frailty, sarcopenia and multimorbidity that are not currently captured by other registries, despite their profound impact on patient outcomes. This research could provide pivotal insights into the prevalence of frailty, sarcopenia and multimorbidity among the UK’s CLTI population and their corresponding effects on clinical outcomes. Findings from the study will be shared at global scientific conferences and submitted to be published in peer-reviewed journals.

Thromboprophylaxis strategies in patients undergoing endovenous thermal ablation: a UK survey

Introduction: It remains unclear whether patients undergoing endovenous thermal ablation (EVTA) for superficial venous incompetence (SVI) should receive pharmacological thromboprophylaxis. A survey was conducted to assess current thromboprophylaxis practices across the UK in patients undergoing EVTA for SVI. Methods: To examine the thromboprophylaxis practices of clinicians performing EVTA for SVI in the UK, an online survey was developed using the Qualtrics online survey tool. The survey link was circulated via email to members of the multidisciplinary collaborative Vascular and Endovascular Research Network (VERN) and promoted through social media. The primary focus of the survey was to gather information regarding venous thromboembolism (VTE) prophylaxis during EVTA for SVI. Results: A total of 32 vascular surgeons and one vascular nurse specialist based in the UK participated in the survey. All respondents reported routine prescription of compression therapy in the immediate postoperative period. Of all the respondents, 67% (n=22) reported routine prescription of pharmacological thromboprophylaxis during the peri-procedural period. Extended prophylaxis was routinely offered by 15% (n=5) of all respondents. Among those who provided extended prophylaxis, the majority (80%, n=4) used low molecular weight heparin (LMWH), while 20% (n=1) opted for a direct-acting oral anticoagulant (DOAC). Conclusion: The findings from this survey indicate that a significant proportion of patients undergoing EVTA for SVI routinely receive pharmacological thromboprophylaxis, with a single perioperative dose of LMWH being the prevailing practice. However, there is a notable lack of robust high-quality evidence to substantiate this practice. Grade A evidence is required to assess the potential benefit of pharmacological thromboprophylaxis in the context of EVTA to guide the development of clinically relevant guidelines. Should pharmacological thromboprophylaxis prove to offer no additional benefit for this specific patient population, this could result in cost savings for the NHS and enable patients to avoid unwanted side effects associated with anticoagulation therapy.

The Vascular and Endovascular Research Network (VERN)

AbstractThe Vascular and Endovascular Research Network (VERN) was set up to promote research, to improve the treatment of vascular diseases and to improve the synthesis and dissemination of evidence. The network represents a particular form of collaboration involving trainee doctors and specialists from a wide variety of medical disciplines. It undertakes multicentre projects, which are mostly observational studies and the data collected are analysed and published in a short period of time. This form of research has several advantages including fostering collaboration between different institutes, countries and researchers with different levels of expertise. It also promotes accelerated delivery of evidence and individual professional development. The network has an executive committee that meets every 2 weeks to discuss projects and the entire committee meets every month. An appointed member of the executive committee coordinates the centres participating in projects. Although there has been some scepticism with respect to research collaboratives, raising concerns over the accountability and the contribution of authors, it is paramount that research conducted by a collaborative maintains the same scientific rigour and ethical standards as research conducted by individual academic units.

The DEFINITE Audit: a prospective audit of diabetic foot debridement in theatre – a protocol

Background: People with diabetes are commonly affected by foot ulceration (DFU) and subsequent or concurrent infection (DFI). Surgical debridement is often needed to contain infection. Despite international guidelines, there remains significant variation in surgical practice of diabetic foot wound debridement in the operating theatre. Methods: Diabetic Foot Ulcer Debridement in Theatre Audit (DEFINITE) is a global multicentre, prospective audit of consecutive patients undergoing a debridement or minor amputation in theatre for a diabetic foot complication. DEFINITE is led by the Vascular and Endovascular Research Network (VERN). The primary outcome is adherence to recommended practice as outlined in the International Working Group on the Diabetic Foot and Global Vascular Guidelines. Secondary outcomes are incidence of healing, re-admission, further amputation (minor and major) and mortality at 90 days. Anonymised data will be collected via REDCap. Eligibility and study registration at all hospital institutions performing in-theatre management of diabetic foot complications are eligible to participate after obtaining appropriate institutional level audit approvals. A lead clinician will be responsible for approvals and data management. Pathway to impact: This audit addresses shared patient-clinician priorities and is supported by the UK Vascular Society multidisciplinary Special Interest Group on the Diabetic Foot. The results will be presented at international scientific meetings and submitted for publication in peer-reviewed publications. The results will also be used to initiate improvement in patient care.

