Single-session mechanical thrombectomy for iliofemoral deep vein thrombosis using a dual mechanism of action device combining basket and rotational thrombectomy

OBJECTIVE

Interventional treatments for acute iliofemoral deep vein thrombosis (DVT) remain controversial after publication of the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) study. Interventions have been shown to reduce post-thrombotic syndrome severity and improve quality of life in DVT patients, but have been accompanied by risk of major bleeding from thrombolytics. We describe thrombus removal using a novel combined basket-rotational thrombectomy device that minimizes the need for thrombolytics or repeat procedures.

METHODS

The aim of this prospective, nonrandomized, multicenter, first-in-human study of 19 patients with acute iliofemoral DVT was to evaluate the safety and performance of the Pounce venous thrombectomy system ≤12 months after treatment. The primary performance end point was defined as procedural success through achievement of Society of Interventional Radiology (SIR) grade II lysis in treated vessels with freedom from procedural adverse events. Secondary end points included venous disease severity assessments using the Villalta scale and the Venous Clinical Severity Score, patient quality-of-life measurement using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life questionnaire, and calf circumference measurements taken at baseline, 24 hours, and 1 month.

RESULTS

The primary end point of complete or near-complete thrombus removal (Society of Interventional Radiology grade II or III) was achieved in all patients. All study device-related safety end points were met, with no major bleeding or device-related adverse events. Of the 19 patients treated, 16 (84.2%) did not receive thrombolytics during the procedure. Post-thrombotic syndrome (Villalta scale >4) was identified in 17 of 19 patients (89.5%) at baseline, 4 of 13 patients (30.8%) available for follow-up at 6 months, and 2 of 11 patients (18.2%) at 12 months. The median Venous Clinical Severity Score decreased (P < .001) from 8.5 (interquartile range [IQR], 7-10) at baseline to 4 (IQR, 2-4) at 1 month after the procedure and was similar at 6 months (2; IQR, 2-5) and 12 months (2; IQR, 1.5-3) after the procedure. The median Venous Insufficiency Epidemiological and Economic Study-Quality of Life questionnaire score improved (P < .001) by 39 from baseline (57; IQR, 53.5-74) to 1 month (96; IQR, 86-101) after the procedure, and remained high at 6 months (99; IQR, 75-103) and 12 months (98; IQR, 94.5-100). The median calf circumference decreased (P = .089) from 39 cm (IQR, 35-47.8 cm) at baseline to 36 cm (IQR, 32.5-40.5 cm) at 24 hours after the procedure and was 34.5 cm (IQR, 33.2-38.5 cm) at 1 month.

CONCLUSIONS

The Pounce device is safe and effective for removal the of thrombus in patients with acute iliofemoral DVT. Initial results demonstrate improvements in venous disease severity and patient quality of life.

Cost Effectiveness of Early Endovenous Thrombus Removal for Acute Iliofemoral Deep Vein Thrombosis in the United Kingdom

OBJECTIVE

Early clot removal using endovascular intervention aims to reduce post-thrombotic syndrome (PTS) following iliofemoral deep venous thrombosis (DVT). This may reduce long term morbidity but incurs a higher initial cost. This study examined the cost effectiveness of catheter directed thrombolysis (CDT) and pharmacochemical thrombectomy (PMT) compared with oral anticoagulation (OAC) alone for treatment of acute iliofemoral DVT in the United Kingdom.

METHODS

A combined decision tree (acute DVT complications) and Markov model (long term complications [PTS]) was used for decision analytic modelling with five states: no PTS, mild PTS, moderate PTS, severe PTS, and dead. All patients started with acute DVT. Patients who survived acute complications transitioned into the Markov model. Cycle time was six months. A healthcare payer perspective and lifetime horizon was used, adjusting for excess mortality due to history of thrombosis. Data for probabilities, transition probabilities, mortality, and utilities were obtained from the published literature. Cost data were obtained from UK NHS tariffs and published literature. Outcomes were mean lifetime cost, quality adjusted life years (QALYs), and cost effectiveness.

RESULTS

Over a patient's lifetime, OAC was more costly (£37 206) than CDT (£32 043) and PMT (£36 288). Mean lifetime QALYs for OAC (12.9) were lower than CDT (13.5) and PMT (13.3). Therefore, in the incremental cost effectiveness analysis, both CDT and PMT were dominant: CDT was less costly (-£5 163) and more effective (+0.6 QALYs) than OAC, and PMT was also less costly (-£917) and more effective (+0.3 QALYs) than OAC. Results were robust to univariable sensitivity analyses, but probabilistic sensitivity analyses suggested considerable parameter uncertainty.

CONCLUSION

Early interventional treatment of iliofemoral DVT is cost effective in the UK. Future clinical and epidemiological studies are needed to characterise parameter uncertainty. Further analysis of modern practice, alternative treatments, and optimised care models is warranted.

Randomized controlled trials of interventions for acute iliofemoral deep venous thrombosis

Venous thromboembolism (VTE), notably deep venous thrombosis (DVT), represents a significant cardiovascular disease with high morbidity from post-thrombotic syndrome (PTS). Recent advancements in early thrombus removal technologies have prompted randomized controlled trials (RCT) to assess their efficacy and safety, particularly for iliofemoral DVT (IF-DVT), which carries the greatest risk of developing PTS. This narrative review summarizes these trials and introduces upcoming innovations to evaluate acute intervention for IF-DVT. Specific technologies discussed include catheter-directed thrombolysis, pharmacomechanical catheter-directed thrombolysis, ultrasound-accelerated catheter-directed thrombolysis, and non-lytic mechanical thrombectomy. This review underscores the importance of patient selection, with those presenting with extensive, symptomatic IF-DVT likely to benefit most.

