Vascular Society Research Articles

ThP8.11 - Causes of delay to surgical interventions in patients with transient ischaemic attack and stroke

Abstract Aims The UK National Institute for Health and Care Excellence (NICE) guidelines and vascular society of surgery Great Britain and Ireland (VSGBI) emphasize the importance of scheduling carotid endarterectomy (CEA) within 2 weeks of symptom onset to reduce the risk of recurrent stroke. However the National vascular Surgery report for 2023 showed that this target was met in only 52% of patients. This study aimed to examine the possible causes of these delays. Methods This study analysed patient or hospital-derived factors impacting the timing of surgical intervention for patients with symptomatic carotid disease. A retrospective database was established to gather data on CEAs performed during an 8-month interval (January to August 2023) at a major teaching hospital. Results 36 patients underwent CEA; 13 (36.1%) received the procedure within 2 weeks of symptom onset, while 23 (63.9%) experienced delays. The main reasons for not meeting the two-week timeframe were associated with surgical scheduling, patient presentation, and referral processes. Specifically, among the 23 patients facing delays, 10 (43.5%) were due to surgical scheduling, 6 (26.1%) encountered delays in presenting to medical services, 5 (21.7%) were affected by delayed patient referral or review, and 2 (8.7%) were from lack of patient fitness. None however ended up with recurrent stroke while awaiting surgery on best medical management. Conclusions Prompt surgical intervention can reduce the risk of recurrent strokes. 63.9% of CEAs encountered delays, primarily associated with surgical scheduling. Prioritised pooled lists may be the answer.

VS ASM 2023 Prize/Highest Scoring Abstracts

The Vascular Societies’ Annual Scientific Meeting 2023, in conjunction with the VSGBI, BACPAR, SVN and SVT, took place at The Convention Centre, Dublin, on the 22nd-24th November 2023. Here are the 2023 prize/highest scoring abstracts

Updates from the Vascular Societies

JVSGBI is owned by the Vascular Society for Great Britain and Ireland (VSGBI), for all affiliated societies and the wider vascular community. Here’s the latest society news

Editor’s foreword

Welcome to the August 2024 edition of the Journal of Vascular Societies Great Britain and Ireland (JVSGBI).

Aortic Outcome after Implementation of a Treatment Strategy for Type B Aortic Dissection Involving the Aortic Arch

ObjectiveTo evaluate outcomes achieved after implementing a treatment strategy for non-A non-B (NANB) (B 1-2 D according to the latest consensus document of the Society of Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) acute aortic dissection (AAD). MethodsThis retrospective observational study adhered to the STROBE checklist. All cases of NANB AAD (B 1-2 D) treated at our Institution between January 2016 and December 2022 were reviewed. Morbidity, mortality, aortic-related reintervention, and remodelling were analysed. ResultsAmong 519 cases of acute aortic syndrome, n=22 (4.2%) patients presented with NANB AAD (B 1-2 D) (n=16,72.7% men, mean age 61.5 years+/14.7). Eleven cases were managed with best medical treatment (BMT) alone. Among them, one patient (9.1%) died suddenly two days after diagnosis for aortic rupture. Frozen elephant trunk procedure (FET) was required in the remaining 11 patients: 7(31.8%) needed emergent operation for risks of impending aortic rupture/retrograde AD extension and 4(26.7%) underwent delayed surgery within a month from initial presentation. Overall, in-hospital mortality was 9.1% with both FET and BMT. At a median follow-up of 40 months (range 2 days-200 months) no other deaths occurred. A statistically significant differences in the rate of FL thrombosis (100% vs 55.5%, p=.033) and a significant positive aortic remodelling in zone 3 (p<.001) and 4 (p=0.038) were reported in operated versus medically managed patients. ConclusionThe best treatment for NANB is not established. We advocate for medical stabilisation with an operative approach that favours open surgery in the acute post dissection period, promotes aortic remodelling and carries acceptable risk in centres where FET is performed routinely.

Long-term patient-reported outcomes among patients undergoing revascularization vs medical therapy for intermittent claudication: Presented at the Thirty-eighth Annual Meeting of the Western Vascular Society, Kauai, Hawaii, September 7-10, 2023.

