Vascular Society Research Articles

Editor’s foreword

Welcome to the third issue of the Journal of Vascular Societies Great Britain and Ireland (JVSGBI). The journal is certainly going from strength to strength, and I hope that you find the May edition both informative and enjoyable. On behalf of the Editorial Board, thank you to all authors who have submitted articles. This issue includes two editorials. The first is a personal journey with respect to equality, diversity and inclusion from Mr Neeraj Bhasin, a Consultant Vascular Surgeon, in West Yorkshire. The second editorial examines what the recently published Vascular PAD-QIF CQUIN, means for vascular patients, clinicians and patients. The full report is also a supplement to this issue, and can be located on the JVSGBI website, for easy reference. This issue includes four original research articles, which cover a variety of research topics including: outcomes of revascularisation in elderly CLTI patients; a study of the reliability of WIfI risk stratification in the diabetic foot clinic; factors associated with delays to carotid endarterectomy in the Republic of Ireland; and a study of training in open aortic aneurysm surgery. We also have two trial protocols: the first (VENUM) aims to evaluate the provision of undergraduate vascular teaching in UK medical schools, whilst the second (WALKSTRONG) aims to test the feasibility of a novel home exercise programme for patients with intermittent claudication. Finally, this issue also contains the JVSGBI's first case report and literature review – distal venous arterialisation for 'no-option' CLTI. It is particularly pleasing to see such a wide variety of study designs, research topics and our first publication from a non UK centre. Recently, the JVSGBI Editorial Board took the decision to acknowledge the sterling and essential input of article reviewers. Therefore from this point forward each article will include a note of gratitude to the individual article reviewers. A list of reviewers will also be published in each November edition. Additionally, as Editor in Chief, I am proud to advise that time from article submission to on-line publication at www.jvsgbi.com is taking approximately eight weeks and that all articles have free, open access. A Twitter notification is sent out when articles are published online via @VSjournalGBI. Our Twitter following is growing – if you are not yet following us on social media please visit and follow to receive the latest news from the journal. Finally, I hope that you enjoy reading this issue of JVSGBI. Please do continue to submit your work for publication, and follow us on social media.

A survey of surgical site infection prevention practice in UK vascular surgery

Background: Surgical site infections (SSI) have a significant impact on morbidity and mortality within vascular surgery. Despite the publication of several guidelines, there is a lack of consensus regarding the most effective perioperative practice to minimise the incidence of SSI. This study aimed to assess the current practice of SSI prevention among UK vascular surgeons. Methods: An online survey developed using the current National Institute for Health Care and Excellence (NICE), Centers for Disease Control and Prevention (CDC) and World Health Organisation (WHO) SSI prevention guidelines was piloted in a tertiary vascular centre before being distributed by email to the members of the Vascular Society of Great Britain and Ireland. The survey contained 15 question domains across preoperative, perioperative and postoperative phases to establish current SSI prevention practice. The survey was open for 1 month with reminder emails at 2 and 3 weeks. Results: A total of 109 respondents from 47 UK hospitals completed the survey, 90 of which were consultants (82.6%). The median reported SSI rate was 7.5% (IQR 5–10%). Lower limb arterial and major limb amputations were highlighted as the highest risk procedures of SSI. Empirical criteria are used by 67.2% of respondents to diagnose SSI, and over half (52.2%) of surgeons used this alone. Most respondents use alcoholic chlorhexidine gluconate (69.6%) skin preparation and basic wound dressings (67.6%). Around half (52.5%) of respondents reported that they would use negative pressure wound therapy for closed wounds. Formal wound surveillance was not undertaken by 73.7% of respondents. Conclusions: There is little agreement in current guidelines on the best practice to prevent SSI. Unsurprisingly then, clinical practice follows suit and continues to show little consensus on prevention measures used. There also appears to be a disparity in registry level, clinical perception and literature data for SSI rates. Well-designed high-quality trials are needed to provide evidence-based recommendations in this field.

