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In 2001, Collin and Murie[1] challenged the concept of endovascular repair (EVAR) for abdominal aortic aneurysm (AAA) in an editorial that remains controversial even now. EVAR offers minimally invasive treatment which can be done under local or regional anaesthesia, reducing postoperative pain, hospital stay and 30-day mortality compared with conventional open aortic aneurysm repair (OAR)[4]. In patients unfit for OAR (the EVAR 2 cohort), EVAR is pretty well tolerated and can minimize the risk of death from subsequent AAA rupture. Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. [Extracted from the article]

This article discusses a study that examined the prevalence of tobacco smoking among patients undergoing elective vascular surgery in the UK. The study found that 25.4% of patients were actively smoking at the time of surgery, while 57.6% were former smokers and 17.0% had never smoked. The highest smoking rates were observed in patients undergoing lower limb bypass, carotid surgery, and abdominal aortic aneurysm repair. The study also identified demographic and clinical factors associated with smoking, such as age, sex, and geographical region. The findings suggest the need for targeted smoking cessation interventions and improvements in quality care for this patient population. [Extracted from the article]

Real and present danger [ABSTRACT FROM AUTHOR]

Compulsory registration needed [ABSTRACT FROM AUTHOR]

Background Single-centre series of the management of patients with ruptured abdominal aortic aneurysm ( AAA) are usually too small to identify clinical factors that could improve patient outcomes. Methods IMPROVE is a pragmatic, multicentre randomized clinical trial in which eligible patients with a clinical diagnosis of ruptured aneurysm were allocated to a strategy of endovascular aneurysm repair ( EVAR) or to open repair. The influences of time and manner of hospital presentation, fluid volume status, type of anaesthesia, type of endovascular repair and time to aneurysm repair on 30-day mortality were investigated according to a prespecified plan, for the subgroup of patients with a proven diagnosis of ruptured or symptomatic AAA. Adjustment was made for potential confounding factors. Results Some 558 of 613 randomized patients had a symptomatic or ruptured aneurysm: diagnostic accuracy was 91·0 per cent. Patients randomized outside routine working hours had higher operative mortality (adjusted odds ratio ( OR) 1·47, 95 per cent confidence interval 1·00 to 2·17). Mortality rates after primary and secondary presentation were similar. Lowest systolic blood pressure was strongly and independently associated with 30-day mortality (51 per cent among those with pressure below 70 mmHg). Patients who received EVAR under local anaesthesia alone had greatly reduced 30-day mortality compared with those who had general anaesthesia (adjusted OR 0·27, 0·10 to 0·70). Conclusion These findings suggest that the outcome of ruptured AAA might be improved by wider use of local anaesthesia for EVAR and that a minimum blood pressure of 70 mmHg is too low a threshold for permissive hypotension. [ABSTRACT FROM AUTHOR]

Objectives: Foam sclerotherapy of the great saphenous vein is a relatively new and promising treatment option for patients with axial reflux. Its usefulness may be limited by low primary occlusion rates. We present a standard technique for catheter-directed foam sclerotherapy, which facilitates foam delivery precisely to its intended site of action and potentially improves occlusion rates. Methods: A consecutive series of 53 patients were treated with foam sclerotherapy using a standard technique for foam delivery at Malmö University Hospital between September 2006 and April 2007. Patients were treated with 3% polidocanol foam through an introducer sheath, which was inserted percutaneously over a guidewire in the great saphenous vein (GSV). All successfully treated patients were examined by colour duplex one week after the procedure. Results: Primary technical success with delivery of foam along the length of the GSV was achieved in 50 of 53 limbs (94%). All treated GSVs were occluded at one week duplex. Conclusion: The use of an endovascular sheath inserted percutaneously over a guidewire under duplex ultrasound control is feasible in most patients and has resulted in high primary occlusion rates. [ABSTRACT FROM AUTHOR]

Overused? [ABSTRACT FROM AUTHOR]

The article discusses amputations in patients with diabetes. The author notes the increased incidence in the number of patients with type II diabetes worldwide, adding that amputation rates in type II diabetics has also increased. Topics include the identification of patients at high risk for foot ulceration, data supporting the benefits of multidisciplinary care of patients with ulcerated feet in preventing amputation, and limb-saving revascularization procedures.

