Vascular Society Research Articles

President's Address - Vascular Society of India

President's Address - Vascular Society of India

Accuracy evaluations of three ruptured abdominal aortic aneurysm mortality risk scores using an independent dataset

ObjectiveTo date, no single scoring system for predicting 30-day mortality in patients with ruptured abdominal aortic aneurysms (rAAAs) has been endorsed by any vascular society or proven to definitively predict treatment futility. Three recently developed scoring systems for predicting 30-day mortality in patients with rAAA have been validated by their respective institutional data. The purpose of this study was to evaluate the accuracy of these rAAA mortality risk scores using an independent community hospital dataset. MethodsConsecutive patients presenting with rAAA at Saint Joseph Hospital between January 1, 2009, and February 28, 2017, were used for validation. Logistic regression analysis was used to evaluate the association between risk score and odds of death. Confidence intervals were calculated using the Wilson method. Comparisons were made between models by calculating the area under the receiver operating characteristic (AUC) curves. ResultsComplete data from 38 patients was used for accuracy evaluation. The AUCs for the Dutch Aneurysm Score, Harborview Medical Center score, and Vascular Surgery Group of New England (VSGNE) score were 0.762, 0.792, and 0.860, respectively, for all patients. When evaluating 30-day mortality for patients undergoing ruptured endovascular aneurysm repair, the scores were 0.802, 0.893, and 0.927, respectively. The difference between scores did not reach statistical significance. All three indexes significantly associated with the mortality rate using logistic regression. ConclusionsEach risk score accurately predicted 30-day mortality using the independent dataset. The results suggest that the VSGNE score is the most accurate; however, differences in accuracy between each scoring system did not reach statistical significance. The Harborview Medical Center scoring system is based only on preoperative variables. Although the VSGNE score had the highest AUC in this analysis, it is dependent on intraoperative variables. The authors favor a single risk assessment tool, with consensus vascular societal approval, that incorporates preoperative variables and includes a tool for the prediction of treatment futility.

Editorial introductions

Current Opinion in Lipidology was launched in 1990. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of lipidology is divided into six sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Erik S.G. StroesErik S.G. Stroes is Chair of the Department of Vascular Medicine at the Academic Medical Center, Amsterdam, The Netherlands. After gaining his Doctor of Medicine degree from Erasmus University, Rotterdam, The Netherlands, he then specialized in internal medicine at University Medical Center, Utrecht, The Netherlands, and later in vascular medicine at the Academic Medical Center, Amsterdam. Professor Stroes’ research interests include the role of the vessel wall in atherosclerosis development and lipid disorders in relation to atherogenesis. He has been an investigator in numerous lipid-lowering trials using various surrogate markers, such as intima-media thickness and flow-mediated dilation, and more recently 3T magnetic resonance imaging as a surrogate marker for vascular disease progression. He has also been involved in the development of novel therapeutic moieties for dyslipidemia, such as lipoprotein lipase gene therapy, antisense oligonucleotide inhibition of apolipoprotein B synthesis, and reconstituted high-density lipoprotein infusion. He has been the recipient of numerous research grants and several awards. Professor Stroes is Chair of the Dutch Atherosclerosis Society, member of the Vascular Biology Working Group, member of the American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology, and former Chair of the Dutch Internist Vascular Society. He has published more than 300 papers in various peer-reviewed journals and authored several book chapters in the field. Gerald F. WattsGerald F. Watts (DSc, DM, PhD, FRCP, FRACP) trained at Imperial College (St Mary's Hospital) and King's College (St Thomas’ Hospital) in the University of London. He is a consultant physician, specializing in lipid disorders and cardiovascular medicine, within the department of cardiology at Royal Perth Hospital, as well as Winthrop Professor of Cardiometabolic Medicine in the University of Western Australia. He is Chair of The Familial Hypercholesterolaemia (FH)-Australasia Network and executive board member of the International Atherosclerosis Society. His research interests include lipid disorders and cardiovascular prevention, with clinical interest focusing on delivering improved health care for patients and families with FH. Professor Watts is actively involved in undergraduate medical education and supervisors PhD students and post-doctoral fellows. He has authored over 500 published works, including scientific articles, reviews, book chapters and monographs, and is associate editor of Atherosclerosis, Journal Clinical Lipidology and Metabolism.

