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Nickinson A, Birmpili P, Weale A, Chetter I, Boyle J, Loftus I, Davies R, Sayers RD. What is the current practice for managing patients with chronic limb-threatening ischaemia in vascular surgery services? A survey of UK vascular surgeons. Ann R Coll Surg Engl 2021; 103:694-700. [PMID: 34448653 DOI: 10.1308/rcsann.2021.0075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Ato Nickinson
- University of Leicester, UK.,University Hospitals of Leicester NHS Trust, UK
| | - P Birmpili
- Vascular Society of Great Britain and Ireland, UK
| | | | - I Chetter
- Vascular Society of Great Britain and Ireland, UK.,University of Hull, UK
| | - J Boyle
- Vascular Society of Great Britain and Ireland, UK.,Cambridge University Hospitals NHS Foundation Trust, UK
| | - I Loftus
- Vascular Society of Great Britain and Ireland, UK.,St George's University Hospitals NHS Foundation Trust Vascular Institute, UK
| | - Rsm Davies
- University of Leicester, UK.,University Hospitals of Leicester NHS Trust, UK
| | - R D Sayers
- University of Leicester, UK.,University Hospitals of Leicester NHS Trust, UK.,Royal College of Surgeons of England, UK
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE. J Vasc Surg 2021; 75:4S-22S. [PMID: 34153348 DOI: 10.1016/j.jvs.2021.04.073] [Citation(s) in RCA: 209] [Impact Index Per Article: 69.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.
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Matyushkin AV, Mustafin AK. [Results of carotid endarterectomy in patients after previous stroke]. Khirurgiia (Mosk) 2021:50-56. [PMID: 33710826 DOI: 10.17116/hirurgia202103150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the most optimal period of surgical treatment after previous stroke. MATERIAL AND METHODS There were 186 patients with significant ICA stenosis and previous unilateral stroke for the period 2008-2014 at the Pletnev Hospital (Moscow). Surgical approach was used in 136 (73.1%) patients (group I), conservative treatment at the neurological department - in 50 (26.9%) patients (group II). We analyzed neurological and cognitive status in both groups, regression of symptoms depending on the period after stroke, early and long-term postoperative outcomes. RESULTS In early postoperative period, 7 (5.1%) cerebral ischemic events (transient ischemic attack (TIA) and stroke) occurred in the 1st group. No correlation of neurological complications and type of intervention was revealed. In long-term period, stroke occurred in 3.6% in the first group and in 14% in the second group over the same period. Surgical treatment was followed by more complete recovery of neurological functions (NIHSS score 6.2±0.5 versus 7.0±0.8; modified Rankin score 1.5±0.2 versus 2.1±0.5, p<0.05) and cognitive mechanisms (MoCA score 22.04±1.48 versus 20.04±1.48, p<0.05). CONCLUSION Carotid endarterectomy and carotid artery stenting are effective for prevention of recurrent stroke. Carotid artery repair accelerates recovery of cognitive functions and regression of neurological symptoms in these patients.