Editor's Choice - Management of Lower Extremity Venous Outflow Obstruction: Results of an International Delphi Consensus

OBJECTIVE

The endovascular treatment of venous obstruction has expanded significantly in recent years. Best practices for optimal patient outcomes are not well established and the evidence base is poor. The purpose of this study was to obtain consensus on management criteria for patients with lower extremity venous outflow obstruction.

METHODS

The study was conducted as a two round Delphi consensus. Statements addressed imaging, symptoms and other baseline measures, differential diagnosis, treatment algorithm, indications for stenting, inflow and outflow assessment, successful procedural outcomes, post-procedure therapies and stent surveillance, and clinical success factors. Statements were prepared by six expert physicians (round 1, 40 statements) and an expanded panel of 24 physicians (round 2, 80 statements) and sent to a pre-identified group of venous experts who met qualifying criteria. A 9 point Likert scale was used and consensus was defined as ≥ 70% of respondents rating a statement between 7 and 9 (agreement) or between 1 and 3 (disagreement). Round 1 results were used to guide rewording and splitting compound statements for greater clarity in round 2.

RESULTS

In round 1, 75 of 110 (68%) experts responded, and 91 of 121 (75%) experts responded in round 2. Round 1 achieved consensus in 32/40 (80%) statements. Consensus was not reached in the treatment algorithm section. Round 2 achieved consensus in 50/80 (62.5%). Statements reaching consensus were imaging (2/3, 66%), symptoms and other baseline measures (12/24, 50%), differential diagnosis (2/8, 25%), treatment algorithm (10/17, 59%), indications for stenting (10/10, 100%), inflow and outflow assessment (2/2, 100%), procedural outcomes (2/2, 100%), post-procedure therapies and stent surveillance, (5/7, 71%), and clinical success factors (5/7, 71%).

CONCLUSION

This study demonstrated that considerable consensus was achieved between venous experts on the optimal management of lower extremity venous outflow obstruction. There were multiple domains where consensus is lacking, highlighting important areas for further investigation and research.

Use of patient-reported outcome measures in patients with venous thromboembolism: communication from the ISTH SSC Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease

Patient-reported outcome measures (PROMs) are patient-completed instruments that capture patient-perceived health status and well-being. PROMs measure disease impact and outcomes of care as reported by those who experience the disease. After pulmonary embolism or deep vein thrombosis, patients may face a broad spectrum of complications and long-term sequelae beyond the usual quality-of-care indicators of recurrent venous thromboembolism (VTE), bleeding complications, and survival. The full impact of VTE on individual patients can only be captured by assessing all relevant health outcomes from the patient's perspective in addition to the traditionally recognized complications. Defining and measuring all important outcomes will help facilitate treatment tailored to the needs and preferences of patients and may improve health outcomes. The International Society on Thrombosis and Haemostasis Scientific and Standardization Committee Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease endorsed the International Consortium for Health Outcomes Measurement (ICHOM) VTE project on development of a standardized set of patient-centered outcome measures for patients with VTE. In this communication, the course and result of the project are summarized, and based on these findings, we propose recommendations for the use of PROMs during clinical follow-up of patients with VTE. We describe challenges to implementation of PROMs and explore barriers and enablers.

Leg Ulcer Pathway Acceleration (LUPA) study

BACKGROUND

Leg ulcers are common, costly, and significantly impair quality of life, but their management is variable and associated with considerable delays in healing. The aim of this study was to design an accelerated leg ulcer care pathway in a community and hospital setting to improve patient outcomes.

METHODS

A new referral pathway was developed using a series of healthcare professional and patient interviews, focus groups, and stakeholder workshops. The referral pathway, investigation and treatment protocols were further informed by clinical guidelines to develop the Leg Ulcer Pathway Acceleration care pathway. The outcomes of a consecutive series of patients enrolled in the Leg Ulcer Pathway Acceleration care pathway were compared with the outcomes of patients from a historical leg ulcer cohort from the same community and hospital setting.

RESULTS

A total of 110 eligible patients were enrolled and followed prospectively through the Leg Ulcer Pathway Acceleration care pathway. Their outcomes were compared with those of 183 patients with venous leg ulcers identified from existing hospital and community ulcer centres, and acting as the historical control group. The 110 patients in the Leg Ulcer Pathway Acceleration group consisted of 73 (66 per cent) men, had a mean(s.d.) age of 55.7(17.2) years, and had a median initial ulcer duration of 14.5 (i.q.r. 6-30) months. The 183 patients in the historical control group consisted of 119 (65 per cent) men, had a mean(s.d.) age of 56.4(17.2) years, and had a median initial ulcer duration of 13.5 (i.q.r. 6-47) months. Venous disease was treated in 67/110 (61 per cent) and deep venous disease was treated in 33/110 (30 per cent) of patients in the Leg Ulcer Pathway Acceleration cohort. In contrast, only 16/183 (8 per cent) of patients in the control group were treated for superficial venous insufficiency and 4/183 (2 per cent) of patients in the control group were treated for deep venous disease. Ulcer healing rates at 12 months were 80 and 20 per cent in the Leg Ulcer Pathway Acceleration group and the control group respectively (P < 0.001). Adjusted for baseline characteristics, the OR for a healed ulcer at 12 months was 21.21 (95 per cent c.i.. 11.32 to 42.46) (P < 0.001).

CONCLUSION

The introduction of an accelerated leg ulcer care pathway significantly improves ulcer healing when compared with historical controls.