Risk of insulin-dependent diabetes mellitus in patients undergoing carotid endarterectomy

ObjectiveThere is conflicting evidence regarding the association of diabetes mellitus (DM) and insulin use with outcomes after carotid endarterectomy (CEA). Therefore, we sought to evaluate the risk of insulin-dependent DM (IDDM) and noninsulin-dependent DM (NIDDM) on 30-day outcomes after CEA. MethodsWe identified patients undergoing CEA from the Targeted Vascular module of the National Surgical Quality Improvement Program (2011-2015) and stratified patients on the basis of their preprocedural symptom status. We compared 30-day outcomes between nondiabetics and patients with NIDDM or IDDM, with 30-day stroke/death as the primary end point. ResultsOf 16,739 CEA patients, 9784 (58%) were asymptomatic, of whom 6720 (69%) had no diagnosis of DM, 1109 (11%) had IDDM, and 1955 (20%) had NIDDM. Of the 6955 symptomatic patients, 4982 (72%) had no diagnosis of DM, 810 (12%) had IDDM, and 1163 (17%) had NIDDM. Among asymptomatic patients, patients with IDDM experienced higher rates of 30-day stroke/death compared with those without DM (3.4% vs 1.5%; P < .001), whereas those with NIDDM experienced rates similar to those of patients without DM (2.1% vs 1.5%; P = .1). Moreover, asymptomatic patients with IDDM and an anatomic high-risk criterion experienced a 30-day stroke/death rate of 6.6%. After adjustment, IDDM was associated with 30-day stroke/death in asymptomatic patients compared with patients without DM (odds ratio, 2.3; 95% confidence interval, 1.5-3.4; P < .001), but NIDDM was not (odds ratio, 1.4; 95% confidence interval, 1.0-2.1; P = .1). In comparison, among symptomatic patients, those with IDDM and NIDDM experienced similar rates of 30-day stroke/death as patients without DM (4.9% vs 3.6% and 4.0% vs 3.6%; both P > .1). After adjustment, neither IDDM nor NIDDM was associated with 30-day stroke/death in symptomatic patients compared with symptomatic patients without DM. ConclusionsRates of 30-day stroke/death after CEA in asymptomatic patients with IDDM exceed international vascular societies' guideline thresholds for acceptable outcomes in asymptomatic patients, especially those with anatomic high-risk criteria. Thus, asymptomatic patients with IDDM may not benefit from CEA, although more data are needed about the natural history of carotid disease in this population.

Publication Fate of Abstracts Presented at Four British Surgical Meetings: An 11-Year Follow-Up

BackgroundThe gold standard for research is publication within a peer-reviewed journal. There is a discrepancy between the number of abstracts presented at scientific meetings and the number published as full articles. We identified publication rates for the 2012 meetings of four British surgical societies. These were the Association of Surgeons of Great Britain & Ireland (ASGBI), the Vascular Society of Great Britain and Ireland, the British Transplantation Society (BTS), and the Association of Coloproctology of Great Britain and Ireland (ACPGBI). We also compared publication rates with these societies' 2001 meetings and identified univariate factors associated with publication. Materials and methodsPubMed was searched to identify publications stemming from meeting abstracts. We extracted abstract characteristics to identify factors associated with publication and also characteristics of subsequent publications to enable comparison. ResultsPublication rates were 24.1% (ASGBI), 24.6% (BTS), 21.7% (ACPGBI), and 39.4% (Vascular Society of Great Britain and Ireland). Rates for ASGBI, BTS, and ACPGBI meetings were significantly lower compared to 2001 meetings (P = 0.001-0.026). Mean time to publication was 12.1-22.0 mo. Mean 5-y impact factor differed significantly between meetings (P = 0.001), with the BTS meeting having the highest mean 5-y impact factor (4.658). Factors associated with publication included being an oral presentation (ASGBI P = 0.001), multi-institution study (ASGBI P = 0.003), or randomized-controlled trial (BTS P = 0.049). ConclusionsReduced publication rates may represent increased acceptance of low-quality abstracts at meetings or a more competitive journal submission process. Further data are required to strengthen conclusions. Nonetheless, authors and meeting organizers should push for higher quality abstracts to promote future peer-reviewed journal publication.