The persistent challenges faced by vascular surgery services during the UK coronavirus pandemic: a snapshot qualitative survey.

The coronavirus (COVID-19) pandemic continues to affect the NHS. The Vascular and Endovascular Research Network (VERN) COvid Vascular sERvice (COVER) study has prospectively shown the significant global impact of the COVID-19 pandemic on vascular surgery. The aim of this study is to investigate the way in which this second wave has affected surgeons' ability to treat patients with urgent vascular conditions, using contemporaneous snapshot data from 30 UK vascular centres. This is a contemporary (18-28 January 2021) re-run of the Tier 1 COVER survey. This used closed and open questions, related to centres' provision of common vascular services, threshold for treatment, imaging, screening, staff and theatre availability, multidisciplinary team input, clinics, personal protective equipment, vaccination policies and case-backlogs. The survey was disseminated to clinicians via email. A service reduction score was calculated. Forty-two complete responses were received from 30 vascular centres (England, Northern Ireland, Scotland and Wales). Overall, 56.7% of units are performing only urgent procedures. The threshold for abdominal aortic aneurysm (AAA) repair has increased in the majority of UK centres (60%). One in six AAA screening programmes have stopped all screening activity: 30% having a significantly reduced programme and only half running as normal. Waiting lists are increasing for AAA, lower limb revascularisation and venous disease. Overall, these data suggest that vascular care in the NHS is facing unprecedented pressures due to COVID-19. Vascular stakeholders will have to urgently address these issues in the coming months. ISRCTN 80453162 (registered prospectively).

Editor's Foreword

Welcome to the fifth issue of the Journal of Vascular Societies Great Britain and Ireland (JVSGBI). We are really delighted with the success of the journal, and this issue marks the first anniversary of the launch at the Vascular Societies GB&amp;I Annual Scientific meeting last year. The increasing interest in the JVSGBI has been demonstrated by the growing number of submitted articles and the impressive website stats (over 3,000 views). This issue includes three editorials. The first by Andrew Garnham (VSGBI President Elect) and Rachael Forsythe (Rouleaux President) provides a thoughtful reflection on the problem of bullying, undermining and harassment in (vascular) surgical training highlighted as a persistent problem by a Rouleaux Club paper in this edition. The second editorial from Dr Una Adderley, National Wound Care Strategy Programme (NWCSP) Director, outlines past achievements and future plans for the programme. Finally, Duygu Yenidogan-Schmidt, Chair of the Executive Committee of AAA UK, a newly formed patient representative group giving national representation to AAA patients and relatives, highlights the origins, purpose and aims of this group. I am sure these editorials will be of great interest to readers. There are four original research articles, the first from the Rouleaux Club, the UK Vascular Surgery Trainees’ Association, reports the findings from their recent bullying, undermining and harassment survey. The second from the Vascular and Endovascular Research Network (VERN) reports the findings from the Tier 3 COVID-19 Vascular Service (COVER) study. The final two original articles present the findings from the James Lind Alliance Priority Setting Partnership from the Vascular Services and Venous Conditions Groups. It is fantastic to see vascular trainees continuing to undertake meaningful and impactful research and choose the JVSGBI to disseminate their work. This edition also contains a research protocol from Ravindhran et al for a systematic review which aims to study changes in functional health status following open abdominal aortic aneurysm repair. Finally, in this issue there is a short educational report entitled ‘Intraoperative management of REBOA’ and a case report entitled ‘Carotid web: an important cause of stroke in young people’. The National Wound Care Strategy Programme Guidelines for lower limb wounds are published as a supplement to this issue and can be located on the journal website. This is our fifth issue, and we would like to take the opportunity to thank all the authors who have submitted articles during the last year, which is building on the success of the journal – your contribution has been really appreciated and I hope you are delighted with your publication. We would also like to thank all the reviewers for their timely and thorough contributions. Finally, please do continue to share your work by submitting articles for publication.