Summary: Randomised controlled trials are the gold standard in clinical research, but remain rare due to their expense and a perceived lack of 'real‐world' applicability. At the same time, there has been an exponential increase in routinely collected data which presents opportunities for audit, quality improvement, adverse event reporting and more efficient clinical research. Registry‐based research benefits from reduced cost, large sample size and real‐world applicability, with methodological developments, particularly registry‐based randomised controlled trials and causal inference techniques, showing promise. Limitations include data quality and validity, the need for data linkage, the restrictions of fixed data fields, regulatory barriers, and privacy and security concerns. However, the principal factor hampering current efforts is a lack of anaesthesia‐specific datasets in the UK and the fact that most surgical registries do not collect any anaesthetic data. This presents an opportunity for anaesthetists, through enhanced engagement and collaboration, to influence and improve the design of these datasets and increase the value and volume of data collected. Better datasets, coupled with a growing appreciation of new analysis methodologies, would allow significant progress towards realising the potential of routinely collected data for patient benefit. At the same time, work should begin on the development of a minimum dataset for anaesthesia to underpin new data sharing networks and, ideally, a national registry of anaesthesia. [ABSTRACT FROM AUTHOR]

Approximately half of all patients with a diabetic foot ulcer have co-existing peripheral arterial disease. Identifying peripheral arterial disease among patients with foot ulceration is important, given its association with failure to heal, amputation, cardiovascular events and increased risk of premature mortality. Infection, oedema and neuropathy, often present with ulceration, may adversely affect the performance of diagnostic tests that are reliable in patients without diabetes. Early recognition and expert assessment of peripheral arterial disease allows measures to be taken to reduce the risk of amputation and cardiovascular events, while determining the need for revascularization to promote ulcer healing. When peripheral arterial disease is diagnosed, the extent of perfusion deficit should be measured. Patients with a severe perfusion deficit, likely to affect ulcer healing, will require further imaging to define the anatomy of disease and indicate whether a revascularization procedure is appropriate. [ABSTRACT FROM AUTHOR]

Diabetes is a complex disease with many serious potential sequelae, including large vessel arterial disease and microvascular dysfunction. Peripheral arterial disease is a common large vessel complication of diabetes, implicated in the development of tissue loss in up to half of patients with diabetic foot ulceration. In addition to peripheral arterial disease, functional changes in the microcirculation also contribute to the development of a diabetic foot ulcer, along with other factors such as infection, oedema and abnormal biomechanical loading. Peripheral arterial disease typically affects the distal vessels, resulting in multi-level occlusions and diffuse disease, which often necessitates challenging distal revascularisation surgery or angioplasty in order to improve blood flow. However, technically successful revascularisation does not always result in wound healing. The confounding effects of microvascular dysfunction must be recognised - treatment of a patient with a diabetic foot ulcer and peripheral arterial disease should address this complex interplay of pathophysiological changes. In the case of non-revascularisable peripheral arterial disease or poor response to conventional treatment, alternative approaches such as cell-based treatment, hyperbaric oxygen therapy and the use of vasodilators may appear attractive, however more robust evidence is required to justify these novel approaches. [ABSTRACT FROM AUTHOR]