Predictive value of angiographic characteristics for endovascular revascularization of ischemic diabetic foot

Background Endovascular techniques have undergone major advances with regard to the treatment of infrapopliteal arterial occlusive disease. Objective The objective of this study was to determine angiographic characteristics of infrapopliteal arterial lesions that are dependent predictors of endoluminal revascularization in diabetic patients with ischemic foot ulcers. Patients and methods The present study included 64 patients with ischemic diabetic foot ulcers who were admitted to the vascular surgery unit at Gamal Abdel Naser Hospital (Alexandria) during October 2014–December 2015. Informed consent was obtained from all patients. Patients underwent angioplasty and were followed-up for an average of 12 months. The clinical and procedural data of all included patients were collected. Preprocedural and postprocedural angiographic images were reviewed to classify lower-limb arterial involvement according to the Joint Vascular Society Council classification of calf and foot scores. Foot lesions were graded according to The University of Texas wound classification system. Clinical results (healing, nonhealing, or major amputation) were compared with baseline clinical data and angiographic results using Student's t test. All statistical analyses were performed using SAS software. Results During the study period, 64 percutaneous procedures were performed, with an immediate technical success rate of 89.8%. Before the procedure, the mean ± SD calf and foot scores were 7.8 ± 1.6 and 7.3 ± 2.3, respectively. After the procedure, the mean calf and foot scores were 4.8 ± 2.3 and 5.9 ± 2.6, respectively. The limb salvage rate was 87%, and the major amputation rate was 9.4%. Among all the clinical and angiographic variables included in the analysis, only preprocedural and postprocedural foot scores were significantly associated with the clinical outcome (P Conclusion Preprocedural and postprocedural foot scores represent the most significant angiographic parameters to evaluate chances for ulcer healing, and consequently to determine the success of the revascularization procedure.

#VascularSurgery

To characterize the vascular surgery Twitter network. A total of 20,841 consecutive tweets by 8,282 unique Twitter accounts regarding vascular surgery from October 23, 2014 to January 15, 2018 were analyzed. Twitter analytics, including activity metrics, content analysis, user characteristics, engagement, and network analysis were performed using Symplur Signals, a health care social media analytics platform. Vascular surgery tweets, the number of users tweeting about vascular surgery, and vascular surgery tweet impressions have increased by an annual average of 77.8%, 55.3%, and 209.1% from 2015 to 2017, respectively. Twitter activity trend analysis showed consistent growth over the study period with an average of 25.7±2.6 additional tweets per month (P<0.001). As for tweet content, 2,220 tweets (10.7%) were pertaining to patients, and 2,198 tweets (10.5%) were regarding new or innovative topics. 15,422 tweets (74.0%) included links to journals or websites and 6,826 tweets (32.8%) contained at least 1 image. Deep venous thrombosis, pulmonary embolism, diabetes, endovascular interventions, trauma, and practice guidelines were among the most commonly discussed health topics. Physicians composed 5,618 tweets (27%), while patients submitted 2,447 tweets (11.7%). As for engagement, 8,886 tweets (42.6%) were retweets, 11,816 tweets (56.7%) mentioned at least 1 other user, and 786 tweets (3.8%) were replies. Network analysis revealed central hubs to be vascular surgery societies, academic institutions, academic journals, and physicians. The use of Twitter to discuss vascular surgery is growing rapidly with increasing use by vascular surgeons and vascular medicine physicians. An effort to involve more patients in the vascular surgery Twitter social network may allow for more opportunities to educate, and garner interest and support for vascular surgery.