800 The Impact of the COVID-19 Pandemic on The Management of Patients with Vascular Conditions: The Vascular and Endovascular Research Network (VERN) COVID-19 Vascular Service (COVER) Tier 3 Study

IntroductionThe COVID-19 pandemic has had significant impact on healthcare delivery internationally. The aim of this study was to evaluate the changes in the management of vascular conditions during the COVID-19 pandemic compared to pre-pandemic standards.MethodAn international multicentre prospective cohort study was conducted over a 4-week period from March 2020. All patients referred to vascular services with acute vascular conditions were eligible to participate. Data on patient demographics, diagnosis and treatment delivered during the pandemic were collected. If there was a deviation from the pre-pandemic management plan, this ‘ideal’ plan was recorded, and the severity of modification scored on a 5-point scale.ResultsA total of 1801 patients from 52 centres in 19 countries were included in the study, most commonly referred with lower limb conditions (54.4%). Only 2.3% of patients had a confirmed diagnosis of COVID-19. A deviation from the pre-pandemic treatment standard occurred in 35% of unruptured ≥5.5cm diameter abdominal aortic aneurysms, 24.7% of patients with carotid disease, 17% with acute or chronic limb-threatening ischaemia and 12.7% with diabetic foot conditions. Of these modifications, 40.7% were significant, such as endovascular instead of open aneurysm repair or treatment delays, 38.1% major, such as non-operative management of carotid and lower limb disease, and 4.9% life-changing/ending including major amputation or palliation.ConclusionsThe COVID-19 pandemic has significantly impacted upon the management decisions for vascular conditions, independent of COVID status, with 17% of all-referred patients receiving suboptimal care due to limited resources and difficulty accessing services.

O5 Outcomes of vascular and endovascular interventions performed during the COVID-19 pandemic: The Vascular and Endovascular Research Network (VERN) COvid-19 Vascular sERvice (COVER) Tier 2 study

IntroductionThe COVID-19 pandemic forced rapid adaptations to healthcare provision. The COvid-19 Vascular sERvice (COVER) Study aimed to contemporaneously report outcomes for patients undergoing vascular interventions worldwide during the pandemic.MethodsCOVER is an international multi-centre observational cohort study of outcomes following vascular interventions during the pandemic. The primary outcome was to capture procedural information on all open and endovascular interventions undertaken. Secondary outcomes included in-hospital mortality and changes in management resulting from the pandemic.Results1103 patients from 57 institutions in 19 countries were enrolled. Mean age was 66.9±13.9 (75·6% male). The rate of suspected/confirmed COVID-19 infection was 4·0%. Overall, in-hospital mortality was 11.0%. Aortic interventions had a mortality of 15·2% (23/151), amputations 12·1% (28/232), carotid interventions 10·7% (11/103) and lower limb revascularisation 9·8% (51/521). Increased risk of in-hospital mortality was noted for patients with chronic obstructive pulmonary disease, lower respiratory tract infection, Caucasian ethnicity and those undergoing urgent/immediate surgery. Choice of procedure deviated from standard management in 7·1% cases. Adjusting for confounders, antiplatelet (OR 0·503 (0·273-0·928) and oral anticoagulant (OR 0·411 (0·205-0·824) reduced risk of in-hospital mortality.ConclusionsPatients undergoing vascular intervention during the pandemic had substantially higher overall and condition-specific mortality compared to pre-pandemic cohort reports, despite low COVID-19 infection rates.

P33 Changes to acute vascular care management during the COVID-19 pandemic: The Vascular and Endovascular Research Network (VERN) COvid-19 Vascular sERvice (COVER) Tier 3 study

IntroductionThe COVID-19 pandemic forced rapid adaptations to healthcare provision. The COvid-19 Vascular sERvice (COVER) Study aimed to contemporaneously report changes to practice and subsequent outcomes of vascular patients managed during the pandemic.MethodsCOVER is a three-tiered international multi-centre observational cohort study aiming to quantify the specific impact of the pandemic on the provision of vascular and endovascular surgery and the adjustments made to standard vascular practice during this time. The primary outcome of Tier 3 was to identify how the management of all referred urgent vascular cases changed throughout the COVID-19 pandemic. Secondary outcomes included longitudinal data to identify condition-specific outcomes for these patients at 3, 6 months and 1 year. Over a minimum four-week period, contributing vascular centers contemporaneously collected prospective data on the management of all urgent referrals received during this time.ResultsData from over 1693 patients worldwide has been obtained and is currently undergoing analysis. Provisional results suggest that approximately 18% of patients had significant changes to their care during the pandemic. Full descriptive results of management changes during the pandemic itself will be reported at the NRCM meeting.ConclusionsIt is anticipated that this work will highlight significant deviation in the management of urgent vascular referrals when compared to pre-pandemic best practice guidelines. It will be crucial to identify and monitor the ongoing impact this has on patient care.