Background: The UK Multicentre Aneurysm Screening Study (MASS) demonstrated reduced mortality from screening for abdominal aortic aneurysm (AAA). As a result, the National Health Service AAA Screening Programme was introduced in England. This study reports the results from an early-implementation screening centre. Methods: Men aged 65 years were invited to attend an ultrasound assessment. Data were analysed for 15 months from the onset of the screening programme. Results: A total of 6091 men aged 65 years were invited between April 2009 and June 2010, of whom 2037 (33·4 per cent) failed to attend. There were 162 self-referrals (median age 71·3 years) so that 4216 men were screened. Of those scanned, 4146 (98·3 per cent) had an aortic diameter of less than 3·0 cm, 65 (1·5 per cent) had an aneurysm measuring 3·0-5·4 cm, and five (0·1 per cent) had an aneurysm with a diameter of 5·5 cm and above. The presence of an aneurysm was more common in those who self-referred than in the invited group ( P < 0·001). All 70 screen-detected aneurysms were found in white men. Conclusion: The prevalence of AAA was lower than expected. This reflects the younger age of this cohort compared with those in published large multicentre studies and the diverse ethnic background of the local population. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: The aim was to analyse contemporary data on the number of surgical revascularization procedures performed each year in England, and their outcome. Methods: Hospital Episode Statistics and Office for National Statistics data were used to quantify numbers and identify factors associated with outcome after all femoropopliteal and femorodistal bypass procedures performed between 2002 and 2006. Outcome measures were repeat bypass, major amputation, death and a composite measure. Single-level multivariable logistic regression modelling was used to quantify the effect of these variables on outcome. Results: A total of 21 675 femoropopliteal and 3458 femorodistal bypass procedures were performed. Mean in-hospital mortality rates were 6·7 and 8·0 per cent respectively. One-year survival rates were 82·8 and 79·1 per cent; both increased over the study interval. The mean 1-year major amputation rate after femoropopliteal bypass was 10·4 per cent, which decreased significantly over the 5 years ( P < 0·001); after distal bypass the rate of 20·8 per cent remained unchanged ( P = 0·456). Diabetes mellitus and chronic kidney disease were significant predictors of adverse outcome for both procedures: odds ratio (OR) at 1 year 1·56 (95 per cent confidence interval 1·46 to 1·67; P < 0·001) and 2·15 (1·88 to 2·45; P < 0·001) respectively for femoropopliteal bypass. Previous femoral angioplasty was associated with an increased rate of major amputation 1 year after proximal bypass (OR 1·18, 1·05 to 1·33; P = 0·004). Conclusion: Although all mortality rates are improving, the major amputation rate remains high after femorodistal bypass. Adverse events occurred after 37·6 per cent of femoropopliteal and 49·7 per cent of femorodistal bypasses; diabetes and chronic renal failure were the main predictors of poor outcome. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Diabet. Med. 28, 1144-1153 (2011) Abstract Aim To quantify global variation in the incidence of lower extremity amputations in light of the rising prevalence of diabetes mellitus. Methods An electronic search was performed using the EMBASE and MEDLINE databases from 1989 until 2010 for incidence of lower extremity amputation. The literature review conformed to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Results Incidence of all forms of lower extremity amputation ranges from 46.1 to 9600 per 105 in the population with diabetes compared with 5.8-31 per 105 in the total population. Major amputation ranges from 5.6 to 600 per 105 in the population with diabetes and from 3.6 to 68.4 per 105 in the total population. Significant reductions in incidence of lower extremity amputation have been shown in specific at-risk populations after the introduction of specialist diabetic foot clinics. Conclusion Significant global variation exists in the incidence of lower extremity amputation. Ethnicity and social deprivation play a significant role but it is the role of diabetes and its complications that is most profound. Lower extremity amputation reporting methods demonstrate significant variation with no single standard upon which to benchmark care. Effective standardized reporting methods of major, minor and at-risk populations are needed in order to quantify and monitor the growing multidisciplinary team effect on lower extremity amputation rates globally. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate the training experience of current UK vascular trainees in the modern management of venous disease. Method: A web-based questionnaire of the 145 members of the Rouleaux Club (www.rouleauxclub.com), which represents UK vascular trainees. Members were asked to complete the survey between June and October 2009 with regular email reminders being sent out to non-responders. Results: One hundred and twenty-three trainees (85% response rate) representing all 17 UK training Deaneries responded. Seventy-eight per cent reported having received no formal venous duplex training either for diagnosis of venous disease or to guide endovenous therapy. Operative experience of great and small saphenous vein surgery improved with years of training. Surgical experience for recurrent varicose veins was poor. Experience with endovenous techniques was limited and variable. No experience of endovenous laser ablation or radiofrequency ablation was reported by 39% and 67% of trainees, respectively. Experience and/or training with foam sclerotherapy was limited to < 40%. Many of those reporting no experience with endovenous ablation techniques were within the final two years of their training. Less than 25% of trainees reported having had any experience (assisted/performed) of advanced venous interventions such as thrombolysis techniques for deep venous thrombosis, inferior vena cava filter placement/removal, venous stenting or deep venous reconstruction. Less than a quarter of trainees are currently involved in the acute management of deep venous thrombosis. The majority (76%) of current trainees would like a formal approved UK venous training course to be offered. Conclusion: The current level of training in the management of venous disease will not allow UK vascular trainees to become the competent all round vascular specialists of the future. [ABSTRACT FROM AUTHOR]

The article focuses on a study that investigated the prevalence of lower extremity amputation in England between 2003 and 2008 using data extracted from the Hospital Episode Statistics database. The study found that the amputation rate remained stable and that the mortality rate decreased over time. It also found that differences in amputation rate, mortality rate, and above- and below-knee amputation rates in different areas. Patients with diabetes and revascularization rates are noted.

The article discusses a study which examined the relationship between case volume and lower limb vascular surgery outcomes. The meta-analyses included 452,093 patients from 10 studies. It discovered positive relationship between hospital volume and outcome. Study authors concluded that higher-volume hospitals have reduced amputation and mortality rates following lower limb vascular surgery.

The article presents a study which examines the extent reintervention after endovascular aortic aneurysm repair (AVAR) and the risk of patients needing reintervention. The study examined all patients who undergo infrarenal EVAR and utilized Kaplan-Meier survival curves to measure the freedom from reintervention. Results indicate that reintervention was higher in those who needed an intraoperative adjunct and in patients who did not had an intraoperative computed tomography angiography.

Aortic dissection represents the most common aortic emergency, affecting 3 to 4 per 100 000 people per year and is still associated with a high mortality. Twenty percent of the patients with aortic dissection die before reaching hospital and 30% die during hospital admission. Aortic dissections may be classified in 3 ways: according to their anatomical extent (the Stanford or DeBakey systems), according to the time from onset (acute or chronic), and according to the underlying pathology (the European Society of Cardiologists' system). Advances in endovascular technology have provided new treatment options. Hybrid endovascular and conventional open surgical repair represent the mainstay of treatment for acute type A dissection. Medical management remains the gold standard for acute and uncomplicated chronic type B dissection, though endovascular surgery offers exciting potential in the management of complicated type B dissection through sealing of the intimal entry tear. [ABSTRACT FROM AUTHOR]

The article offers information on the development of medical model for elective abdominal aortic aneurysm (AAA) repair and carotid endarterectomy (CEA) services. A study was conducted to develop a specialized vascular services that could provide patient survival. A strategic model may lead to improved outcome after AAA and CEA.