Pediatric Vascular Surgical Practice Patterns

Vascular surgeons infrequently care for pediatric patients. As such, variability in operative management and available hospital resources at free-standing children's hospitals (CHs) may exist. The study aims were (1) to determine vascular surgeon comfort level with pediatric vascular surgery and (2) to determine variations in pediatric vascular surgery practice patterns. A survey composed of clinical vignettes emailed to all members of Vascular and Endovascular Surgery Society was designed to assess operative management of pediatric vascular conditions and hospital resources. Comparisons of surgeon satisfaction between free-standing CHs and a CH within an adult general hospital were made using Wilcoxon rank-sum tests. Comparison of surgeon comfort between hospital types was made using a McNemar's test. P-values less than or equal to 0.05 indicated statistical significance. Response rate was 18% (93/525) with 96% (89/93) indicating completion of a 2year vascular fellowship. Surgeon satisfaction with operative equipment (P=0.002), support staff (P<0.001), and vascular laboratory availability (P=0.01) was significantly lower at CHs. Eighty-seven percent of surgeons operated on fewer than 2 children over the preceding 3 months. For the different clinical vignettes, there was a wide variation in practice patterns with a range of 50-89% of the surgeons performing fewer than 5 cases over the preceding 10 years. There was a significant decrease in surgeon's comfort level with elective pediatric vascular operations compared to the operative management of pediatric vascular trauma (P=0.0025). Most vascular surgeons do not feel comfortable in the operative management of pediatric vascular disease, and optimal resource availability within pediatric CHs may be lacking. Centralized care of this patient population may be warranted.

Invited commentary

Invited commentary

Information for authors and editorial policies

Information for authors and editorial policies

No consensus on physicians' preferences on vascular access management after kidney transplantation: Results of a multi-national survey.

Objective:Arteriovenous fistulas for hemodialysis vascular access are a burden for the cardiovascular system. After successful kidney transplantation, prophylactic arteriovenous fistula ligation may improve cardiac outcomes; however, evidence is scarce. This survey investigates physicians’ preference for management of arteriovenous fistulas and identifies the factors associated with preference for either arteriovenous fistula ligation or maintenance.Materials and methods:A survey was sent to members of eight national and international Nephrology and Vascular Surgery societies. The survey comprised eight case vignettes of asymptomatic patients with a functioning arteriovenous fistula after kidney transplantation. Characteristics possibly associated with treatment preferences were arteriovenous fistula flow, left ventricular ejection fraction, and patient age. Respondents were asked to state preference to maintain or ligate the arteriovenous fistula. Linear mixed-effects models were used to investigate the association of treatment preference with case characteristics.Results:A total of 585 surveys were returned. A reduced left ventricular ejection fraction of 30% (beta 0.60, 95% confidence interval 0.55; 0.65) and a high flow of 2500 mL/min (beta 0.46, 95% confidence interval 0.41; 0.51) were associated with a higher preference for arteriovenous fistula ligation. Disagreement among respondents was considerable, as in four out of eight cases less than 70% of respondents agreed on the arteriovenous fistula management strategy.Conclusion:Although respondents recognize a reduced left ventricular ejection fraction and a high flow as the risk factors, the high disagreement on management preferences suggests that evidence is inconclusive to recommend arteriovenous fistula ligation or maintenance after kidney transplantation. More research is needed to determine optimal arteriovenous fistula management after successful kidney transplantation.