Research priorities for vascular services: results of the UK Vascular James Lind Alliance Priority Setting Process

Introduction: The configuration of vascular services is a challenging process where treatment options, access and delivery of services is variable. There is a significant financial burden to the NHS due to rising demand for vascular services; however, guidelines for treatment options and delivery are frequently based on low levels of clinical and cost effectiveness evidence. Therefore, further research is required but capacity is limited and funding is highly competitive. To address this issue, the Vascular Society of Great Britain and Ireland (VSGBI) in association with the James Lind Alliance (JLA) undertook a national Priority Setting Process (PSP) for vascular conditions. This paper presents the results of this process, with a focus on the topic of ‘vascular services’. Methods: A modified JLA Priority Setting Partnership was implemented in three overarching phases: (1) a clinician-led survey to gather clinician research priorities; (2) a patient and carer-led survey to gather patient and carer research priorities; (3) a consensus workshop to discuss clinician and patient priorities and agree a list of joint research priorities. Consensus was achieved using the nominal group technique and a ranked ‘top 10’ list of research priorities for vascular services was established. Results: In the first phase (clinician-led survey), 481 clinicians submitted 1,231 research priorities related to vascular conditions in general. Of these, 338 service-related research priorities were reduced to 16 overarching summary priorities recirculated for interim scoring. In the second phase (patient and carer-led survey), 373 patients and carers submitted 582 research priorities. Of these, 25 service-related priorities were developed and recirculated for interim scoring. In the third phase (consensus workshop), clinician and patient priorities were amalgamated into 18 priorities for discussion. The final ‘top 10’ list of vascular service research priorities relate to: service configuration (organisation, access and delivery), patient experience, education and training (staff and patients), lifestyle and prevention, audit and evaluation and outcomes, diagnostics screening and risk assessment and communication. Conclusion: The ‘top 10’ vascular service-related priorities demonstrate the research areas considered to be most important from the perspective of patients, carers and healthcare professionals. Researchers can now focus their efforts on addressing these important questions and funders should increase their investment to support new research in these areas of greatest importance.

Research priorities in diabetic foot disease

Introduction: Diabetic foot disease is a life-changing event for patients and is associated with high burdens to society in terms of cost, mortality and morbidity. The Vascular Society Diabetic Foot Specialist Interest Group (VSDFSIG), in association with the James Lind Alliance (JLA), aimed to identify and develop key research priorities for preventing and managing diabetic foot disease. Methods: A modified JLA Priority Setting Partnership was undertaken. Two separate processes to identify research priorities were undertaken with healthcare professionals and patients and carers, led by the VSDFSIG. This exercise produced a list of 12 research priorities. The final workshop was attended by patients, carers and healthcare professionals from a variety of backgrounds involved in the care of people with diabetes and foot pathology. The research priorities were graded to produce a final list of ranked priorities. A final sandpit event addressed the priorities to generate research projects or programmes of research. Results: A total of 481 healthcare professionals and 373 patients and carers submitted over 100 research priorities relating to diabetic foot disease. These related to diabetic foot disease prevention (including prevention of recurrence and amputation), improving foot outcomes (treatment, risk assessment, blood flow, health promotion) and determining factors that affect healing time (delays in referral, foot infection, antibiotics, larval therapy). Four themes were discussed at the sandpit event relating to potential research projects. Conclusions: The top 12 research priorities in the prevention and management of diabetic foot disease and potential research projects that will inform researchers, clinicians and funders on the direction of future research priorities are presented.

Research priorities for venous conditions: results of the UK Vascular James Lind Alliance Priority Setting Process

Introduction: Venous disease comprises a range of conditions of varying severity, which can result in pain and discomfort and a reduced quality of life. The annual costs for the treatment and management of venous disease in the UK is in the order of billions of pounds. It is vitally important to direct finite National Health Service (NHS) funding into areas that will maximise health outcomes and reduce the burden on the NHS. To address the issue of where best to target resources and research, the Vascular Society of Great Britain and Ireland (VSGBI) in association with the James Lind Alliance (JLA) undertook a national Priority Setting Process (PSP) for vascular conditions. This paper presents the results of this process, with a focus on the topic of ‘venous conditions’. Methods: A modified JLA Priority Setting Partnership was developed to gather clinician, patient and carer research priorities for vascular conditions. Consensus workshops were held to discuss clinician and patient priorities and agree a list of joint research priorities. Consensus was achieved using the nominal group technique and a ranked ‘top 10’ list of research priorities for venous conditions was established. Results: In the first phase (clinician-led survey), 481 clinicians submitted 1,231 research questions related to vascular conditions in general. Of these, 130 venous-specific research priorities were reduced to 13 overarching summary priorities recirculated for interim scoring. In the second phase (patient and carer-led survey), 373 patients and carers submitted 582 research priorities. Of these, 101 venous-specific priorities were reduced to 22 overarching summary priorities and recirculated for interim scoring. In the third phase (consensus workshop), clinician and patient priorities were amalgamated into 14 priorities for discussion. The final ‘top 10’ list of venous condition research priorities relate to: access to specialist venous services, prevention, wound healing, pain management, education and compliance. Conclusions: The ‘top 10’ venous-related priorities demonstrate the research areas considered to be most important from the perspective of patients, carers and healthcare professionals. Researchers can now focus their efforts on developing research questions and studies to address these priorities and funders should increase their investment to support new studies in these areas of greatest importance.