Study protocol for COvid-19 Vascular sERvice (COVER) study: The impact of the COVID-19 pandemic on the provision, practice and outcomes of vascular surgery.

The novel Coronavirus Disease 2019 (COVID-19) pandemic is having a profound impact on global healthcare. Shortages in staff, operating theatre space and intensive care beds has led to a significant reduction in the provision of surgical care. Even vascular surgery, often insulated from resource scarcity due to its status as an urgent specialty, has limited capacity due to the pandemic. Furthermore, many vascular surgical patients are elderly with multiple comorbidities putting them at increased risk of COVID-19 and its complications. There is an urgent need to investigate the impact on patients presenting to vascular surgeons during the COVID-19 pandemic. The COvid-19 Vascular sERvice (COVER) study has been designed to investigate the worldwide impact of the COVID-19 pandemic on vascular surgery, at both service provision and individual patient level. COVER is running as a collaborative study through the Vascular and Endovascular Research Network (VERN), an independent, international vascular research collaborative with the support of numerous national and international organisations). The study has 3 'Tiers': Tier 1 is a survey of vascular surgeons to capture longitudinal changes to the provision of vascular services within their hospital; Tier 2 captures data on vascular and endovascular procedures performed during the pandemic; and Tier 3 will capture any deviations to patient management strategies from pre-pandemic best practice. Data submission and collection will be electronic using online survey tools (Tier 1: SurveyMonkey® for service provision data) and encrypted data capture forms (Tiers 2 and 3: REDCap® for patient level data). Tier 1 data will undergo real-time serial analysis to determine longitudinal changes in practice, with country-specific analyses also performed. The analysis of Tier 2 and Tier 3 data will occur on completion of the study as per the pre-specified statistical analysis plan.

Current medical management of patients with peripheral arterial disease and potential benefits of risk-factor optimization: A Vascular and Endovascular Research Network (VERN) collaboration

Current medical management of patients with peripheral arterial disease and potential benefits of risk-factor optimization: A Vascular and Endovascular Research Network (VERN) collaboration

Observational study of the medical management of patients with peripheral artery disease.

Previous research has suggested that patients with peripheral artery disease (PAD) are not offered adequate risk factor modification, despite their high cardiovascular risk. The aim of this study was to assess the cardiovascular profiles of patients with PAD and quantify the survival benefits of target-based risk factor modification. The Vascular and Endovascular Research Network (VERN) prospectively collected cardiovascular profiles of patients with PAD from ten UK vascular centres (April to June 2018) to assess practice against UK and European goal-directed best medical therapy guidelines. Risk and benefits of risk factor control were estimated using the SMART-REACH model, a validated cardiovascular prediction tool for patients with PAD. Some 440 patients (mean(s.d.) age 70(11) years, 24·8 per cent women) were included in the study. Mean(s.d.) cholesterol (4·3(1·2) mmol/l) and LDL-cholesterol (2·7(1·1) mmol/l) levels were above recommended targets; 319 patients (72·5 per cent) were hypertensive and 343 (78·0 per cent) were active smokers. Only 11·1 per cent of patients were prescribed high-dose statin therapy and 39·1 per cent an antithrombotic agent. The median calculated risk of a major cardiovascular event over 10 years was 53 (i.q.r. 44-62) per cent. Controlling all modifiable cardiovascular risk factors based on UK and European guidance targets (LDL-cholesterol less than 2 mmol/l, systolic BP under 140 mmHg, smoking cessation, antiplatelet therapy) would lead to an absolute risk reduction of the median 10-year cardiovascular risk by 29 (20-38) per cent with 6·3 (4·0-9·3) cardiovascular disease-free years gained. The medical management of patients with PAD in this secondary care cohort was suboptimal. Controlling modifiable risk factors to guideline-based targets would confer significant patient benefit.