A systematic review of reported outcomes in people with lower limb chronic venous insufficiency of the deep veins

OBJECTIVE

The prevalence of lower limb chronic venous insufficiency (CVI) of the deep veins is increasing and presents a significant burden to patients and health care services. To improve the evaluation of interventions it is necessary to standardise their reporting. The aim of this study was to perform a systematic review of the outcomes of interventions delivered to people with CVI of the deep veins as part of the development of a novel core outcome set (COS).

METHODS

Following the Core Outcome Measures in Effectiveness Trials (COMET) framework for COS development, a systematic review was conducted to PRISMA guidance. The protocol was preregistered on PROSPERO (CRD42021236795). MEDLINE, Embase, Emcare, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews and Clinicaltrials.gov were searched from January 2018 to January 2021. Clinical trials and observational studies involving more than 20 participants, reporting outcomes for patients with CVI of the deep veins were eligible. Outcomes were extracted verbatim, condensed into agreed outcome terms and coded into domains using standard COMET taxonomy. Outcome reporting consistency, where outcomes were fully reported throughout the methods and results of their respective articles was also assessed.

RESULTS

Some 103 studies were eligible. There were 1183 verbatim outcomes extracted, spanning 22 domains. No outcome was reported unanimously, with the most widely reported outcome of primary patency featuring in 51 articles (<50%). There was a predominant focus on reporting clinical outcomes (n = 963 [81%]), with treatment durability (n = 278 [23%]) and clinical severity (n = 108 [9%]) reported frequently. Life impact outcomes were relatively under-reported (n = 60 [5%]). Outcome reporting consistency was poor, with just 50% of outcomes reported fully.

CONCLUSIONS

Outcome reporting in studies of people with CVI of the deep veins is currently heterogeneous. Life impact outcomes, which likely reflect patients' priorities are under-reported. This study provides the first step in the development of a COS for people with lower limb CVI of the deep veins.

A Systematic Review of the Safety and Efficacy of Inferior Vena Cava Stenting

OBJECTIVE

Inferior vena cava (IVC) stenting may provide benefit to patients with symptomatic obstruction; however, there are no devices currently licensed for use in the IVC and systematic reviews on the topic are lacking. The aim of this study was to carry out a systematic review of the literature and meta-analysis to investigate the safety and efficacy of IVC stenting in all adult patient groups.

DATA SOURCES

The Medline and Embase databases were searched for studies reporting outcomes for safety and effectiveness of IVC stenting for any indication in series of 10 or more patients.

REVIEW METHODS

A systematic review of the literature was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Thirty-three studies were included describing 1 575 patients. Indications for stenting were malignant IVC syndrome (229 patients), thrombotic disease (807 patients), Budd-Chiari syndrome (501 patients), and IVC stenosis post liver transplantation (47 patients). The male:female ratio was 2:1 and the median age ranged from 30 to 61 years. The studies included were not suitable for formal meta-analysis as 30/33 were single centre retrospective studies with no control groups and there was considerable inconsistency in outcome reporting. There was significant risk of bias in 94% of studies. Median reported technical success was 100% (range 78 - 100%), primary patency was 75% (38 - 98%), and secondary patency was 91.5% (77 - 100%). Major complications were pulmonary embolism (three cases), stent migration (12 cases), and major bleeding (15 cases), and there were three deaths in the immediate post-operative period. Most studies reported improvement in clinical symptoms but formal reporting tools were not used consistently.

CONCLUSION

The evidence base for IVC stenting consists of predominantly single centre, retrospective, observational studies that have a high risk of bias. Nonetheless the procedure appears safe with few major adverse events, and studies that reported clinical outcomes demonstrate improvement in symptoms and quality of life. Randomised controlled trials and prospective registry based studies with larger patient numbers and standardised outcome are required to improve the evidence base for this procedure.

Development of an international standard set of outcome measures for patients with venous thromboembolism: an International Consortium for Health Outcomes Measurement consensus recommendation

The International Consortium for Health Outcomes Measurement assembled an international working group of venous thromboembolism experts and patient representatives to develop a standardised minimum set of outcomes and outcome measurements for integration into clinical practice and potentially research to support clinical decision making and benchmarking of quality of care. 15 core outcomes important to patients and health-care professionals were selected and categorised into four domains: patient-reported outcomes, long term consequences of the disease, disease-specific complications, and treatment-related complications. The outcomes and outcome measures were designed to apply to all patients with venous thromboembolism aged 16 years or older. A measurement tool package was selected for inclusion in the core standard set, with a minimum number of items to be measured at predefined timepoints, which capture all core outcomes. Additional measures can be introduced to the user by a cascade opt-in system that allows for further assessment if required. This set of outcomes and measurement tools will facilitate the implementation of the use of patient-centred outcomes in daily practice.

O079 Predictive value for elevated platelet-derived SGPVI in venous in-stent stenosis in patients with post-thrombotic syndrome

Introduction

In-stent stenosis following intervention for post-thrombotic syndrome (PTS) occurs in ∼30% of cases, despite therapeutic anticoagulation. Our aim was to investigate whether platelets are involved.

Methods

Blood was taken from case-matched patients before and after venous stenting. Flow-cytometry was used to assess platelet activation (P-selectin and/or phosphatidylserine exposure) while= functional activity was measured by plate-based aggregation and through a flow-cell model of thrombus formation. Soluble glycoprotein VI (sGPVI) was measured in plasma. Patients with in-stent stenosis requiring reintervention (&gt;50% diameter reduction) were compared with those who did not.