Ibero-American Society of Interventionism (SIDI) and the Spanish Society of Vascular and Interventional Radiology (SERVEI) Standard of Practice (SOP) for the Management of Inferior Vena Cava Filters in the Treatment of Acute Venous Thromboembolism.

Objectives: to present an interventional radiology standard of practice on the use of inferior vena cava filters (IVCFs) in patients with or at risk to develop venous thromboembolism (VTE) from the Iberoamerican Interventional Society (SIDI) and Spanish Vascular and Interventional Radiology Society (SERVEI). Methods: a group of twenty-two interventional radiologist experts, from the SIDI and SERVEI societies, attended online meetings to develop a current clinical practice guideline on the proper indication for the placement and retrieval of IVCFs. A broad review was undertaken to determine the participation of interventional radiologists in the current guidelines and a consensus on inferior vena cava filters. Twenty-two experts from both societies worked on a common draft and received a questionnaire where they had to assess, for IVCF placement, the absolute, relative, and prophylactic indications. The experts voted on the different indications and reasoned their decision. Results: a total of two-hundred-thirty-three articles were reviewed. Interventional radiologists participated in the development of just two of the eight guidelines. The threshold for inclusion was 100% agreement. Three absolute and four relative indications for the IVCF placement were identified. No indications for the prophylactic filter placement reached the threshold. Conclusion: interventional radiologists are highly involved in the management of IVCFs but have limited participation in the development of multidisciplinary clinical practice guidelines.

Vascular Society Diabetic Foot Specialist Interest Group Collaborative

Background: Diabetes mellitus is one of the fastest growing health crises of our time. One of the major complications is diabetic foot ulcers, many of which fail to heal. Tenotomy – transection of tendon fibres – may help to redistribute pressure in the foot and therefore help ulcer healing and prevent recurrence. The aim of this survey was to explore the availability of pressure relieving adjuncts, including tenotomy, in diabetic foot services and interest in collaborating in further research studies. Methods: An online survey was performed of healthcare professionals involved in the management of diabetic foot ulcers to explore the multidisciplinary composition of diabetic foot services, offloading therapies available and interest in collaborating in further research. Results: The survey gained 168 responses from 10 countries. Most responders were orthopaedic surgeons (61.3%, 103/168). Of those who responded, 70.8% (119/168) had a dedicated diabetic foot clinic and 99 (58.9%) reported having an active tenotomy service. 73.8% (124/168) of responders wished to further collaborate and 82.1% (138/168) were willing to help involve their patients in a future trial. Conclusions: The results of this survey showed the variation in tenotomy practice and an appetite for collaborative research in this area. The Vascular Society of Great Britain and Ireland Diabetic Foot Specialist Interest Group will address these uncertainties through targeted collaborative research to investigate tenotomy as a potential clinical and cost-effective treatment in diabetic foot care.

Research priorities for patients with peripheral arterial disease: a James Lind Alliance Priority Setting Partnership