Study protocol for the groin wound infection after vascular exposure (GIVE) audit and multicentre cohort study

IntroductionSurgical site infections (SSIs) following groin incision for arterial exposure are commonplace and a significant cause of morbidity and mortality following major arterial surgery. Published incidence varies considerably. The primary aim of GIVE will be to compare individual units’ practice with established guidelines from The National Institute for Health and Care Excellence (NICE). Secondary aims will be to describe the contemporary rate of SSI in patients undergoing groin incision for arterial exposure, to identify risk factors for groin wound infection, to examine the value of published tools in the prediction of SSI, to identify areas of equipoise which could be examined in future efficacy/effectiveness trials and to compare UK SSI rates with international centres. Methods and analysisThis international, multicentre, prospective observational study will be delivered via the Vascular and Endovascular Research Network (VERN). Participating centres will identify all patients undergoing clean emergency or elective groin incision(s) for arterial intervention during a consecutive 3-month period. Follow up data will be captured at 90 days after surgery. SSIs will be defined according to the Centres for Disease Control and Prevention (CDC) criteria. Data will be gathered centrally using an anonymised electronic data collection tool or secure email transfer. Ethics and disseminationThis study will be registered as a clinical audit at all participating UK centres; research ethics approval is not required. National leads will oversee the appropriate registration and approvals in countries outside the UK as required. Site specific reports of SSI rates will be provided to each participating centre. Study results will be disseminated locally at each site, publicised on social media and submitted for peer-reviewed publication.

Cardiovascular risk reduction in referrals to outpatient vascular clinics

Introduction Patients with peripheral arterial disease (PAD), aneurysmal disease (AD) or carotid atherosclerosis are at high cardiovascular risk, necessitating secondary cardiovascular protection. The aim of this study was to determine compliance with cardiovascular risk reduction guidelines in new patients referred to vascular clinics. Methods A multicentre collaborative national observational audit of new patients referred to eight tertiary general vascular clinics over a three-month period in England and Wales was conducted by the Vascular and Endovascular Research Network (VERN). Referral letters, case notes and investigations were reviewed by local investigators, and data analysed by VERN. Results A total of 656 patients were included in the study: 73.2% had PAD, 23.2% had AD and 3.7% had carotid atherosclerosis. A third (37.5%) were current smokers, two-thirds (61.7%) were on antiplatelet therapy and two-thirds (61.5%) were on statin therapy. Smoking was more prevalent in the PAD cohort (PAD 41.4%, AD 27.5%, p=0.003). However, more PAD patients were on antiplatelet therapy (PAD 63.9%, AD 53.3%, p=0.024). Both antiplatelet and statin prescription significantly increased with the number of cardiovascular risk factors. Patients with a previous cardiac or cerebrovascular history were more likely to have stopped smoking, and to be on antiplatelet and statin therapy (p&lt;0.0001 for each). Overall, 47.3% of patients were on both antiplatelet and statin therapy, and 28.9% were on antiplatelet and statin therapy and not smoking. Conclusions This study highlights deficiencies in cardiovascular risk minimisation in patients with established vascular disease. Patients with concomitant cardiac or cerebrovascular disease were more likely to be on best medical therapy.

Multi-Centre Study on Cardiovascular Risk Management on Patients Undergoing AAA Surveillance

The risk of cardiovascular events and death in patients with abdominal aortic aneurysms (AAA) is high. Screening has been introduced to reduce AAA related mortality; however, after AAA diagnosis, cardiovascular modification may be as important to patient outcomes as surveillance. The aim of this study was to assess cardiovascular risk reduction in patients with small AAA. Institutional approval was granted for The Vascular and Endovascular Research Network (VERN) to retrospectively collect data pertaining to cardiovascular risk reduction from four tertiary vascular units in England. Patients with small AAA (January 2013-December 2015) were included. Demographic details, postcode, current medications, and smoking status were recorded using a bespoke electronic database and analysed. In a secondary analysis VERN contacted all AAA screening units in England and Wales to assess their current protocols relating to CV protection. In total, 1053 patients were included (mean age 74±9 years, all men). Of these, 745 patients (70.8%) had been prescribed an antiplatelet agent and 787 (74.7%) a statin. Overall, only 666 patients (63.2%) were prescribed both a statin and antiplatelet. Two hundred and sixty eight patients (32.1%) were current smokers and the proportion of patients who continued to smoke decreased with age. Overall, only 401 patients (48.1%) were prescribed a statin, antiplatelet, and had stopped smoking. In the secondary analysis 38 AAA screening units (84% national coverage) replied. Thirty-one units (82%) suggest changes to the patient's prescription; however, none monitor compliance with these recommendations or assess whether the general practitioner has been made aware of the AAA diagnosis or prescription advice. Many patients with small AAA are not prescribed an antiplatelet/statin, and still smoke cigarettes, and therefore remain at high risk of cardiovascular morbidity and mortality. National guidance to ensure this high risk group of patients is adequately protected from poor cardiovascular outcomes is lacking.