Summary: Interventions from randomised controlled trials can only be replicated if they are reported in sufficient detail. The results of trials can only be confidently interpreted if the delivery of the intervention was systematic and the protocol adhered to. We systematically reviewed trials of anaesthetic interventions published in 12 journals from January 2016 to September 2019. We assessed the detail with which interventions were reported, using the Consolidated Standards of Reporting Trials statement for non‐pharmacological treatments. We analysed 162 interventions reported by 78 trials in 18,675 participants. Detail sufficiently precise to replicate the intervention was reported for 111 (69%) interventions. Intervention standardisation was reported for 135 (83%) out of the 162 interventions, and protocol adherence was reported for 20 (12%) interventions. Sixty (77%) out of the 78 trials reported the administrative context in which interventions were delivered and 36 (46%) trials detailed the expertise of the practitioners. We conclude that bespoke reporting tools should be developed for anaesthetic interventions and interventions in other areas such as critical care. [ABSTRACT FROM AUTHOR]

We conducted a survey and semi-structured qualitative interviews to investigate current anaesthetic practice for arteriovenous fistula formation surgery in the UK. Responses were received from 39 out of 59 vascular centres where arteriovenous access surgery is performed, a response rate of 66%. Thirty-five centres reported routine use of brachial plexus blocks, but variation in anaesthetic skill-mix and practice were observed. Interviews were conducted with 19 clinicians from 10 NHS Trusts including anaesthetists, vascular access and renal nurses, surgeons and nephrologists. Thematic analysis identified five key findings: (1) current anaesthetic practice showed that centres could be classified as 'regional anaesthesia dominant' or 'local anaesthesia/mixed'; (2) decision making around mode of anaesthesia highlighted the key role of surgeons as frontline decision makers across both centre types; (3) perceived barriers and facilitators of regional block use included clinicians' beliefs and preferences, resource considerations and patients' treatment preferences; (4) anaesthetists' preference for supraclavicular blocks emerged, alongside acknowledgement of varied practice; (5) there was widespread support for a future randomised controlled trial, although clinician equipoise issues and logistical/resource-related concerns were viewed as potential challenges. The use of regional anaesthesia for arteriovenous fistula formation in the UK is varied and influenced by a multitude of factors. Despite the availability of anaesthetists capable of performing regional blocks, there are other limiting factors that influence the routine use of this technique. The study also highlighted the perceived need for a large multicentre, randomised controlled trial to provide an evidence base to inform current practice. [ABSTRACT FROM AUTHOR]

Background: Emergency surgery encompasses more than 50 per cent of the surgical workload; however, research efforts are disproportionally low. The mode of anaesthesia used during emergency surgery may affect outcomes, but the extent of research and the impact of the different modes of anaesthesia used are unclear. Methods: MEDLINE and Embase were searched using scoping review methodology with a rapid systematic search strategy, identifying any study comparing locoregional (local, nerve block, subarachnoid, epidural) anaesthesia with general anaesthesia. All studies describing outcomes of emergency surgery with differing modes of anaesthesia were identified. Excluded were: studies published before 2003, studies enrolling patients aged less than 18 years and studies using sedation only. Results: Forty‐two studies were identified, describing 11 surgical procedures. Most publications were retrospective cohort studies (32). A very broad range of clinical and patient‐reported outcomes were described, with wide variation in the outcomes reported in different studies. Conclusion: Reporting of mode of anaesthesia is inconsistent across different procedures and is often absent. There is a need for directed research efforts to improve the reporting standards of anaesthesia interventions, to understand the role of different modes of anaesthesia in specific emergency surgical procedures, and to standardize outcome reporting using core outcome sets. [ABSTRACT FROM AUTHOR]

Background: Although delivering a chosen mode of anaesthesia for certain emergency surgery procedures is potentially beneficial to patients, it is a complex intervention to evaluate. This qualitative study explored clinician and patient perspectives about mode of anaesthesia for emergency surgery. Methods: Snowball sampling was used to recruit participants from eight National Health Service Trusts that cover the following three emergency surgery settings: ruptured abdominal aortic aneurysms, hip fractures and inguinal hernias. A qualitative researcher conducted interviews with clinicians and patients. Thematic analysis was applied to the interview transcripts. Results: Interviews were conducted with 21 anaesthetists, 21 surgeons, 14 operating theatre staff and 23 patients. There were two main themes. The first, impact of mode of anaesthesia in emergency surgery, had four subthemes assessing clinician and patient ideas about: context and the 'best' mode of anaesthesia; balance in choosing it over others; change and developments in anaesthesia; and the importance of mode of anaesthesia in emergency surgery. The second, tensions in decision‐making about mode of anaesthesia, comprised four subthemes: clinical autonomy and guidelines in anaesthesia; conforming to norms in mode of anaesthesia; the relationship between expertise, preference and patient involvement; and team dynamics in emergency surgery. The results highlight several interlinking factors affecting decision‐making, including expertise, preference, habit, practicalities, norms and policies. Conclusion: There is variation in practice in choosing the mode of anaesthesia for surgery, alongside debate as to whether anaesthetic autonomy is necessary or results in a lack of willingness to change. [ABSTRACT FROM AUTHOR]