Introduction: Peripheral arterial disease (PAD) is a common health problem associated with reduced mobility, functional capacity and quality of life. Significant research exists in the field of vascular surgery, but its relevance to the research priorities of patients/carers and clinicians/healthcare professionals is unknown. The aim of this process, conducted by the Vascular Society of Great Britain and Ireland with the James Lind Alliance (JLA), was to identify the key research priorities for PAD, from the perspective of patients/carers and clinicians/healthcare professionals. Methods: A modified JLA Priority Setting Partnership was performed in three stages: (1) a clinician/healthcare professional-led Delphi process; (2) a patient/carer-led JLA process; and (3) amalgamation of patient/carer and clinician/healthcare professional-led results for a final round of JLA-led prioritisation. The clinician/healthcare professional Delphi process surveyed vascular clinicians/healthcare professionals, inviting them to submit important research priorities for vascular surgery. This generated a list of priorities which were redistributed for interim scoring. The priorities fitted into nine specific Special Interest Groups (SIGs), one being PAD. This was followed by a patient/carer Delphi process (in association with the JLA) using a similar two-stage process. Finally, research priorities formed by these two processes were amalgamated to produce a refined list relevant to PAD. The PAD SIG then held a final JLA consensus workshop which was attended by patients/carers and clinicians/healthcare professionals, where a nominal group technique was used to produce a ranked top 10 list of research priorities specific to PAD. Results: In the clinician/healthcare professional Delphi process, 481 clinicians/healthcare professionals submitted 1,231 research priorities related to vascular conditions. Two hundred and six PAD-specific priorities were amalgamated into 17 priorities which were recirculated for scoring according to perceived importance. For patients/carers, 582 research priorities were submitted by 373 individuals, and 114 PAD specific priorities were amalgamated into 9. These were recirculated for scoring according to perceived importance. After amalgamation of both sets of priorities, 12 remained, which were discussed at the final consensus meeting, resulting in a final ranked list of 10 PAD-specific research priorities. Research priority themes included improving outcomes, maximising non-invasive therapy, education and diagnosis, and stopping/slowing down PAD and cardiovascular disease progression. Conclusions: We have identified the top 10 PAD-related research priorities from the perspective of patients/carers and clinicians/healthcare professionals. This should provide guidance for researchers, clinicians, healthcare professionals and funders to ensure that proposed PAD research is addressing priorities that are considered important to all parties.

Research priorities for aortic diseases: results of the James Lind Alliance/Vascular Society GBI priority setting exercise

Abstract Background: In order to identify research priorities for aortic disease, a partnership between the Vascular Society of Great Britain and Ireland (VSGBI) and the James Lind Alliance (JLA) was established to capture the interests of a wide group of patients, carers and health professionals. One of the aims of the partnership was to establish the top 10 research priorities in the field of aortic disease. Methods: A modified JLA Priority Setting Partnership was undertaken, during which healthcare professionals, patients and carers participated independently in two Vascular Society of Great Britain and Ireland (VSGBI)-led Delphi processes identifying research priorities in aortic disease. An aortic Special Interest Group composed of patients and healthcare professionals assessed the two lists of priorities, amalgamating similar priorities and generating a final list for ranking. An offer was sent to various patients, carers and healthcare professionals from different backgrounds with an interest in aortic disease to attend the final consensus workshop where a ranked top 10 list of aortic disease research priorities was produced using a nominal group technique. Results: A total of 1,231 research priorities relating to general vascular surgery were submitted by 481 clinicians. From these, 162 aortic-specific research priorities were identified and combined into 15 final clinical priorities. In addition, 582 research priorities related to vascular surgery in general were submitted by 373 patients or carers. From these, 24 further aortic-specific research priorities were identified after combining similar priorities. Amalgamation of the clinician and patient priorities resulted in 18 priorities that were taken to the final consensus workshop, where a ranked top 10 list of aortic disease research priorities was produced. These priorities include themes of diagnosis, surveillance, management, recovery and predisposition. Conclusion: A collaborative effort between healthcare professionals and patients has identified a ranked top 10 list of aortic disease research priorities. This list will inform and guide clinicians, researchers and funders for the foreseeable future and will support future research that encompasses the important interests and representation of the wider network involved and affected by aortic disease.

Do we need a UK vascular journal? Survey of multidisciplinary UK vascular specialists

Background: Prior to the development of the Journal of Vascular Societies Great Britain & Ireland (JVSGBI), there were limited opportunities for UK based vascular health professionals to publish research relevant for UK vascular practice. A survey was developed to evaluate the appetite and potential infrastructure for a UK vascular journal amongst vascular healthcare professionals. Methods: In May 2020, an online questionnaire was administered by The Vascular Society of Great Britain and Ireland (VSGBI) Research Committee, surveying vascular health professionals regarding the development of a UK-specific vascular journal. The survey was disseminated via email to multi-disciplinary members of the vascular community with links promoted on social media. Results: Responses were received from 359 individuals identifying predominantly as surgeons (38%), nurses (8%), technologists (10%), radiologists (20%), trainees (10%), physiotherapists (7%) and other (7%). The majority of participants (67%) indicated they would be in favour of a UK-specific vascular journal and that it should be available as an online quarterly publication. Almost three quarters (74%) of respondents thought a subscription fee should be included in societies’ membership fees. Free text comments highlighted a few concerns, suggesting the focus should instead be to improve the quality of existing vascular journals. However, most respondents welcomed the idea of a journal relevant to UK practice, with inclusivity of all UK vascular professions to encourage more collaborative working. Conclusions: Overall, feedback collected from the survey was positive and suggested a demand for a UK-specific vascular journal, providing an indication that the development of such a journal should be further explored. The results of this survey helped to inform the development of the JVSGBI.