PC118. #VascularSurgery

To characterize the vascular surgery Twitter network. There were 35,791 consecutive tweets mentioning vascular surgery from October 23, 2014, to January 15, 2018, that we analyzed. Twitter analytics, including activity metrics, content analysis, user characteristics, engagement, and network analysis were obtained using Symplur Signals, a healthcare social media analytics platform. Vascular surgery tweets, the number of users tweeting about vascular surgery, and vascular surgery tweet impressions have increased by 114%, 124%, and 271% over the past 2 years, respectively. Physician users have increased by 68.2% over the same time period. Twitter activity trend analysis showed consistent annual growth over the study period with an average 28.4 ± 3.4 additional tweets per month (P < .001; Fig). As for tweet content, 2731 tweets (7.6%) were pertaining to patients, and 2677 tweets (7.5%) were regarding new or innovative topics (Table), 30,837 tweets (86.2%) included links to websites or journals, and 8127 tweets (22.7%) contained at least one image (Table). Deep venous thrombosis, pulmonary embolism, healthcare, diabetes, endovascular interventions, and trauma were among the most commonly discussed health topics (Table). A small portion of tweets were composed by physicians (15.3%) and patients (1.1%). As for engagement, 9086 tweets (25.4%) being retweeted, 482 replies (1.3%), and 11,730 mentions (32.8%). Network analysis revealed central hubs to be vascular surgery societies, academic institutions, academic journals, and physicians. The use of Twitter to discuss vascular surgery is growing rapidly with increasing use by vascular surgeons and vascular medicine physicians. An effort to involve more patients in the vascular surgery Twitter social network may allow for more opportunities to educate, and garner interest and support for vascular surgery.Table#VascularSurgeryNo. of tweetsUsers who tweetedImpressionsTweets per userAll vascular surgery tweets35,791100.0%8926100.0%186,656,5364.0User identity Physicians546415.3%240226.9%16,319,5552.3 Provider organization28838.1%4755.3%16,092,1696.1 Advocate organization28117.9%6367.1%11,794,7284.4 Media organization7332.0%2162.4%11,706,8663.4 Patients3831.1%2052.3%912,7161.9Content Tweet contains link30,83786.2%698478.2%160,179,2874.4 Tweet contains image812722.7%366541.1%79,199,2262.2 Patient related tweets27317.6%174119.5%22,584,2091.6 Innovation related tweets26777.5%149516.7%10,632,1351.8Topic DVT/PE778612.8%343438.5%44,532,7612.3 Healthcare17272.8%4344.9%8,707,6494.0 Diabetes14412.4%100111.2%13,387,6141.4 Endovascular8031.3%3974.4%2,529,6232.0 Trauma7151.2%4835.4%3,712,0991.5 Guidelines6531.1%5115.7%3,524,7491.3 Venous disease6501.1%4094.6%1,560,5321.6 Aortic aneurysm2890.5%2212.5%2,370,6121.3 PAD2270.4%1711.9%739,0051.3 EVAR1670.3%1071.2%549,8151.6 Tobacco930.2%740.8%1,752,5401.3DVT, Deep venous thrombosis; EVAR, endovascular aneurysm repair; PAD, peripheral arterial disease; PE, pulmonary embolism. Open table in a new tab

Effects of chronic kidney disease on clinical outcomes in patients with peripheral artery disease undergoing endovascular treatment: Analysis from the K-VIS ELLA registry

ObjectivesChronic kidney disease (CKD) is a risk factor for peripheral artery disease (PAD), but the impact of CKD in PAD patients who received endovascular treatment (EVT) is not well studied. Aim of this study is to clarify the impact of CKD in patients with PAD in real EVT era. MethodsUsing the Korean Vascular Intervention Society (K-VIS) endovascular therapy in lower limb artery disease registry (ELLA) registry, we analyzed 3434 patients who underwent EVT. Baseline characteristics, in-hospital events, and overall- and major adverse limb events (MALE)-free survival were analyzed. Results2739 patients (3548 target limbs) were included. 272 patients featured CKD (9.9%). Limbs in CKD patients had higher Rutherford scores, higher prevalence of critical limb ischemia (CLI). There were no differences in technical success rates in non-CKD vs. CKD group comparison and non-severe CKD vs. severe CKD group comparison (p = 0.050, 0.581, respectively). In-hospital death (p < 0.001) and short-term unexpected amputation (p = 0.028) were more frequent in the CKD group. The short-term outcome differences between severe and non-severe CKD were insignificant. Kaplan–Meier curves favored overall and MALE-free survival in non-CKD patients compared with CKD patients, but there was no difference in overall- or MALE-free survival between non-severe CKD and severe CKD groups. ConclusionPAD patients with CKD showed worse short-term mortality, short-term unexpected amputation outcome, and overall- and MALE-free survival than those without CKD in real EVT era. These findings might provide additive prognostic information for PAD patients with CKD who will be treated with EVT.