Long-term patient-reported outcomes among patients undergoing revascularization vs medical therapy for intermittent claudication: Presented at the Thirty-eighth Annual Meeting of the Western Vascular Society, Kauai, Hawaii, September 7-10, 2023.

Evaluating growth patterns of abdominal aortic aneurysms among women: Presented at the Thirty-eighth Annual Meeting of the Western Vascular Society, Kauai, Hawaii, September 9-13, 2023.

Evaluating growth patterns of abdominal aortic aneurysms among women: Presented at the Thirty-eighth Annual Meeting of the Western Vascular Society, Kauai, Hawaii, September 9-13, 2023.

Volumetric analysis of acute uncomplicated type B aortic dissection using an automated deep learning aortic zone segmentation model

BackgroundMachine learning techniques have shown excellent performance in three-dimensional medical image analysis, but have not been applied to acute uncomplicated type B aortic dissection (auTBAD) using Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS)-defined aortic zones. The purpose of this study was to establish a trained, automatic machine learning aortic zone segmentation model to facilitate performance of an aortic zone volumetric comparison between patients with auTBAD based on the rate of aortic growth. MethodsPatients with auTBAD and serial imaging were identified. For each patient, imaging characteristics from two computed tomography (CT) scans were analyzed: (1) the baseline CT angiography (CTA) at the index admission and (2) either the most recent surveillance CTA or the most recent CTA before an aortic intervention. Patients were stratified into two comparative groups based on aortic growth: rapid growth (diameter increase of ≥5 mm/year) and no or slow growth (diameter increase of <5 mm/year). Deidentified images were imported into an open source software package for medical image analysis and images were annotated based on SVS/STS criteria for aortic zones. Our model was trained using four-fold cross-validation. The segmentation output was used to calculate aortic zone volumes from each imaging study. ResultsOf 59 patients identified for inclusion, rapid growth was observed in 33 patients (56%) and no or slow growth was observed in 26 patients (44%). There were no differences in baseline demographics, comorbidities, admission mean arterial pressure, number of discharge antihypertensives, or high-risk imaging characteristics between groups (P > .05 for all). Median duration between baseline and interval CT was 1.07 years (interquartile range [IQR], 0.38-2.57). Postdischarge aortic intervention was performed in 13 patients (22%) at a mean of 1.5 ± 1.2 years, with no difference between the groups (P > .05). Among all patients, the largest relative percent increases in zone volumes over time were found in zone 4 (13.9%; IQR, −6.82 to 35.1) and zone 5 (13.4%; IQR, −7.78 to 37.9). There were no differences in baseline zone volumes between groups (P > .05 for all). The average Dice coefficient, a performance measure of the model output, was 0.73. Performance was best in zone 5 (0.84) and zone 9 (0.91). ConclusionsWe describe an automatic deep learning segmentation model incorporating SVS-defined aortic zones. The open source, trained model demonstrates concordance to the manually segmented aortas with the strongest performance in zones 5 and 9, providing a framework for further clinical applications. In our limited sample, there were no differences in baseline aortic zone volumes between patients with rapid growth and patients with no or slow growth.

Comparative study of left vertebral artery revascularization in patients with and without aberrant left vertebral anatomy: Presented at the Thirty-eighth Annual Meeting of the Western Vascular Society, Kauai, Hawaii, September 9-12, 2023.

Comparative study of left vertebral artery revascularization in patients with and without aberrant left vertebral anatomy: Presented at the Thirty-eighth Annual Meeting of the Western Vascular Society, Kauai, Hawaii, September 9-12, 2023.

Characterization of long-term survival in Medicare patients undergoing arteriovenous hemodialysis access: Presented at the Midwestern Vascular Surgical Society Annual Meeting, Boston, Massachusetts, September 7-9, 2023.

Characterization of long-term survival in Medicare patients undergoing arteriovenous hemodialysis access: Presented at the Midwestern Vascular Surgical Society Annual Meeting, Boston, Massachusetts, September 7-9, 2023.

Socioeconomic factors predict successful supervised exercise therapy completion: Presented at the Thirty-seventh Annual Meeting of the Eastern Vascular Society, Washinton, D.C., September 7-9, 2023.

Socioeconomic factors predict successful supervised exercise therapy completion: Presented at the Thirty-seventh Annual Meeting of the Eastern Vascular Society, Washinton, D.C., September 7-9, 2023.