Research priorities for lower limb amputation in patients with vascular disease

Introduction: Major lower limb amputation (MLLA) is a life-changing event often associated with high mortality and morbidity rates. Research into MLLA surgery is limited. The Vascular Society of Great Britain and Ireland (VSGBI) in partnership with the James Lind Alliance (JLA) aimed to identify and develop key research priorities for MLLA. Methods: A modified JLA Priority Setting Partnership was undertaken, encompassing all vascular practice. Two separate Delphi processes to identify research priorities were undertaken with healthcare professionals, patients and carers, led by the VSGBI. The priorities were then scored by the same participants and amalgamated to produce a list for final ranking. The final consensus meeting was attended by patients, carers and healthcare professionals from a variety of backgrounds involved in the care of people with MLLA. Using a nominal group technique, a ranked list of the top ten research priorities were identified. Results: A total of 481 clinicians submitted 1,231 research priorities relating to vascular surgery in general. Sixty-three MLLA-specific research priorities were combined into five final priorities. Three hundred and seventy-three patients or carers submitted 582 research priorities related to vascular surgery in general. Nine MLLA-specific research priorities were identified after combining similar priorities. The final consensus meeting produced a ranked top 10 list of research priorities relating to: MLLA prevention, supporting rehabilitation, improving clinical outcomes following MLLA (preventing/treating pain including phantom limb pain and improving wound healing) and research into information provision for patients undergoing MLLA. Conclusions: The top 10 MLLA research priorities provide guidance for researchers, clinicians and funders on the direction of future research questions that are important to both healthcare professionals and patients.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Extracranial Cerebrovascular System.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Extracranial Cerebrovascular System.

Resilience of elective cancer surgery systems during COVID-19 lockdowns: an international, multicentre, prospective cohort study

BackgroundSurgery is the main modality of cure for solid cancers and was prioritised to continue during SARS-CoV-2 outbreaks. This study aimed to identify areas for health system strengthening by comparing the delivery of elective cancer surgery during COVID-19 in periods of lockdown versus light restriction. MethodsIn this international, multicentre, prospective cohort study, we enrolled patients with 15 cancer types who had a decision for surgery during the SARS-CoV-2 pandemic (between Jan 21, 2020 and April 14, 2020) to Aug 31, 2020. Any hospital worldwide providing elective cancer surgery was eligible. The primary outcome was the non-operation rate (proportion of patients who did not undergo planned surgery). Reasons for non-operation were classified as COVID-19 related (societal, operational, or personal) or unrelated. Average national Oxford COVID-19 Stringency Index scores were calculated for each patient during their wait for surgery and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). Cox proportional-hazards regression models were used to explore associations between lockdowns and non-operation. This study was registered at ClinicalTrials.gov, NCT04384926. FindingsWe enrolled 27 700 participants, of whom 20 006 patients (8526 men and 11480 women) from 466 hospitals and 61 countries did not receive surgery after a minimum of 3-months' follow up (median 23 weeks [IQR 16–30]). All patients had a COVID-19-related reason for non-operation. Light restrictions were associated with a 0·6% reference non-operation rate, moderate lockdowns with a 5·5% rate (HR 0·81, 95% CI 0·77–0·84, p<0·0001), and full lockdowns with a 15·0% rate (0·51, 0·50– 0·53, p<0·0001). In sensitivity analyses, including adjustment for SARS-COV-2 case notification rates, moderate (0·84, 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001) remained independently associated with non-operation. Frail patients with advanced cancer, particularly those from low-income and middle-income countries and those requiring postoperative critical care, were more likely to not have an operation. InterpretationCancer surgery systems worldwide were affected by lockdowns, including in the UK, with one in seven patients not undergoing planned surgery. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which could include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies. In the UK, a whole-health system approach is required to mitigate against further harm for NHS patients. FundingNational Institute for Health Research (NIHR) Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, Economic and Social Research Council, European Society of Coloproctology, Medtronic, NIHR Academy, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study

SummaryBackgroundSurgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.MethodsThis international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.FindingsOf eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays.InterpretationCancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services.FundingNational Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

Fifteen-year trends in participation of women in presentation and leadership positions in the Southern Association for Vascular Surgery, 2006 to 2020

ObjectiveThe implementation of integrated vascular surgery training programs was recently shown to be associated with an increase in women entering the field. However, whether this has precipitated a subsequent increase in the active participation of women in academic vascular societies remains unclear. We sought to examine the trends of academic inclusion of women vascular surgeons and surgical trainees over the past 15 years at the Southern Association for Vascular Surgery (SAVS). MethodsScientific programs for annual meetings of the SAVS, and program matriculation statistics from the Accreditation Council for Graduate Medical Education, were reviewed for the period of 2006 to 2020. Yearly rates and 3-year averages of conference and society participation and vascular surgery training program matriculation rates were calculated and compared with proportion testing. Spearman correlation testing was used to compare trends, with ρ ≥0.600 defined as a strong correlation. ResultsExamining 3-year means, the average number of women authors per SAVS abstract increased from 0.78 to 1.42 over the course of the study period (P < .001), and the overall rate of women authors steadily increased from 12.8% to 21.5% (P < .001). Although this remains less than the proportion of women matriculating into vascular surgery programs in 2019 (29.3%; P = .007), the upward trend of women entering vascular surgery overall, and particularly vascular surgery fellowship, strongly correlates with the average number of women authors on abstracts at SAVS (ρ = 0.709 and ρ = 0.737, respectively). The percentage of women presenting authors increased from 9.7% to 28.4% (P = .004), but there was no increase in the percentage of women senior authors (10.1% to 9.6%; P = .92). In the 15-year period, only one abstract of 347 (0.3%) had full authorship by women vs 35.1% with full authorship by men (P < .001). Although the increase of women matriculating into vascular surgery programs over the study period did not correlate with the increase of women in senior leadership positions (ρ < 0.600), there was an increase in the number of women in committee chair positions (0.0% to 25.9%; P = .005), which correlated strongly with increasing society membership (ρ = 0.716). Additionally, there was an increase in women holding executive council positions from 0% to 10.0% (P = .08), although this was not statistically significant. ConclusionsParticipation of women authoring and presenting papers at the SAVS has increased over the past 15 years at a rate that strongly correlates with the increasing rate of women entering vascular surgery training programs. It is important that society leadership opportunities continue to parallel this trend as we seek to further improve diversity in vascular surgery.

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.

Provision of exercise services in patients with peripheral artery disease in the United Kingdom.

ObjectivesSupervised exercise programmes (SEPs) are a vital treatment for people with intermittent claudication, leading improvements in walking distance and quality of life and are recommended in multiple national and international guidelines. We aimed to evaluate the use and structure of SEPs in the United Kingdom (UK).DesignWe conducted an anonymous online survey using the Jisc platform comprising of 40 questions. The survey was designed to address key areas such as access, provision, uptake and delivery of SEPs in the United Kingdom. Ethical approval was obtained from Coventry University (P108729).MethodsThe list of trusts providing vascular services was obtained from the National Vascular Registry (NVR) report. The survey was disseminated via social media, The Vascular Society of Great Britain and Ireland and the Society for Vascular Technology. Data were exported to a Microsoft Excel document and analysed using simple descriptive statistics.ResultsOf 93 vascular units identified, we received response from 48. Of these, 23 had access to an exercise programme (48%). The majority of SEPs were exclusively for PAD patients (77%), with 21% using integrated services. 67% of respondents were providing a circuit-based programme, and 5 out of 23 were meeting the dose recommendations in the UK National Institute for Health and Care Excellence (NICE) guidelines. Respondents felt that programmes were moderately to extremely important to patients, slightly to very important to clinicians and not at all important to slightly important to commissioning/funding bodies.ConclusionSEPs are a well-established first-line treatment for patients with IC and they are recommended by NICE guidelines. Despite this, many patients still do not have access to an exercise programme, and clinicians do not feel that they have support from commissioning/funding bodies to develop them. There is an urgent need for funding, development and delivery of SEPs in the United Kingdom.