Intravenous thrombolysis for acute ischaemic stroke in patients on direct oral anticoagulants.

Whereas intravenous thrombolysis (IVT) is allowed for acute ischaemic stroke in patients on vitamin K antagonists with international normalized ratio≤1.7, there are no similar recommendations for patients on direct oral anticoagulants (DOACs), notably due to the lack of coagulation tests to assess the therapeutic effects. Although the literature is scarce, consisting of small case series and retrospective studies, considering the frequency of this situation the French Vascular Neurology Society and the French Study Group on Haemostasis and Thrombosis have worked on a joint position paper to provide a practical position regarding the emergency management of ischaemic stroke in patients on DOACs. Based on a review of the literature, the authors wrote a first text that was submitted to a broad panel of members from the two societies. The text was then amended by the authors to address experts' comments and to reach a consensus. In patients with normal renal function and who stopped the DOAC for at least 48h, the management should not differ from that in patients without oral anticoagulant. In patients who are still on DOACs, mechanical thrombectomy is encouraged preferentially when applicable in first line. Otherwise, when specific tests are available, values <50ng/ml indicate that IVT is allowed. In the absence of specific tests, standard tests (thrombin time, prothrombin time and activated partial thromboplastin time) can be used for dabigatran and rivaroxaban, although interpretation of these tests may be less reliable. In some patients on dabigatran, idarucizumab may be used before IVT. In this expert opinion paper, it is suggested that IVT can be performed in patients selected according to the time elapsed since the drug was last taken, renal function, type of hospital where the patient is admitted and plasma concentration of DOAC.

United States Endovenous Ablation Practice Trends: 4-Year Review of Medicare Provider Utilization and Payment Database

The exponential growth of endovenous ablation in the United States during the last few years has raised concerns of overuse from vascular societies and payers. The reasons for such growth are unclear (ie, increased awareness, less invasive procedure, or inappropriate overuse). In addition, physicians performing these procedures outside of their scope of practice raise concerns regarding adequacy of training. The Medicare Provider Utilization and Payment Database can be used to evaluate practice trends in Medicare beneficiaries. The Medicare Provider Utilization and Payment Database was queried for endothermal ablation Current Procedural Terminology codes 36475, 36476, 36478, and 36479 from 2012 through 2015. These results were imported into a relational database program. Queries were designed to ascertain the practice trends of all providers, inclusive of all specialties, and the data were exported to a spreadsheet program for analysis. Analysis for ablations per patient was calculated by assessing the number of beneficiaries that underwent at least one ablation by a provider in relation to the total number of ablations performed by that provider. Most saphenous vein ablations were done by vascular surgery (29%), cardiology (21%), and general surgery (14%) practitioners. The remaining one-third was performed by 41 other provider specialties. Regional variation was significant, with 47% of ablations being performed in the south (Florida, 10.4%; Texas, 9%). The southern region also had the highest growth with >127,000 cases added in 2015 (150% growth). Ablations per patient averaged 1.8 in the aggregate data set. Independent annual assessment of ablations per patient remained relatively constant: 2012, mean 1.8; 2013, mean 1.8; 2014, mean 1.8; and 2015, mean 1.9. Vascular surgery, cardiology, and general surgery specialties trended closer to the average, whereas the less represented specialties trended above the average. When the threshold was set to two ablations/patient for the year 2015, there were 295 providers above the threshold representing 20% of providers. Growth was noted during the 4 years with an increase in providers of 354 (16%), ablations of 37,682 (28%), and patients of 17,002 (23%). The provider and procedural growth rates during the time period of the database were 10% and 26%, respectively, for vascular surgery, 35% and 51% for cardiology, and −9% and −0.4% for general surgery. Endovenous ablation is performed by a wide variety of subspecialists with different levels of formal training for the management of chronic venous disease. There was an annual increase in the number of providers and ablations performed during this 4-year period of evaluation. Most ablations (64%) were performed by formally trained vascular surgeons, cardiologists, and general surgeons. The number of ablations per patient was higher than average in specialties without any vascular training. This data analysis can help establish better guidelines and governance for the use of endovenous ablation. As our health care system shifts from a fee-for-service to a value-based system and taxpayer-funded resources in Medicare patients become less available, it is important that practice trends be scrutinized using data-driven initiatives.