Improved long-term functional outcomes and mortality of patients with vascular-related amputations utilizing the lower extremity amputation pathway: Presented at the Thirty-eighth Western Vascular Society Annual Meeting, Koloa, Hawaii, September 10, 2023.

Improved long-term functional outcomes and mortality of patients with vascular-related amputations utilizing the lower extremity amputation pathway: Presented at the Thirty-eighth Western Vascular Society Annual Meeting, Koloa, Hawaii, September 10, 2023.

Creating hemodialysis autogenous access in children and adolescents: Presented at the Thirty-eighth Annual Meeting of the Western Vascular Society, Koloa, Hawaii, September 9-12, 2023.

Creating hemodialysis autogenous access in children and adolescents: Presented at the Thirty-eighth Annual Meeting of the Western Vascular Society, Koloa, Hawaii, September 9-12, 2023.

Patterns of Care in the Diagnosis and Management of Intracranial Atherosclerosis‐Related Large‐Vessel Occlusion: The Rescue‐LVO Survey

Background We aimed to determine the current practice patterns among neurointerventional practitioners frequently involved in treating intracranial atherosclerosis‐related large‐vessel occlusion (ICAS‐LVO) during mechanical thrombectomy. Methods We conducted an international online survey of neurointerventionalist members of the Society of Vascular and Interventional Neurology and Society of Neurointerventional Surgery. The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO. Results A total of 184 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 38.3% reported an incidence of 6% to 10% of ICAS‐LVO during mechanical thrombectomy. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis after multiple mechanical thrombectomy attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS)±angioplasty. However, in patients who achieved recanalization with a severe fixed focal stenosis, most (58%) recommended primary medical management. The preferred medication during acute RS was intravenous antiplatelet therapy (65%), and after acute RS, it was dual oral antiplatelet therapy (65%). Fear of hemorrhagic complications (74%) was the most compelling reason not to perform RS±angioplasty. Of respondents, 24% were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before mechanical thrombectomy treatment. Conclusions The findings of this survey highlight the variations in practice in the medical and endovascular management of ICAS‐LVO. In addition, it informs the situation of equipoise in the treatment decision in ICAS‐LVO, which can then be incorporated into the design of future randomized clinical trials.

Updates from the Vascular Societies

JVSGBI is owned by the Vascular Society for Great Britain and Ireland (VSGBI), for all affiliated societies and the wider vascular community. Here’s the latest society news.

Updates from the Vascular Societies

JVSGBI is owned by the Vascular Society for Great Britain and Ireland (VSGBI), for all affiliated societies and the wider vascular community. Here’s the latest society news.

Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease.

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

Screening for Hypertension in Adults of a Northern Delta Province in Vietnam.

The proportion of people with hypertension is increasing, and those affected are relatively younger. Worldwide, it is estimated that people with high blood pressure are more than 1.5 billion people. In Vietnam, from 2002 to 2008, according to a national survey on hypertension and its risk factors within the prevention and control of cardiovascular disease program, the prevalence of hypertension was 25.1%. This is alarming because high blood pressure can cause serious complications, including death. The study aimed to explore the blood pressure characteristics and hypertension prevalence in adults in a northern delta province of Vietnam, and describe some risk factors in hypertensive subjects screened through the program. This was a cross-sectional study collecting data from people aged 18 years or older in 10 cantons and the city of Nam Dinh from July 15th to July 31st, 2020. Using semi-automatic OMRON sphygmomanometers, sitting blood pressure was measured three times according to standardized methods specified by the Ministry of Health and two National Vascular Societies. Blood pressure screening of 183,632 adults included 84,438 males, which accounted for 45.98%, with an average age of 60.36 ± 13.18 years. The estimated prevalence of hypertension was 27.20% (95% CI: 27.00% - 27.41%). The older the age, the higher the rate of hypertension in both sexes; the prevalence of hypertension over 65 years was 45.36%. Hypertension grade 1 accounted for 17.14%, followed by hypertension at grade 2 at 6.69%, and grade 3 at 1.15%; notably, the percentage of prehypertension accounted for 49.64%. The percentage of treated hypertension in Nam Dinh province was 56.85%, but the percentage of uncontrolled hypertension was 85.63%. The prevalence of hypertension in Nam Dinh province was relatively high (27.20%), although the number of treated patients was also high (56.85%); moreover, the proportion of uncontrolled hypertension remained extremely high (85.63%). Local campaigns and suitable interventions are required to detect hypertension in the early stages and increase awareness for treatment in the population.