Results

Forty-five patients were recruited (median age: 43yrs (33–55yrs); 65% female), and 19/45 (42%) required reintervention (median time: 3wks (1day-3mths)). There was no difference in platelet activation or reactivity after stenting, but P-selectin exposure pre-stent was significantly higher in patients who developed in-stent stenosis (2.7%±0.4 vs 1.7%±0.2; P&lt;0.05). Pre-stent sGPVI levels were increased in patients who developed in-stent stenosis (18.9±3.6ng/mL vs. 7.4±0.9ng/mL; P&lt;0.01). Platelet reactivity to collagen-related peptide, a GPVI-specific platelet agonist, was reduced in patients who developed in-stent stenosis (logEC50 = -6.5M±0.3 vs -7.2M±0.2; P&lt;0.05; n=33). Pre-stent platelet accumulation (26.6AU±0.5 vs 19.0AU±8.1; P=0.04) was significantly increased in PTS patients compared with healthy controls.

Conclusion

Venous stenting does not activate platelets, but patients who developed in-stent stenosis exhibited greater levels of pre-stent platelet activation, greater loss of platelet surface GPVI in the form of sGPVI and reduction in reactivity to GPVI activation. sGPVI may have potential to risk stratify patients undergoing venous stenting and predict who requires closer surveillance.

Take-home message

Soluble GPVI may have potential to risk-stratify patients undergoing deep venous reconstruction and predict who requires closer surveillance.

Performance of Open and Closed Cell Laser Cut Nitinol Stents for the Treatment of Chronic Iliofemoral Venous Outflow Obstruction in Patients Treated at a Single Centre

OBJECTIVE

A number of dedicated self expanding nitinol stents have been developed for use in the venous system, with both open cell (OC) and closed cell (CC) designs available. Data comparing these different designs are lacking. The objective of this study was to evaluate outcomes in patients treated with open and closed cells for unilateral chronic iliac vein obstruction.

METHODS

A single centre retrospective cohort study was conducted, including all patients treated with a dedicated nitinol venous stent between 2014 and 2019. Stent patency and details of re-interventions (including lysis, venoplasty, reinforcement, extension, arteriovenous fistula formation) were examined in the first post-operative year. Subgroup analysis described outcomes for patients treated with OC and CC stents ending above the inguinal ligament and those who required extension into the common femoral vein. Cox regression analysis was used to identify factors associated with loss of primary patency.

RESULTS

A total of 207 patients were included (OC 100 patients, CC 107 patients). There was no significant difference between the groups for age (OC 42 years, CC 44 years); gender (OC and CC 67% female); presence of post-thrombotic lesions (OC 71%, CC 73%); stenting across the inguinal ligament (OC 58%, CC 56%), or presence of inflow disease (OC 49%, CC 47%). Primary and cumulative patency at 12 months were similar between groups (primary: OC 63%, CC 65%; cumulative: OC 93%, CC 90%). Patients with a CC stent across the inguinal ligament had a greater risk of needing multiple re-interventions at one year compared with those with an OC stent (odds ratio 2.84, 95% confidence interval [CI] 1.16 - 6.9) but overall, the only factor significantly associated with loss of primary patency was inflow vessel disease (hazard ratio 3.39, 95% CI 1.73 - 6.62, p < .001).

CONCLUSION

OC and CC dedicated nitinol venous stents were observed to perform similarly in terms of patency and symptom improvement at one year. Disease of the inflow vessels was the most important factor associated with a loss of stent patency irrespective of stent design.

Mechanical characteristics of venous stents to overcome challenges of venous outflow obstruction

BACKGROUND

Many challenges posed by the venous outflow obstruction (VOO) are unique to the venous system which require specific mechanical characteristics of stents to overcome them. Therefore, this article aims to review and discuss these challenges and the stent mechanical characteristics required to overcome them.

METHODS

A literature search was performed with Pubmed with the terms "mechanical characteristics of venous stents" and "mechanical properties of venous stents".

RESULTS

The venous system poses unique anatomical, physiological and pathological challenges when compared to the arterial counterpart. Several mechanical characteristics specific to venous stents which include the size, inherent forces, and flexibility are important to overcome these unique challenges when treating VOO. The most important stent inherent forces for venous stents include the chronic outward force, radial resistive force, and crush resistance. Various stent materials and designs, particularly laser-cut versus braided-structure stents, and open-cell versus closed-cell stents, determine the mechanical characteristics including the inherent forces of the venous stents. The desired mechanical characteristics of stents needed to overcome the venous system challenges often in conflict or with opposing effects. Therefore, it is important to fine adjust and optimise these characteristics.

CONCLUSIONS

There are many anatomical, physiological, and pathological challenges unique to the venous system which need to be overcome by the stent system mechanically when treating VOO. Therefore, dedicated venous stents with optimal mechanical characteristics are being developed with different designs and properties to treat VOO. Further research and innovations are needed to improve the stent technology that targets the venous system specifically.

A review of the incidence, outcome and management of venous stent migration

INTRODUCTION

Percutaneous endovenous stenting has emerged during the last decade as the primary method of treating symptomatic venous outflow obstruction. A recognised complication of venous stenting is stent migration. The aim of this systematic review was to identify the number of cases reported in the published literature describing stent migration, to recognise risk factors that may be associated with this complication, and outcomes following migration.

METHODS

A review was conducted following MOOSE and PRIMSA guidelines and registered on PROSPERO. MEDLINE, EMBASE, and PubMed databases and key references were searched using specified keywords. All relevant data for primary procedure and subsequent presentation with stent migration was retrieved. Data was assessed as too low quality to allow for statistical analysis.