Background: The literature on antiplatelet therapy for peripheral artery disease has historically been summarized inconsistently, leading to conflict between international guidelines. An umbrella review and meta‐analysis was performed to summarize the literature, allow assessment of competing safety risks and clinical benefits, and identify weak areas for future research. Methods: MEDLINE, Embase, DARE, PROSPERO and Cochrane databases were searched from inception until January 2019. All meta‐analyses of antiplatelet therapy in peripheral artery disease were included. Quality was assessed using AMSTAR scores, and GRADE analysis was used to quantify the strength of evidence. Data were pooled using random‐effects models. Results: Twenty‐eight meta‐analyses were included. Thirty‐three clinical outcomes and 41 antiplatelet comparisons in 72 181 patients were analysed. High‐quality evidence showed that antiplatelet monotherapy reduced non‐fatal strokes (3 (95 per cent c.i. 0 to 6) fewer per 1000 patients), In symptomatic patients, it reduced cardiovascular deaths (8 (0 to 16) fewer per 1000 patients), but increased the risk of major bleeding (7 (3 to 14) more events per 1000). In asymptomatic patients, monotherapy reduced non‐fatal strokes (5 (0 to 8) fewer per 1000), but had no other clinical benefit. Dual antiplatelet therapy caused more major bleeding after intervention than monotherapy (37 (8 to 102) more events per 1000), with very low‐quality evidence of improved endovascular patency (risk ratio 4·00, 95 per cent c.i. 0·91 to 17·68). Conclusion: Antiplatelet monotherapy has minimal clinical benefit for asymptomatic peripheral artery disease, and limited benefit for symptomatic disease, with a clear risk of major bleeding. There is a lack of evidence to guide antiplatelet prescribing after peripheral endovascular intervention. [ABSTRACT FROM AUTHOR]

Background: Case series and a post hoc subgroup analysis of a large randomized trial have suggested a potential benefit in treating ruptured abdominal aortic aneurysms (rAAAs) using endovascular aneurysm repair (EVAR) with local anaesthesia (LA) rather than general anaesthesia (GA). The uptake and outcomes of LA in clinical practice remain unknown. Methods: The UK National Vascular Registry was interrogated for patients presenting with rAAA managed with EVAR under different modes of anaesthesia between 1 January 2014 and 31 December 2016. The primary outcome was in‐hospital mortality. Secondary outcomes included: the number of centres performing EVAR under LA; the proportion of patients receiving this technique; duration of hospital stay; and postoperative complications. Results: Some 3101 patients with rAAA were treated in 72 hospitals during the study: 2306 underwent on open procedure and 795 had EVAR (LA, 319; GA, 435; regional anaesthesia, 41). Overall, 56 of 72 hospitals (78 per cent) offered LA for EVAR of rAAA. Baseline characteristics and morphology were similar across the three EVAR subgroups. Patients who had surgery under LA had a lower in‐hospital mortality rate than patients who received GA (59 of 319 (18·5 per cent) versus 122 of 435 (28·0 per cent)), and this was unchanged after adjustment for factors known to influence survival (adjusted hazard ratio 0·62, 95 per cent c.i. 0·45 to 0·85; P = 0·003). Median hospital stay and postoperative morbidity from other complications were similar. Conclusion: The use of LA for EVAR of rAAA has been adopted widely in the UK. Mortality rates appear lower than in patients undergoing EVAR with GA. Improves 30‐day survival [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to develop a 48‐h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C‐statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48‐h mortality in the IMPROVE data was reasonable (C‐statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C‐statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life‐saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non‐intervention rates, while respecting the wishes of the patient and family. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Peripheral artery disease is common in people with diabetes‐related foot ulceration and is a risk factor for amputation. The best method for the detection or exclusion of peripheral artery disease is unknown. This study investigated the utility of clinical examination and non‐invasive bedside tests in screening for peripheral artery disease in diabetes‐related foot ulceration. Methods: Some 60 people presenting with new‐onset ulceration participated. Accuracy of pulses, ankle pressure, toe pressure, toe–brachial index (TBI), ankle–brachial pressure index (ABPI), pole test at ankle, transcutaneous oxygen pressure and distal tibial waveform on ultrasound were examined. The gold standard diagnostic test used was > 50% stenosis in any artery or monophasic flow distal to calcification in any ipsilateral vessel on duplex ultrasound. Results: The negative and positive likelihood ratios of pedal pulse assessment (0.75, 1.38) and the other clinical assessment tools were poor. The negative and positive likelihood ratios of ABPI (0.53, 1.69), transcutaneous oxygen pressure (1.10, 0.81) and ankle pressure (0.67, 2.25) were unsatisfactory. The lowest negative likelihood ratios were for tibial waveform assessment (0.15) and TBI (0.24). The highest positive likelihood ratios were for toe pressure (17.55) and pole test at the ankle (10.29) but the negative likelihood ratios were poor at 0.56 and 0.74. Conclusions: Pulse assessment and ABPI have limited utility in the detection of peripheral artery disease in people with diabetes foot ulceration. TBI and distal tibial waveforms are useful for selecting those needing diagnostic testing. [ABSTRACT FROM AUTHOR]