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Affiliation(s)
- A V Matyushkin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A Kh Mustafin
- Pirogov Russian National Research Medical University, Moscow, Russia
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Matzek LJ, Smith BB, Mauermann WJ, Bower TC, Smith MM. Same-Day Cancellation in Vascular Surgery: 10-Year Review at a Large Tertiary Care Center. Ann Vasc Surg 2020; 62:349-355. [DOI: 10.1016/j.avsg.2019.06.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 10/26/2022]
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 803] [Impact Index Per Article: 133.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Naylor AR, Vega de Ceniga M. Something Old, Something New, Something Borrowed, and Something Blue. Eur J Vasc Endovasc Surg 2017; 54:413-414. [PMID: 28888385 DOI: 10.1016/j.ejvs.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 11/17/2022]
Affiliation(s)
- A R Naylor
- Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
| | - M Vega de Ceniga
- Department of Vascular Surgery Hospital de Galdakao-Usansolo, Galdakao, Bizkaia, Spain
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Kjørstad KE, Baksaas ST, Bundgaard D, Halbakken E, Hasselgård T, Jonung T, Jørgensen GT, Jørgensen JJ, Krog AH, Krohg-Sørensen K, Laxdal E, Mathisen SR, Oskarsson GV, Seljeskog S, Settemsdal I, Vetrhus M, Viddal BA, Wesche J, Aasgaard F, Mattsson E. Editor's Choice - The National Norwegian Carotid Study: Time from Symptom Onset to Surgery is too Long, Resulting in Additional Neurological Events. Eur J Vasc Endovasc Surg 2017; 54:415-422. [PMID: 28844552 DOI: 10.1016/j.ejvs.2017.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 07/19/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE/BACKGROUND The objective was to observe for 1 year all patients in Norway operated on for symptomatic carotid stenosis with respect to (i) the time from the index event to surgery and neurological events during this time; (ii) the level in the healthcare system causing delay of surgical treatment; and (iii) the possible relationship between peri-operative use of platelet inhibitors and neurological events while awaiting surgery. METHODS This was a prospective national multicentre study of a consecutive series of symptomatic patients. Patients were eligible for inclusion when referred for surgery. An index event was defined as the neurological event prompting contact with the healthcare system. All 15 departments in Norway performing carotid endarterectomy (CEA) participated. RESULTS Three hundred and seventy one patients were eligible for inclusion between 1 April 2014 and 31 March 2015, and 368 patients (99.2%) were included. Fifty-four percent of the patients contacted their general practitioner on the day of the index event. Primary healthcare referred 84.2% of the patients to hospital on the same day as examined. In hospital median time from admission to referral for vascular surgery was 3 days. Median time between referral to the operating unit and actual CEA was 5 days. Overall, 61.7% of the patients were operated on within 2 weeks of the index event. Twelve patients (3.3%) suffered a new neurological event while awaiting surgery. The percentage of patients on dual antiplatelet therapy was lower (25.0%) in this group than among the other patients (62.6%) (p = .008). The combined 30 day mortality and stroke rate was 3.8%. CONCLUSION This national study with almost complete inclusion and follow-up shows that the delays occur mainly at patient level and in hospital. The delay is associated with new neurological events. Dual antiplatelet therapy is associated with reduced risk of having a new neurological event before surgery.
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Affiliation(s)
- K E Kjørstad
- University Hospital of North Norway, Tromsø, Norway.
| | | | | | | | | | - T Jonung
- Haukeland University Hospital, University of Bergen, Bergen, Norway
| | | | - J J Jørgensen
- Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway
| | - A H Krog
- Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway
| | - K Krohg-Sørensen
- Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway
| | - E Laxdal
- Haukeland University Hospital, University of Bergen, Bergen, Norway
| | | | | | - S Seljeskog
- Akershus University Hospital, Lørenskog, Norway
| | | | - M Vetrhus
- Stavanger University Hospital, Stavanger, Norway
| | - B A Viddal
- Stavanger University Hospital, Stavanger, Norway
| | - J Wesche
- University of Oslo, Oslo, Norway; Akershus University Hospital, Lørenskog, Norway
| | - F Aasgaard
- St. Olav's University Hospital, Trondheim, Norway
| | - E Mattsson
- St. Olav's University Hospital, Trondheim, Norway; Norwegian University of Science and Technology, Trondheim, Norway
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Abstract
Background: For optimal stroke prevention, best practices guidelines recommend carotid endarterectomy (CEA) for symptomatic patients within two weeks; however, 2013 Ontario data indicated that only 9% of eligible patients from outpatient Stroke Prevention Clinics (SPCs) achieved this target. The goal of our study was to identify modifiable system factors that could enhance the quality and timeliness of care among patients needing urgent CEA. Methods: We conducted a retrospective chart review of transient ischemic attack/stroke patients assessed in Champlain Local Health Integrated Network SPCs between 2011 and 2014 who subsequently underwent CEA. Descriptive statistics were used to define patient characteristics, timelines from symptom onset to CEA, and system factors that contributed to delays or improvements in care. Multivariate analysis was used to determine statistically significant variations between groups. Results: Seventy-five records were eligible for study inclusion. Median time from initial symptoms to CEA was 31 days, with 21.3% of patients undergoing surgery within 2 weeks. Significant delays were common in patient presentation and assessment following symptom onset, wait times for vascular imaging and neurological assessment, and time from surgical assessment to CEA completion. Rapid testing and triage, coupled with collaborative initiatives among SPC, surgical, and radiology teams were associated with significantly improved timelines. Conclusions: Success factors for rapid CEA are multifaceted, including system changes that address public awareness of stroke and 911 response, improvements in vascular imaging access, and redesign of clinical services to promote collaboration and fast-tracking of care. Implementation of performance measures to monitor and guide clinical innovations is recommended.