RESULTS

Between 1994 and 2020, 31 articles were identified comprised of 29 case reports and 2 case series providing data for 54 events of venous stent migration with 47/54 providing some data for stent used. Mean age of patients in who migration occurred was 50 years (range 19-88) and 57.6% (n=30) were male. Most reported cases were 60mm or less in length (38/46, 82.6%) and only 3 of the reports were stents greater than 14mm in diameter (3/47, 3.6%). None of the papers reported migration of stents of more than 100mm in length. In 85% of the migrated stent events, retrieval was attempted with 56% via an endovascular approach. The immediate outcome was satisfactory in 100% of the reported attempts whether by endovascular or open surgical approaches.

CONCLUSIONS

This literature review would suggest that the risk of migration is rare but may be underreported. The majority of reported cases are shorter and smaller diameter stents. The paucity of published data and the short term follow up provided suggest more formal data collection would provide a truer reflection of incidence however clear strategies to avoid migration need to be followed to prevent this complication from occurring.

Medium-term outcomes after inferior vena cava reconstruction for acute and chronic deep vein thrombosis and retroperitoneal fibrosis

OBJECTIVE

In the present study, we evaluated the technical and clinical outcomes after endovascular inferior vena cava (IVC) reconstruction in patients with nonmalignant obstruction.

METHODS

The preoperative, procedural, and follow-up medical records and imaging studies were retrospectively reviewed for 59 consecutive patients who had undergone endovascular IVC reconstruction for nonmalignant obstruction from February 2014 to January 2019. The patients were classified into three groups according to the quality of their infrainguinal inflow vessels. The outcomes measured were the primary, primary-assisted, and secondary patency rates, reintervention rates, and symptomatic resolution.

RESULTS

The indications for treatment were post-thrombotic syndrome (n = 41), acute deep vein thrombosis (n = 12), and retroperitoneal fibrosis (n = 6). The median patient age was 37 years, 11 months, 71.2% were men, and 32.2% had a diagnosis of thrombophilia, with no significant difference in these demographics between the three inflow groups. The median follow-up duration was 2 years, 3 months (range, 6 months to 6 years, 5 months). The whole-cohort primary patency was 91.2%, 71.0%, and 24.1% at 1, 3, and 5 years, respectively. Secondary patency was 76.7% at 1 year and 66.4% at both 3 and 5 years. Inflow group A (no post-thrombotic disease in the femoral or deep femoral veins) demonstrated significantly higher primary patency compared with group B (stenotic disease in one or two infrainguinal inflow veins; P = .009) and significantly higher secondary patency than for both groups B (P = .008) and C (all three infrainguinal inflow veins had stenosed or femoral and/or deep femoral vein occlusion was present; P = .04). In post-thrombotic syndrome patients, the Villalta scores had decreased from a mean of 14.2 to 8.1 at 1 year and 6.8 at 2 years, and the Venous Insufficiency Epidemiological and Economic Study Quality of Life score had improved from a mean of 19.8 to 54.1 and 57.3 at 1 and 2 years, respectively. In the patients with acute deep vein thrombosis, the Villalta score was 2.8 at 1 year and 0 at 2 years. In the patients with retroperitoneal fibrosis, the Venous Insufficiency Epidemiological and Economic Study Quality of Life score had improved from a mean of 25.3 at baseline to 44 at 6 months.

CONCLUSIONS

Endovascular IVC reconstruction for nonmalignant obstruction can achieve good patency and clinical improvement, although the outcomes were poorer for patients with post-thrombotic disease of the femoral and deep femoral veins.

"Inside-Out" Central Venous Access approach with infraclavicular exit for right-sided CRT-D Implantation in bilateral brachiocephalic and superior vena cava occlusion

The use of the "inside-out" approach with an infraclavicular exit site with a dedicated system in the presence of complex central venous occlusion is feasible and safe for the implantation of complex cardiac devices.

DEep VEin Lesion OPtimisation (DEVELOP) trial: protocol for a randomised, assessor-blinded feasibility trial of iliac vein intervention for venous leg ulcers

BACKGROUND

Venous leg ulceration is a widespread, debilitating pathology with high recurrence rates. Conservative treatment using graduated compression dressings may be associated with unacceptable ulcer recurrence rates. Early superficial venous ablation encourages ulcer healing and reduces recurrence. However, many of this cohort display concomitant ilio-caval stenosis, which further contributes to lower limb venous hypertension and ulceration. An approach that combines early superficial venous ablation with early treatment of ilio-caval stenotic disease may significantly improve ulcer healing and recurrence rates. We question whether early iliac vein interrogation with intravascular ultrasound (IVUS), stenting of significant occlusive disease plus superficial venous ablation, in patients with active venous leg ulceration, will produce superior ulcer healing to standard therapy.

METHODS

This is a prospective, multi-centre, randomised controlled, feasibility trial recruiting patients with lower limb venous ulceration and saphenous venous incompetence. Patients will be randomised to undergo either truncal ablation and compression therapy or truncal ablation, simultaneous iliac interrogation with intravascular ultrasound and stenting of significant (> 50%) iliac vein lesions plus compression therapy. The primary feasibility outcome will be the rate of eligible patient participation while the primary clinical outcomes will be ulcer healing and procedural safety. Secondary outcomes include time to healing, quality of life and clinical scores, ulcer recurrence rates and rates of post-thrombotic syndrome. Follow-up will be over a 5-year period. This feasibility trial is designed to include 60 patients. Should it be practicable a total of 594 patients would be required to adequately power the trial to definitively address ulcer-healing rates.

DISCUSSION

This trial will be the first randomised trial to examine the role iliac interrogation and intervention in conjunction with standard operative therapy in the management of venous ulceration related to superficial truncal venous incompetence.

ETHICAL COMMITTEE REFERENCE

C.A. 2111 Galway Clinical Research Ethics Committee REGISTRATION: Clinical Trials.gov registration NCT03640689 , Registered on 21 August 2018.