Background: Surveillance is mandatory for all patients with a thoracic aortic aneurysm (TAA). The frequency of surveillance imaging, however, is not evidence-based, as few data exist regardingTAA growth rates. This study aimed to determine the rate of TAA expansion and to inform surveillance intervals based on TAA diameter. Methods: Patients with a TAA for whom morphological data were available from serial CT scans were studied. Annualized growth rates based on diameter at presentation and time taken to reach a theoretical intervention threshold of 55mm were calculated. The number of patients who would have achieved the threshold undetected was determined based on simulated imaging intervals of 6months, 1, 2 and 3 years. Results: A total of 2916 scans from 995 patients were analysed. The mean aortic expansion rate was 2·76mm per year for all patients, with an exponential increase observed at sizes above 45mm. Only 3·9 per cent of patients with a starting diameter of 30-39mm and 5·3 per cent of those with a diameter of 40-44mm achieved threshold size within 2 years. Conversely, the probability of expansion to more than 55mm was 74·5 per cent in 2 years for patients with a starting diameter of 50-54mm, rising to 85·7 per cent at 3 years. Conclusion: Based on a threshold of 55mm for intervention, most patients with a maximum aortic diameter below 40mm could safely undergo surveillance at 2-yearly intervals. Above 45mm, annual surveillance is recommended. Patients with a diameter greater than 50mm could be optimized for possible repair, if this is clinically appropriate. [ABSTRACT FROM AUTHOR]

Background No condition-specific patient-reported outcome measures exist for patients with abdominal aortic aneurysm ( AAA). The aim of this work was to develop three questionnaires to assess quality of life ( QoL), symptoms and treatment satisfaction in patients with AAA. Methods Semistructured interview techniques were used to explore patients' experiences of having an AAA in a series of focus groups and in-depth interviews. The information gathered was used to inform design and selection of items for the new tools; the overall structure of the new questionnaires was based on tools developed previously for patients with diabetes and other conditions. Results Fifty-four patients (51 men, 3 women; mean age 71·9 years) were recruited from four NHS Trusts to participate in focus groups or interviews, either while under surveillance, or following AAA repair (using open or endovascular techniques). The Aneurysm-Dependent Quality of Life Questionnaire ( AneurysmDQoL) is an individualized measure of the impact of AAA on patients' QoL. Twenty-three domains were chosen specifically for their relevance to patients with AAA, with a further two overview items to assess overall QoL and the impact of AAA on QoL. The Aneurysm Symptom Rating Questionnaire ( AneurysmSRQ) is a 44-item measure assessing physical and psychological symptoms reported by patients with AAA. The Aneurysm Treatment Satisfaction Questionnaire ( AneurysmTSQ) contains 11 items, suitable for patients before and after surgical intervention. Conclusion The iterative development process reported here has confirmed that these three new tools have good face and content validity for patients with AAA. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to present preliminary data on quality of life ( QoL), symptoms and treatment satisfaction gathered using three new abdominal aortic aneurysm ( AAA)-specific patient-reported outcome measures ( PROMs). Methods Patients with AAA were recruited from five National Health Service Trusts to complete the three new PROMs: the AneurysmDQoL, AneurysmSRQ and AneurysmTSQ. Patients were either under surveillance or had undergone AAA repair (open or endovascular) during the preceding 24 months. Data were initially collected as part of a study assessing the psychometric properties of the new measures, before being used in the observational analysis of outcomes presented here. Results Results, although largely non-significant, showed interesting trends. The impact of AAA repair on QoL appeared to worsen progressively after open repair ( OR) and improve progressively after endovascular aneurysm repair ( EVAR). Conversely, symptoms seemed to become progressively worse after EVAR and progressively better after OR. Information and understanding were key sources of dissatisfaction before the intervention, whereas postoperative dissatisfaction was related to bother from symptoms, follow-up and feedback about scan results. Conclusion Although a larger, prospective data set is necessary to explore outcomes more fully with the new AAA-specific PROMs, the observational data presented here suggest there may be clinically important differences in the symptoms, impact on QoL and treatment satisfaction associated with OR and EVAR. [ABSTRACT FROM AUTHOR]