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Shahidi S, Owen-Falkenberg A, Gottschalksen B, Ellemann K. Risk of early recurrent stroke in symptomatic carotid stenosis after best medical therapy and before endarterectomy. Int J Stroke 2016; 11:41-51. [PMID: 26763019 DOI: 10.1177/1747493015609777] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The early recurrence of neurological symptoms (NR) after urgent aggressive best medical therapy (BMT) in symptomatic carotid stenosis is not well documented. AIMS To investigate the risk of ipsilateral NR after urgent aggressive BMT in patients with symptomatic (50-99%) carotid stenosis up to carotid endarterectomy (CEA), with emphasis on the first 14 days after index-event. METHODS Prospective population based study, covering a period of 4½ years. NR rate was determined after initiation of urgent aggressive BMT and until CEA and compared to NR up to 90 days prior to index-event. Urgent BMT consisted of loading dose aspirin and clopidogrel thereafter therapy with aspirin and clopidogrel together with a statin. RESULTS Of 8200 symptomatic patients (ischemic stroke, transient ischemic attack and ocular events), 250 (3%) patients underwent CEA, 47% within 14 days of the index-event and 99% within 14 days of surgical referral. The overall NR from index-event to CEA in symptomatic patients was significantly lower 1.6% (95% CI 0.5-4%) after BMT when compared with NR in the 90 days prior to referral to a stroke clinic 25% (95% CI 20-30%, p < 0.00001). Peri-operative bleeding 5% (95% CI 3-8%) was comparable with other studies. CONCLUSION Urgent aggressive BMT after index-event is associated with a significant reduction in the risk of early NR in CEA candidates. The early risk of recurrent stroke in patients with symptomatic significant carotid stenosis is dramatically reduced after urgent aggressive BMT in specialised stroke clinics.
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Affiliation(s)
- S Shahidi
- Department of Vascular Surgery, Regional Hospital Slagelse, Region Zealand, Denmark
| | - A Owen-Falkenberg
- Department of Vascular Surgery & Anesthesiology, Regional Hospital Slagelse, Region Zealand, Denmark
| | - B Gottschalksen
- Department of Vascular Surgery, Regional Hospital Slagelse, Region Zealand, Denmark
| | - K Ellemann
- Department of Neurology, University Hospital Roskilde, Region Zealand, Denmark
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Editor's Choice – Delays to Surgery and Procedural Risks Following Carotid Endarterectomy in the UK National Vascular Registry. Eur J Vasc Endovasc Surg 2016; 52:438-443. [DOI: 10.1016/j.ejvs.2016.05.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 05/29/2016] [Indexed: 11/20/2022]
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Abstract
The '6-month' threshold for treating symptomatic patients is obsolete. There is compelling evidence that the highest-risk period for stroke (after suffering a transient ischemic attack) is the first 2 weeks, especially the first few days, and that carotid endarterectomy (CEA) confers maximal benefit when performed early. Despite well-documented anxieties, there is increasing evidence that CEA can be performed safely within the first 7 days after onset of symptoms, although risks may be higher when performed within 48 h. The role for carotid artery stenting in the hyperacute period remains uncertain. Centers performing carotid artery stenting within 14 days of symptom onset with risks equivalent to CEA should be encouraged to continue and help others to achieve similar outcomes. For the majority, however, CEA will probably remain the safer option. 'Best medical therapy' and risk factor modification should be started as soon as a transient ischemic attack is suspected, while the early introduction of dual antiplatelet therapy may reduce recurrent events prior to CEA, without increasing perioperative bleeding complications.