An extraordinary conference session

I have attended innumerable sessions at countless conferences over my career but a late afternoon session on Wednesday 22 November 2023 at the Annual Scientific Meeting of the Vascular Society of Great Britain and Ireland at the Convention Centre in Dublin will live long in the memory. It ran from 17:00–18:30 hours in a packed Liffey Hall 2 and was entitled “The patient I cannot forget”. Four vascular surgeons described their experience of a patient who had left them with feelings of which they had not been able to fully let go. The four surgeons were Rachel Bell, Ian Loftus, Becky Sandford and Ross Davenport. Rachel and Ian are vascular surgeons of international renown, both past presidents of the Vascular Society, whilst Becky and Ross are younger consultants in the earlier part of their career but both with extensive training and experience. Telling the story of the four cases was clearly traumatic and there were tears, tissues and soul searching. Two cases involved paediatric trauma, one iatrogenic in an unfamiliar environment. Two cases involved prolonged attempts at limb revascularisation where nothing seemed to go to plan, and the final case outlined the stresses and anxieties of being involved in a coroner’s case. I have never experienced open, honest, transparent reporting of raw, emotional cases in this way.

End of life care in chronic limb threatening ischemia: a retrospective cohort study

ObjectiveChronic limb-threatening ischemia (CLTI) is the end-stage of peripheral artery disease, defined as 2 or more weeks of rest pain and/or tissue loss from objectively proven obstructive arterial disease. Mortality is high, yet literature on end-of-life and palliative care in this setting is scarce. Palliative care is care that is aimed at alleviating the physiological and psychological symptoms and addresses the social and spiritual needs of patients and family/carers. End-of-life care is an umbrella term for palliative care given alongside disease-modifying care. The aim of this study was to evaluate predictors of end-of-life and palliative care and corresponding outcomes using surgical revascularization and amputation as surrogate markers for CLTI. MethodsThis was a retrospective single-center cohort study of people with CLTI who underwent either surgical revascularization (bypass) or amputation between January 2018 and December 2019. Palliative care input was defined as a dedicated palliative care consultation by a palliative care professional, medical doctor, surgeon, or advanced care practitioner. Data was collected on patient demographics, cause and place of death, and palliative and end-of-life care outcomes, which included documentation of preferred place of care/death and care priorities, family involvement in advance care planning discussions, key workers allocated to coordinate palliative care, use of community palliative care registers, hospice referral, time spent in hospital and the intensive care unit toward the end of life, and realization of documented care objectives. The data was analyzed to determine predictors of palliative care and tangible outcomes. ResultsOne-hundred and eighty-six patients were included (116 bypass and 70 amputation) with a median age of 67.5 years (interquartile range, 58-76 years) and most were male (73.7%) with a median survival of 46 months (interquartile range, 21-54 months) and a 2-year survival of 72% (95% confidence interval, 66%-79%). Palliative care consultations occurred for 10.8% of patients, with the median time from consultation to death of 5 days. Of the deceased, only a few had preferred place of care/death (8.1%), care priorities (18.3%), and family involvement during advance care planning (15.1%) documented in their notes. Cause of death was most commonly due to sepsis (n = 30), malignancy (n = 11), and myocardial infarction (n = 10). Mortality and in-hospital death were significantly higher in patients who underwent amputation in comparison to bypass surgery. There was an association of both cardiac and renal dysfunction with palliative care input. Patients with palliative care input were more likely to have documentation of preferred place of care/death, care priorities, and resuscitation decisions; and family involvement in advance care planning decisions. However, this did not translate into a reduction in hospital readmission or time spent in the hospital or intensive care unit towards the end of life. ConclusionsPatients with CLTI are not being offered palliative care in line with The National Institute for Health and Care Excellence or The Vascular Society of Great Britain and Ireland guidance. There was an association between palliative care input and end-of-life care quality. However, input occurred too close to death to have a very significant effect. Further research, development of clinical pathways and services, and better integration between palliative and vascular services is needed to improve the end-of-life care of patients living with CLTI.