Aim To explore the use of hyperspectral imaging (HSI) to predict healing of diabetic foot ulcers in patients with diabetes. Methods We used a HSI technique that incorporated novel software to account for tissue scattering of light, and was validated using blood samples of varying oxygen saturation assessed by blood gas analysis. HSI was then performed on a population newly presenting with diabetic foot ulcers to a specialist clinic, and associations were sought with healing at 12 and 24 weeks. Results The correlation between the results of HSI and blood gas analysis was strong ( r = 0.994). A total of 43 patients (mean ± sd age 62.7 ± 12.2 years; 31 men, 12 women; 37 with Type 2 diabetes, six with Type 1 diabetes) with foot ulcers were included in the prospective clinical study and underwent HSI within 16 days of presentation. In all, 26 ulcers healed within 12 weeks and 28 within 24 weeks. There was a negative association between tissue oxygenation assessed by HSI at baseline and healing by 12 weeks ( P = 0.009), and this was observed in both infected and non-infected ulcers. There was a significant positive correlation between oxygenation assessed by HSI and time to healing ( P = 0.03). No correlations were observed at 24 weeks. Conclusions These findings suggest that HSI may predict healing in routine practice. The fact that the correlation between HSI and healing was negative could be explained by HSI being a measure of oxygenation of haemoglobin and there may be an inverse relationship between this and the oxygenation of extravascular tissue in people with neuropathy and/or microvascular disease. [ABSTRACT FROM AUTHOR]

Background Lifelong surveillance is considered mandatory after endovascular repair ( EVAR) of abdominal aortic aneurysms to detect endograft complications and prevent aneurysm rupture. Current protocols are not cost-effective or clinically effective. The international validity of the St George's Vascular Institute ( SGVI) score for EVAR complications was examined. Methods The ENGAGE registry recruited patients undergoing EVAR at 79 centres in 30 countries. Reinterventions and endograft complications were recorded for up to 3 years after surgery. Preoperative aneurysm morphology was extracted from the registry database, and used to predict whether patients would be at low or high risk of complications after EVAR based on the SGVI score. Kaplan-Meier analysis was used to compare the incidence of endograft complications and reinterventions in patients predicted to be at low risk compared with those predicted to be at high risk. Results Some 1207 patients underwent EVAR, with follow-up of up to 3 years. The SGVI score accurately discriminated freedom from reinterventions (90·5 versus 79·3 per cent in low- versus high-risk patients; P < 0·001), freedom from endograft complications (77·9 versus 69·6 per cent in low- versus high-risk patients; P = 0·012), and freedom from a composite outcome measure of reinterventions or endograft complications (75·0 versus 66·1 per cent in low- versus high-risk patients; P = 0·006) during mid-term follow-up. Conclusion This study has provided international validation of a morphological risk score that predicts mid-term reinterventions and endograft complications. The results may enable risk-stratified surveillance after EVAR. [ABSTRACT FROM AUTHOR]

Background There is significant variation in the mortality rates of patients with a ruptured abdominal aortic aneurysm ( rAAA) admitted to hospital in England. This study sought to investigate whether modifiable differences in hospital structures and processes were associated with differences in patient outcome. Methods Patients diagnosed with rAAA between 2005 and 2010 were extracted from the Hospital Episode Statistics database. After risk adjustment, hospitals were grouped into low-mortality outlier, expected mortality and high-mortality outlier categories. Hospital Trust-level structure and process variables were compared between categories, and tested for an association with risk-adjusted 90-day mortality and non-corrective treatment (palliation) rate using binary logistic regression models. Results There were 9877 patients admitted to 153 English NHS Trusts with an rAAA during the study. The overall combined (operative and non-operative) mortality rate was 67·5 per cent (palliation rate 41·6 per cent). Seven hospital Trusts (4·6 per cent) were high-mortality and 15 (9·8 per cent) were low-mortality outliers. Low-mortality outliers used significantly greater mean resources per bed (doctors: 0·922 versus 0·513, P < 0·001; consultant doctors: 0·316 versus 0·168, P < 0·001; nurses: 2·341 versus 1·770, P < 0·001; critical care beds: 0·045 versus 0·019, P < 0·001; operating theatres: 0·027 versus 0·019, P = 0·002) and performed more fluoroscopies (mean 12·6 versus 9·2 per bed; P = 0·046) than high-mortality outlier hospital Trusts. On multivariable analysis, greater numbers of consultants, nurses and fluoroscopies, teaching status, weekday admission and rAAA volume were independent predictors of lower mortality and, excluding rAAA volume, a lower rate of palliation. Conclusion The variability in rAAA outcome in English National Health Service hospital Trusts is associated with modifiable hospital resources. Such information should be used to inform any proposed quality improvement programme surrounding rAAA. [ABSTRACT FROM AUTHOR]