Quality of life outcomes for patients undergoing venous stenting for chronic deep venous disease

OBJECTIVE

The objective of the study was to evaluate change in venous disease-specific quality of life (QoL) after iliac vein stenting for chronic venous outflow obstruction.

METHODS

We performed a retrospective analysis of all Venous Insufficiency Epidemiological and Economic Study - Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaires completed at a single-center between 2016 and 2019 by patients treated with iliac vein stenting for chronic venous outflow obstruction. Patients were asked to complete the questionnaire at baseline (before stenting) and at subsequent follow-up appointments (after stenting), at 6, 12, 24, and 36 months. The Villalta score was recorded by a venous nurse specialist. The initial unpaired analysis compared all completed VEINES-QoL/Sym and Villalta scores at baseline to all follow-up time-points, and then compared them individually between baseline and each follow-up point. A secondary paired analysis included data only from patients who had completed the questionnaire at baseline and at least one follow-up.

RESULTS

A total of 385 questionnaires from 187 patients who completed the VEINES-QoL/Sym between 2016 and 2019 were included. The median follow-up was 12 months, 127 patients (68%) were female, and 148 (79%) were treated for post-thrombotic syndrome. The median VEINES-QoL score at baseline was 35.69 (interquartile range [IQR], 20.85-46.67). Significant improvement was observed postoperatively and sustained throughout the study period (6 months, 64.81 [IQR, 38.12-83.88]; 12 months, 60.52 [IQR, 33.6-82.3]; 24 months, 60.37 [IQR, 34.31-80.65]; 36 months, 55.98 [IQR, 39.18-81.47]). The VEINES-Sym scores demonstrated similar improvement. A secondary analysis of paired baseline/follow-up data from 61 patients confirmed significant improvement from baseline for VEINES-QoL (6 months +26.45; 12 months, +25.81; 24 months, +30.09; P ≤ .0001), VEINES-Sym (6 months, +23.86; 12 months, +20.43; 24 months, +27.55; P > .001), and Villalta scores (6 months, -3.7; 12 months, -4.2; 24 months, -6.4; P < .0001). The median Villalta score was 14 (IQR, 10-16). This score improved to 9 (IQR, 5-13) at 6 months of follow-up; to 8 (IQR, 5-11) at 12 months; to 7 (IQR, 4-12) at 24 months; and to 6 (IQR, 3.75-10.25) at 36 months (P ≤ .0001). Good correlation between the Villalta and both VEINES-QoL and SYM scores was observed at follow-up (r = 0.69 and r = 0.71, respectively; P < .0001).

CONCLUSIONS

Venous disease-specific QoL improves and severity of post-thrombotic syndrome is decreased after iliac vein stenting for chronic venous outflow obstruction. These improvements are sustained at 36-month follow-up.

Post-thrombotic Syndrome: Preventative and Risk Reduction Strategies Following Deep Vein Thrombosis

Venous disease is common in the general population, with chronic venous disorders affecting 50–85% of the western population and consuming 2–3% of healthcare funding. It, therefore, represents a significant socioeconomic, physical and psychological burden. Acute deep vein thrombosis, although a well-recognised cause of death through pulmonary embolism, can more commonly lead to post-thrombotic syndrome (PTS). This article summarises the pathophysiology and risk factor profile of PTS, and highlights various strategies that may reduce the risk of PTS, and the endovenous management of iliofemoral deep vein thrombosis. The authors summarise the advances in PTS risk reduction strategies and present the latest evidence for discussion.

Effect of thrombophilia on clinical outcomes of chronic post-thrombotic patients after iliofemoral stenting with nitinol venous stents

OBJECTIVE

Thrombophilia is a prothrombotic condition that increases the risk of venous thromboembolism. It is unclear whether the presence of thrombophilia alters the clinical outcomes after deep venous stenting. The aim of the present study was to examine the relationship between thrombophilia and outcomes after stenting for post-thrombotic syndrome.

METHODS

Consecutive patients (2012-2017) receiving a nitinol venous stent for chronic post-thrombotic venous occlusive disease with a minimum of 18 months of follow-up in one center using the same anticoagulation protocol were included. The clinical history and thrombophilia testing results were reviewed. The outcomes were stent patency, which was assessed using duplex ultrasonography at 24 hours, 2 and 6 weeks, 3 months, 6 months, and annually thereafter; and reinterventions, which were performed when the stent diameter was <50% or occluded.

RESULTS

Of the 136 patients who had undergone intervention, 55 (40%) had had a provoked deep vein thrombosis (DVT) and 81 (60%) had had an unprovoked DVT and had therefore undergone thrombophilia testing. Of the 81 patients, 38 (47%) had had either inherited (n = 19; 50%) or acquired (n = 19; 50%) thrombophilia. Of the 136 patients who had undergone stenting, 68 had required reintervention (50%) during follow-up to maintain stent patency. Of the 55 patients with a provoked DVT, 29 (53%) had required reintervention. Of the 81 patients with an unprovoked DVT, 39 (48%) had required reintervention (P = .420). Of the 38 patients with unprovoked DVT and thrombophilia, 17 (45%) had required reintervention. Of the 43 patients with unprovoked DVT and no thrombophilia, 22 (51%) had required reintervention (P = .766). The cumulative patency rate was 80% for patients with provoked DVT and 88% for those with unprovoked DVT (P = .193). The presence of thrombophilia was not associated with patency loss (92% cumulative patency for patients with thrombophilia and 84% for patients without thrombophilia; P = .307).