Is management of complex abdominal aortic aneurysms consistent? A questionnaire-based survey.

Complex abdominal aortic aneurysm (AAA) is a relatively common presentation to the vascular specialist. Despite this there is little consensus on how to manage the often comorbid group of patients. Recent advances in endovascular technology have led to the availability of multiple devices, many of which could be used to treat the same aneurysm. The aim of this study was to quantify this potential variability across vascular specialists from multiple countries. An online survey was emailed to members of the Vascular Society for Great Britain and Ireland (VSGBI), the Canadian Society for Vascular Surgery (CSVS) and the Australian and New Zealand Society for Vascular Surgery (ANZSVS). The survey presented a vignette of a 63-year-old woman with significant respiratory comorbidity and a 54 mm juxtarenal AAA (7 mm neck). There were no other adverse morphological features for endovascular repair. The survey included images and questions related to management of the aneurysm. The survey received 238 responses; 61 from ANZSVS, 65 from CSVS and 112 from VSGBI. VSGBI specialists were significantly more likely to continue surveillance than both ANZSVS (odds ratio [OR] 3.41, 95% confidence interval [CI] 1.61-7.65; P<0.001) and CSVS counterparts (OR 2.61, 95% CI: 1.29-5.47; P<0.01). ANZSVS specialists were significantly more likely to perform an endovascular repair than those from CSVS (OR 3.28, 95% CI: 1.50-7.40; P<0.01) and VSGBI (OR 3.65, 95% CI: 1.81-7.59; P<0.001). CSVS specialists were significantly more likely to manage the aneurysm with open surgery than colleagues from the VSGBI (OR 6.57, 95% CI: 2.58-18.46; P<0.001) and ANZSVS (OR 7.18, 95% CI: 2.22-30.79; P<0.001). Significant variation in the management of a juxtarenal AAA between countries was observed. The same patient would be more likely to have an endovascular repair in Australia and New Zealand, open surgery in Canada and continuing surveillance in the UK and Ireland. This variation reflects the lack of long-term evidence and international consensus on the optimal management of complex AAA.

Prof. Armando Mansilha

&#x0D; Professor of Angiology and Vascular Surgery of the Faculty of Medicine of University of Porto&#x0D; Head of the Department of Angiology and Vascular Surgery at Hospital CUF Porto&#x0D; Secretary General of the Section and Board of Vascular Surgery of the European Union of Medical Specialists (UEMS)&#x0D; ESVS 2015 LOC Chairman&#x0D; President Elect of the European Venous Forum&#x0D; Honorary Member of the Vascular Society of Great Britain and Ireland&#x0D;

Is the management of complex abdominal aortic aneurysms consistent across the UK? A questionnaire-based survey.

Our objective was to quantify variability across the UK in the management of a complex abdominal aortic aneurysm (AAA). An online survey was emailed to all members of the Vascular Society for Great Britain and Ireland. The survey presented a vignette of a 63-year-old woman with significant respiratory co-morbidity whose computed tomographic (CT) angiogram demonstrated a 54 mm AAA with a short (7 mm) proximal neck but no other adverse morphological features for a standard or complex endovascular aneurysm repair (EVAR). The survey included images and questions related to AAA management as well as surgeon access to operating facilities. 111 responses were received. 47% of participants indicated a preference for continuing surveillance, 29% for fenestrated EVAR and 7% each for no operative intervention and open surgical repair. The remainder indicated various preferences including standard EVAR (3%), standard EVAR with endoanchors (3%), chimney EVAR (2%), EVAS (endovascular aneurysm sealing) (1%) and chimney EVAS (1%). Of the 47% who wanted to continue surveillance, once their threshold was reached, 73% would manage with a fenestrated EVAR, 17% with open repair and the remainder with standard EVAR with endoanchors (2%), EVAS (2%) or chimney EVAS (2%). 49% of participants carried out endovascular procedures in hybrid theatres, 36% in radiology angiosuites and 15% in standard operating theatres. The location had no significant effect on the consultant choice of treatment method. The study results support anecdotal variation in practice among vascular specialists. This reflects the lack of solid evidence on the optimal management of complex AAA.