Representation of women in vascular surgery science and societies

ObjectiveMedical schools and surgical residencies have seen an increase in the proportion of female matriculants, with 30% of current vascular surgery trainees being women over the past decade. There is widespread focus on increasing diversity in medicine and surgery in an effort to provide optimal quality of patient care and the advancement of science. The presence of gender diversity and opportunities to identify with women in leadership positions positively correlates with women choosing to enter traditionally male-dominated fields. The purpose of this study was to evaluate the representation of women in regional and national vascular surgical societies over the last 20 years. MethodsA retrospective review of the meeting programs of vascular surgery societies was performed. Data were collected on abstract presenters, moderators, committee members and chairs, and officers (president, president-elect, vice president, secretary, and treasurer). The data were divided into early (1999-2009) and late (2010-2019) time periods. ResultsFive regional and five national societies' data were analyzed, including 139 meetings. The mean percentage of female abstract presenters increased significantly from 10.9% in the early period to 20.6% in the late period (P < .001). Female senior authors increased slightly from 8.7% to 11.5%, but this change was not statistically significant (P = .22). Female meeting moderators increased significantly from 7.8% to 17.2% (P < .001), as well as female committee members increased from 10.9% to 20.3% (P = .003). Female committee chairs increased slightly from 10.9% to 16.9%, but this difference was not statistically significant (P = .13). Female society officers increased considerably from 6.4% to 14.8%. (P = .002). Significant variation was noted between societies, with five societies (three regional and two national) having less than 10% women at the officer level in 2019. There was a wide variation noted between societies in the percentage of female abstract presenters (range, 7.6%-34.9%), senior authors (3.9%-17.9%), and meeting moderators (5.4%-40.7%). ConclusionsOver the past two decades, there has been a significant increase in the representation of women in vascular surgery societies among those presenting scientific work, serving as meeting moderators, and serving as committee members. However, the representation of women among committee chairs, senior authors, and society leadership has not kept up pace with the increase noted at other levels. Efforts to recruit women into the field of vascular surgery as well as to support the professional development of female vascular surgeons are facilitated by the presence of women in leadership roles. Increasing the representation of women in vascular society leadership positions may be a key strategy in promoting gender diversity in the vascular surgery field.

Predictors of adverse events in uncomplicated type B aortic dissection: a systematic review with meta-analysis.

Thoracic endovascular aortic repair (TEVAR) has been selectively used for uncomplicated acute type B aortic dissection (TBAD); however, not all cases will benefit from TEVAR. A search for high risk clinical and radiographic predictors for complications is ongoing. This systematic review and meta-analysis aimed to identify predictors of major adverse events during follow-up of uncomplicated TBAD, in order to identify who might benefit from elective TEVAR. A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) Statement. 16 studies were included in a qualitative synthesis and 10 in the meta-analysis. Several risk factors associated to major adverse events have been described, including: 1) aortic diameter ≥40 mm; 2) greater false lumen diameter (>22 mm); 3) patent false lumen; 4) primary entry tear >10 mm; and 5) greater number of false lumen vessels origin. Quantitative synthesis identified an aortic diameter ≥40 mm significantly associated with major adverse events (HR=3.56; P<0.00001). Reporting of false lumen status, aortic diameters and growth, and demographic data was not always congruent with the most recent recommendations by Society for Vascular Surgery and Society of Thoracic Surgeons, published in 2020. Acute and subacute patients with uncomplicated TBAD presenting with an aortic diameter ≥40 mm and solely treated with BMT have an increased hazard of developing major adverse events (HR), making them potential candidates for TEVAR. Remaining risk factors analysed have weaker evidence.

Risks of emergency vascular surgery in COVID-19 patients

COVID-19 is a global and highly contagious pandemic with substantial morbidity and mortality. It has affected the medical care of other diseases with recommendations to postpone elective surgical procedures to decrease infection rates. New surgical triage guidelines have been recommended by the Vascular Surgery Society to manage urgent and emergent conditions. COVID-19 patients especially severe cases have several pathological findings as demonstrated by clinical research. Some of these pathologies including thrombocytopenia, coagulopathy, and cardiac involvement are important to be considered by the vascular surgeon. The aim of this article was to review the literature and discuss these risks in relation to vascular surgery.