Background: Long-term concerns about the durability of endovascular aortic aneurysm repair (EVAR) remain after the publication of controlled trials. Increased expertise in endograft technology, case selection and postoperative reintervention has created a need for reappraisal of the longer-term efficacy of EVAR using contemporary data. Methods: Patients undergoing infrarenal EVAR between 2004 and 2010 were studied prospectively. Morphological compliance with manufacturers' instructions for use (IFU) was established using three-dimensional computed tomography. The primary outcome measures were all-cause and aneurysm-related mortality, postoperative rupture, reintervention and sac expansion. These adverse events were reported using Kaplan-Meier survival analysis, with comparison within, or outside IFU by the log rank test. Results: Some 478 patients of median age 76 years had a median aneurysm diameter of 62·9 mm. Median follow-up was 44 (range 11-94) months; 198 (41·4 per cent) were compliant with IFU. The 30-day mortality rate was 2·1 per cent (10 of 478 patients): nine (2·0 per cent) of 455 patients who had elective and one (4 per cent) of 23 patients who had non-elective surgery. Aneurysm-related mortality was 0·897 deaths per 100 person-years, and all-cause mortality was 8·558 deaths per 100 person-years, with significantly lower survival outside IFU ( P = 0·012). Two patients had a late rupture (0·138 per 100 person-years), of whom one died. There were 6·120 reinterventions per 100 person-years, with no difference for aneurysms treated outside IFU ( P = 0·136). Primary sac expansion occurred in 6·721 per 100 person-years and secondary sac expansion in 4·142 per 100 person-years. Conclusion: In this series EVAR had a lower aneurysm-related mortality rate than demonstrated in early controlled trials, and with lower sac expansion rates than reported from image repositories. Data from earlier studies should be applied to current practice with caution. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article discusses the symptoms, causes and diagnosis of peripheral arterial disease (PAD), an atherosclerotic process that causes stenosis and occlusion of non-cerebral and non-coronary arteries. The risk factors among these patients include age, sex and ethnicity, smoking, diabetes, hypertension and hyperlipidaemia, and chronic renal insufficiency. The differential diagnosis for PAD including non-vascular common conditions and vascular rare conditions is included. Intervention should be considered when conservative measures have failed and PAD is severely affecting a patient's lifestyle or becoming limb threatening. The treatment and management regime for PAD is highlighted. INSETS: TIPS FOR NON-SPECIALISTS;ONGOING RESEARCH AND FUTURE DIRECTIONS.

Background: Robust risk-adjusted analyses have demonstrated that a reduction in perioperative mortality is associated with the repair of an abdominal aortic aneurysm (AAA) in centres with a high operative caseload (volume). However, the long-term impact of this volume-related effect on mortality remains unknown. Methods: Demographic and clinical data were extracted from UK Hospital Episodes Statistics for patients undergoing elective repair of an infrarenal AAA from 1 April 2000 to 31 March 2005. The long-term mortality of this cohort was investigated through linkage to the UK Office for National Statistics (ONS) registry. Risk-adjusted survival was analysed using Cox proportional hazards modelling to identify the effect of hospital volume on long-term mortality. Results: A total of 14 396 patients with mean age of 72 years, of whom 85·7 per cent were men, underwent elective repair of an infrarenal AAA in England. They were linked to follow-up using ONS data. Risk-adjusted analysis of all-cause mortality by Cox proportional hazards modelling demonstrated a significant effect of hospital volume across all quintiles up to 2 years ( P = 0·013). Remodelling the data after excluding in-hospital mortality still demonstrated the significant effect of hospital volume on late outcome. Conclusion: There is a long-term benefit to patients who undergo elective AAA repair in a high-volume hospital. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Diabet. Med. 27, 544–549 (2010) Aims Foot ulcers are a common and important complication of diabetes. Variation in the clinical presentation of this disease has resulted in a paucity of evidence from comparable studies to guide optimal clinical management. A validated scoring system might help clinicians and researchers in everyday assessment and management of patients or the development and assessment of new therapies. The aim of the present review was to critically appraise the published literature of wound scoring systems for diabetic foot ulcers. Methods An electronic search was performed using the EMBASE and MEDLINE databases from 1966 until 2009 for scoring systems for diabetic foot ulcers. The literature review conformed to PRISMA statement standards. Results The literature search identified 197 articles, of which 180 were excluded. Eleven scoring systems and six validation or comparative studies are described. Conclusions Many scoring systems exist for classification of the diabetic foot, few of which have been validated. Detailed scoring systems offer a valuable method for the comparison of data from different diabetic foot centres. Simplistic scoring systems may be used in clinical practice and the choice of scoring system should be determined by the population under study. [ABSTRACT FROM AUTHOR]

The article presents a study on the result of ruptured abdominal aortic aneurysm (rAAA) in England, the function of endovascular repair (EVAR) and open repair, and the connection between the hospital workload and outcome. The study used co-morbidity and demographic data and propensity scored analysis to the Hospital Episode Statistics data of patients with AAA to quantify the outcome. Results showed that EVAR offers a survival benefit than open repair for non-elective aneurysm operations.