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Affiliation(s)
- A Ross Naylor
- a The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK
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Qureshi MI, Davies AH. Carotid intervention following transient ischaemic attack: What are we waiting for? Vascular 2016; 24:556-8. [PMID: 27136949 DOI: 10.1177/1708538116648063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Transient ischaemic attack secondary to carotid stenosis has the highest risk of stroke recurrence compared with other aetiological subtypes. International guidelines advocate carotid intervention within one to two weeks of the index neurological event. Traditionally, delayed carotid intervention was perceived to be a safer management strategy, yet classic trials of endarterectomy and recent meta-analysis of carotid intervention demonstrate the safety of hyperacute carotid intervention. Data from international studies suggest that targets are not being met, the reasons for which are multifactorial, but patients suffering transient or ocular symptoms are particularly delayed. Efforts should be made to conduct regional studies investigating the root causes of delayed intervention, with subsequent policy adjustment to expedite intervention, and interim optimisation of medical management to reduce the incidence of recurrent stroke.
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Affiliation(s)
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College London, UK
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Batchelder A, Hunter J, Cairns V, Sandford R, Munshi A, Naylor A. Dual Antiplatelet Therapy Prior to Expedited Carotid Surgery Reduces Recurrent Events Prior to Surgery without Significantly Increasing Peri-operative Bleeding Complications. Eur J Vasc Endovasc Surg 2015; 50:412-9. [DOI: 10.1016/j.ejvs.2015.07.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 07/05/2015] [Indexed: 11/28/2022]
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Naylor A. Part One: For the Motion. Carotid Endarterectomy is Safer than Stenting in the Hyperacute Period After Onset of Symptoms. Eur J Vasc Endovasc Surg 2015; 49:623-627. [DOI: 10.1016/j.ejvs.2015.03.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Naylor AR, AbuRahma AF. Debate: Whether carotid endarterectomy is safer than stenting in the hyperacute period after onset of symptoms. J Vasc Surg 2015; 61:1642-51. [PMID: 26004334 DOI: 10.1016/j.jvs.2015.02.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The carotid artery has been a regular battleground for debates regarding many issues, including appropriate management of symptomatic and asymptomatic lesions, the conduct, timing, and safety of such interventions, and now, whether endarterectomy or stenting is safer in the hyperacute period. Our discussants agree that, as a prophylactic procedure, a carotid intervention should occur early after index symptoms to prevent as many strokes as possible. However, which intervention is best?
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Affiliation(s)
- A Ross Naylor
- Vascular Research Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, United Kingdom.
| | - Ali F AbuRahma
- Division of Vascular Surgery & Endovascular Surgery, West Virginia University, Charleston, WVa.
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Naylor A, Sillesen H, Schroeder T. Clinical and Imaging Features Associated with an Increased Risk of Early and Late Stroke in Patients with Symptomatic Carotid Disease. Eur J Vasc Endovasc Surg 2015; 49:513-23. [DOI: 10.1016/j.ejvs.2015.01.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 01/21/2015] [Indexed: 01/01/2023]
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Strömberg S, Nordanstig A, Bentzel T, Österberg K, Bergström G. Risk of Early Recurrent Stroke in Symptomatic Carotid Stenosis. Eur J Vasc Endovasc Surg 2015; 49:137-44. [DOI: 10.1016/j.ejvs.2014.11.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 11/10/2014] [Indexed: 11/29/2022]
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Abbott AL, Nicolaides AN. Improving outcomes in patients with carotid stenosis: call for better research opportunities and standards. Stroke 2014; 46:7-8. [PMID: 25406149 DOI: 10.1161/strokeaha.114.007437] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Anne L Abbott
- From the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (A.L.A.); Imperial College, London, United Kingdom (A.N.N.); and St Georges London/Nicosia Medical School, University of Nicosia, Egkomi, Cyprus (A.N.N.).
| | - Andrew N Nicolaides
- From the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (A.L.A.); Imperial College, London, United Kingdom (A.N.N.); and St Georges London/Nicosia Medical School, University of Nicosia, Egkomi, Cyprus (A.N.N.)