Accuracy Evaluations of Three Ruptured Abdominal Aortic Aneurysm Mortality Risk Scores Using an Independent Data Set

Three recently developed scoring systems for predicting 30-day mortality in patients with ruptured abdominal aortic aneurysms (rAAA) have been validated by their respective institutional data. To date, no single score has been endorsed by any vascular society or proven to predict treatment futility. The purpose of this study was to evaluate the accuracy of these rAAA mortality risk scores using an independent community hospital data set. This study was a retrospective validation of the Dutch Aneurysm Score (DAS), Harborview Medical Group (HMG) score, and Vascular Surgery Group of New England (VSGNE) score using independent data from a prospectively maintained community hospital database. Logistic regression was used to evaluate the association between risk score and odds of death. Confidence intervals for mortality rates were calculated using the Wilson method. Comparisons were made between models by calculating the area under the receiver operating characteristic (AUC) curves. Forty-six patients presented with rAAA during the study period (January 1, 2009-February 28, 2017). The AUCs for the DAS, HMG, and VSGNE scores were 0.762, 0.792, and 0.860, respectively. The difference between the scores did not reach statistical significance. All three scores were statistically significantly associated with mortality rate prediction in logistics regression analysis. Each risk score accurately predicted 30-day mortality using the independent data set. The results suggest that the VSGNE score is the most accurate; however, this did not reach statistical significance. The HMG score demonstrated accuracy and was based only on preoperative variables. Although the VSGNE score had the highest AUC on this analysis, it is dependent on intraoperative variables. We favor the development of a single risk assessment tool, with consensus vascular societal approval, which incorporates preoperative variables and includes a tool for the prediction of treatment futility.

Factors influencing the choice of treatment modality for individual patients with varicose veins.

INTRODUCTION There is evidence of effectiveness for a range of different treatment modalities for varicose veins but limited information about factors that influence treatment choice for individual patients. METHODS A postal survey was sent to 438 UK members of the Vascular Society of Great Britain and Ireland. RESULTS Overall, 251 responses were received (response rate 57%). A total of 222 respondents treated varicose veins using conventional surgery (84%), endothermal ablation (82%) and foam sclerotherapy (68%). The clinical pattern of veins appeared to have the greatest influence on treatment choice. This was followed by guidance from the National Institute for Health and Care Excellence, patient expectations, facilities, cost and whether treatment was carried out in the public or private sector. Respondents were asked to indicate whether each of 13 clinical 'scenarios' (eg very extensive varicose veins in both legs) would influence them towards or against using specified treatment modalities. 'Consensus' was defined as ≥80% of responses either towards or against any treatment modality; and disagreement as 41-59% both towards and against any modality (i.e. ∼50:50 split). There was consensus towards using endothermal ablation for truncal reflux, towards UGFS for localised varicose veins and towards conventional surgery for large, extensive, bilateral veins. There was consensus against UGFS for large truncal veins, and against surgery for obese patients and those with a history of venous thromboembolism. There were important disagreements about the influence of large or extensive veins, about whether patients were obese or slim and about a prior history of venous thromboembolism. CONCLUSIONS Conventional surgery is still widely available in the UK. Disagreements about treatment choice in different clinical scenarios suggest substantial variation in the treatments patients are offered. Attention to identifying subgroups in trials would help to guide treatment choice for individual patients.