CONCLUSIONS

Using our anticoagulation protocol, patients with and without thrombophilia had similar clinical outcomes after deep venous stenting and should not be excluded from iliofemoral venous stenting. We found no significant differences in outcomes in conjunction with appropriate postoperative anticoagulation therapy.

AngioJet Pharmacomechanical Thrombectomy and Catheter Directed Thrombolysis vs. Catheter Directed Thrombolysis Alone for the Treatment of Iliofemoral Deep Vein Thrombosis: A Single Centre Retrospective Cohort Study

OBJECTIVE

Percutaneous thrombus removal is used for the treatment of iliofemoral deep vein thrombosis (DVT), but the efficacy of different treatment modalities has not yet been determined. The aim of this study was to compare the outcomes of patients treated with additional AngioJet pharmacomechanical thrombectomy (PCDT) vs. catheter directed lysis (CDT) alone.

METHODS

A retrospective review of all patients who received thrombolysis for the treatment of symptomatic acute iliofemoral DVT between 2011 and 2017 was carried out. Outcome measures included the incidence of post-thrombotic syndrome (PTS), procedural outcomes (lytic exposure), the incidence of complications, and vessel patency. All patients were followed up for a minimum of one year.

RESULTS

A total of 151 limbs were treated, 70 limbs with PCDT and 81 limbs with CDT alone. Demographic data and prevalence of risk factors were comparable. Incidence of PTS (Villalta score at one year) showed no significant difference (22.2% PCDT vs. 24.7% CDT alone, p = .74). Use of PCDT resulted in a non-statistically significant trend for fewer bleeds (n = 4/63 [6.3%] vs. 13/76 [17.1%]; relative risk 0.37, 95% confidence interval [CI] 0.13-1.08; p = .07), a statistically significant reduction in lysis duration (40 h [95% CI 34-46] vs. 53 h [95% CI 49-58]; p < .001) and a reduction in lytic dose (49 mg [95% CI 42-55] vs. 57 mg [95% CI 52-61]; p = .011) compared with CDT. This reduction was accentuated in 24 cases primarily treated with AngioJet PowerPulse mode (27 h, 95% CI 20-34 [p < .001] and 42 mg, 95% CI 34-50 [p = .009]). Incidences of complications were comparable between groups, with one death due to an intracranial haemorrhage following CDT. Although the incidence of haemoglobinuria was increased following PCDT (12/63 [19.0%] vs. 3/76 [3.9%]; p = .006), no significant difference in acute kidney injury was observed (3/63 [4.8%] vs. 1/76 [1.3%]; p = .33). No significant difference in vessel patency over two years was observed (p = .73).

CONCLUSION

The use of PCDT for the treatment of iliofemoral DVT was observed to provide comparable patient outcomes, comparable vessel patency, an acceptable safety profile, and reduced overall lytic dose.

Iliocaval Venous Obstruction, Cardiac Preload Reserve and Exercise Limitation

Cardiac output during exercise increases by as much as fivefold in the untrained man, and by as much as eightfold in the elite athlete. Increasing venous return is a critical but much overlooked component of the physiological response to exercise. Cardiac disorders such as constrictive pericarditis, restrictive cardiomyopathy and pulmonary hypertension are recognised to impair preload and cause exercise limitation; however, the effects of peripheral venous obstruction on cardiac function have not been well described. This manuscript will discuss how obstruction of the iliocaval venous outflow can lead to impairment in exercise tolerance, how such obstructions may be diagnosed, the potential implications of chronic obstructions on sympathetic nervous system activation, and relevance of venous compression syndromes in heart failure with preserved ejection fraction.

Device profile of the Vici venous stent for chronic iliofemoral venous obstruction recanalization: overview of its safety and efficacy

Introduction: Endovenous stenting is being increasingly used for the management of iliofemoral venous outflow obstruction due to thrombotic or non-thrombotic iliac vein lesions (NIVL). Dedicated venous stents have replaced re-purposed arterial stents but there are limited data on their relative safety and efficacy.Areas covered: This review looks at the available literature on the safety and efficacy of the Veniti Vici Venous stent (Boston Scientific), a specific venous stent, and compares its outcomes with the other venous stents that are currently available. Reported outcomes include patency, clinical efficacy, and the number of adverse events.Expert opinion: The initial clinical trials of the Vici venous stent have shown both good clinical and safety outcomes at 12-24 months follow-up. Longer follow-up data are pending and further trials comparing available stents are required. Current evidence supports its use in the management of deep venous reconstruction, especially in occlusive post-thrombotic disease. Patients should, however, be made aware of the paucity of long-term data and the need for monitoring within a dedicated surveillance program following stent placement.

Correction: In-school eyecare in special education settings has measurable benefits for children's vision and behaviour

[This corrects the article DOI: 10.1371/journal.pone.0220480.].

Endovascular Therapy for Central Venous Thrombosis

Central vein thrombosis is defined as thrombosis of the major vessels draining either the upper or lower extremities. It presents most commonly in the upper limb, where it affects the subclavian veins and the superior vena cava; in the lower limb, it affects the common iliac veins and the inferior vena cava. These different anatomical segments pose unique challenges in both acute and chronic settings, and this article will summarize the current best practice treatment options.

Use of Computed Tomography and Magnetic Resonance Imaging in Central Venous Disease

Successful management of acute deep vein thrombosis and post-thrombotic syndrome depends on careful patient selection and detailed investigation of thrombus extent, composition, and anatomy. This article reviews the use of computerized tomography and magnetic resonance imaging in the assessment of central deep veins of the pelvis and addresses new developments within the field. Despite drawbacks of each imaging modality, when contemplating deep venous reconstruction, cross-sectional imaging should be considered for preoperative planning and to compliment intraoperative imaging tools, including intravascular ultrasound and contrast venography.