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Sidloff DA, Gokani VJ, Stather PW, Choke E, Bown MJ, Sayers RD. National Vascular Registry Report on surgical outcomes and implications for vascular centres. Br J Surg 2014; 101:637-42. [DOI: 10.1002/bjs.9462] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2014] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The National Vascular Registry Report on Surgical Outcomes (NVSRO) coincided with the update of the National Health Service Standard Contract for Specialized Vascular Services in Adults (NHSSCSVS). The latter promises patients minimum standards for vascular centres. The present study aimed to determine whether current data support the standards proposed in the NHSSCSVS.
Methods
Numbers of abdominal aortic aneurysm (AAA) repairs and carotid endarterectomies (CEAs) performed by hospital Trust and surgeon, and their outcomes were obtained from the NVRSO. These were assessed against NHSSCSVS recommendations that included: more than 60 AAA repairs per year per Trust, over 50 CEAs per year per Trust and at least six vascular surgeons per Trust.
Results
Based on NVRSO data, 107 hospital Trusts (92·2 per cent) would fail to meet the minimum standards required to achieve vascular centre status. Outcomes were poorer in these hospitals (overall mortality rate after AAA: 2·7 versus 1·3 per cent; P = 0·007). There were strong associations between number of AAA repairs or CEAs per Trust and better outcomes (AAA repair, P < 0·001; CEA, P = 0·004). These remained significant when analysed by individual surgeon (AAA repair, P < 0·001; CEA, P < 0·001). Trusts undertaking 60 or fewer elective AAA repairs per year had significantly higher elective AAA mortality rates (2·7 versus 1·7 per cent; P = 0·010). Trusts performing a minimum of 50 CEAs per year had significantly lower perioperative mortality/morbidity rates (1·9 versus 3·0 per cent; P = 0·032). Trusts with seven or more surgeons demonstrated lower AAA-related mortality rates (1·7 versus 2·7 per cent; P = 0·018).
Conclusion
Data from the NVRSO suggest that the majority of hospital Trusts presently fail to meet the standards for vascular centre status. NVRSO data support a standard of more than 60 elective AAA repairs and 50 CEAs per Trust per year. A minimum of seven vascular surgeons per unit was associated with better outcomes. These data support the ongoing remodelling of vascular services in the UK.
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Affiliation(s)
- D A Sidloff
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - V J Gokani
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - P W Stather
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - E Choke
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - M J Bown
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK
| | - R D Sayers
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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22
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Rathenborg LK. Commentary on "Comparison of cognitive function after carotid artery stenting versus carotid endarterectomy". Eur J Vasc Endovasc Surg 2013; 47:232. [PMID: 24368206 DOI: 10.1016/j.ejvs.2013.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 11/21/2013] [Indexed: 11/27/2022]
Affiliation(s)
- L K Rathenborg
- Department of Vascular Surgery, University Hospital of Copenhagen, Copenhagen, Denmark.
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Naylor AR. Letter by Naylor Regarding Article, “Urgent Best Medical Therapy May Obviate the Need for Urgent Surgery in Patients With Symptomatic Carotid Stenosis”. Stroke 2013; 44:e156. [DOI: 10.1161/strokeaha.113.003329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- A. Ross Naylor
- Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, United Kingdom
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Sharpe R, Sayers R, London N, Bown M, McCarthy M, Nasim A, Davies R, Naylor A. Procedural Risk Following Carotid Endarterectomy in the Hyperacute Period after Onset of Symptoms. Eur J Vasc Endovasc Surg 2013; 46:519-24. [DOI: 10.1016/j.ejvs.2013.08.014] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 08/27/2013] [Indexed: 11/16/2022]
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