Semaphorin 7a exerts pleiotropic effects to promote breast tumor progression

Understanding what drives breast tumor progression is of utmost importance for blocking tumor metastasis; we have identified that semaphorin 7a is a potent driver of ductal carcinoma in situ (DCIS) progression. Semaphorin 7a is a GPI membrane anchored protein that promotes attachment and spreading in multiple cell types. Here we show that increased expression of SEMA7A occurs in a large percentage of breast cancers and is associated with decreased overall and distant metastasis free survival. In both in vitro and in vivo models, shRNA mediated silencing of SEMA7A reveals roles for semaphorin 7a in the promotion of DCIS growth, motility, and invasion as well as lymphangiogenesis in the tumor microenvironment. Our studies also uncover a relationship between COX-2 and semaphorin 7a expression and suggest that semaphorin 7a promotes tumor cell invasion on collagen and lymphangiogenesis via activation of β₁-integrin receptor. Our results suggest that semaphorin 7a, may be novel target for blocking breast tumor progression.

Rationalising cross-match requests in vascular surgery is safe and cost effective

This study describes how a vascular centre rationalised their blood transfusion policy. A multidisciplinary panel reviewed data for blood transfusion protocols and implemented improvements that were analysed. The number of units cross-matched fell from 272 to 183 over a six month period. Unused blood reduced from 80% to 61%. The study concluded that rationalisation of cross matching policies is safe and provides cost and resource benefits.

The use of heparin in patients with ruptured abdominal aortic aneurysms

The use of systemic heparin in patients with ruptured abdominal aortic aneurysms (rAAAs) remains a contentious issue with no clear guidelines. This review reports the current understanding, at a molecular and clinical level, of the possible benefits and risks of heparin in emergency aneurysm repair (both open and endovascular). MEDLINE, EMBASE, AMED, SCOPUS, CINAHL and Cochrane Library were searched for all articles containing the keywords 'rupture', 'abdominal', 'aneurysm' and 'heparin'. Current experience, indications and outcomes were analyzed. Articles were searched for both endovascular and open repair of AAAs. A total of eight studies were included for analysis in the systematic review. Of these, only one paper focused specifically on heparin use in open repair of ruptures and suggested a benefit. Of the remaining seven, two were self-reporting retrospective studies assessing individual surgeons' practice, one was a case report and the remaining four included mention of heparin use but with no outcome data. The evidence available suggests that a pro-coagulable state exists in rAAAs. This may be responsible for the morbidity and mortality postprocedure, which arises predominantly from multiple organ failure and cardiac compromise rather than outright hemorrhage. This diathesis may respond well to heparin administration, suggesting that heparin administration in ruptured aneurysms is appropriate.

Assessment of surgical competence at carotid endarterectomy under local anaesthesia in a simulated operating theatre

Background

Methods of surgical training that do not put patients at risk are desirable. A high-fidelity simulation of carotid endarterectomy under local anaesthesia was tested as a tool for assessment of vascular surgical competence, as an adjunct to training.

Methods

Sixty procedures were performed by 30 vascular surgeons (ten junior trainees, ten senior trainees and ten consultants) in a simulated operating theatre. Each performed in a non-crisis scenario followed by a crisis scenario. Performance was assessed live by means of rating scales for technical and non-technical skills.

Results

There was a significant difference in technical skills with ascending grade for both generic and procedure-specific technical skill scores in both scenarios (P &lt; 0·001 for all comparisons). Similarly, there was also a significant difference in non-technical skill with ascending grade for both scenarios (P &lt; 0·001). There was a highly significant correlation between technical and non-technical performance in both scenarios (non-crisis: rs = 0·80, P &lt; 0·001; crisis: rs = 0·85, P &lt; 0·001). Inter-rater reliability was high (α≥ 0·80 for all scales).

Conclusion

High-fidelity simulation offers competency-based assessment for all grades and may provide a useful training environment for junior trainees and more experienced surgeons.

Long-term surveillance with computed tomography after endovascular aneurysm repair may not be justified

Background

There is a common perception that a large number of secondary interventions are needed following endovascular aortic aneurysm repair.

Methods

Prospective data were collected for a cohort of 417 consecutive elective patients undergoing infrarenal aortic endograft repair between April 2000 and May 2008. The rate of secondary interventions, associated morbidity and need for reintervention following surveillance imaging were analysed.

Results

The male : female ratio was 11 : 1, median age 76 (range 40–93) years and median aneurysm diameter 6·1 (5·3–11) cm. The overall 30-day mortality rate was 1·7 per cent (seven of 417). Secondary interventions were performed in 31 patients (7·4 per cent), of which six (1·4 per cent) were detected by surveillance. Endoleaks requiring reintervention occurred in 12 patients (2·9 per cent; ten type I and two type III endoleaks). Limb ischaemia secondary to graft occlusion occurred in 17 patients (4·1 per cent); extra-anatomical bypass was needed in 15 patients (3·6 per cent) and the remaining two had an amputation. Graft explantation following late infection was required in two patients (0·5 per cent).

Conclusion

Endoluminal repair of infrarenal aortic aneurysms can be performed with a low reintervention rate. The value of prolonged surveillance seems limited and current surveillance protocols may require revision.

Gaining consent for carotid surgery: a simulation-based study of vascular surgeons

AIM

Despite no formal training in consenting patients, surgeons are assumed to be competent if they are able to perform an operation. We tested this assumption for carotid endarterectomy (CEA).

METHODS

Thirty-two surgeons [Group 1: junior surgical trainees--performed 0 CEA's (n=11); 2: senior vascular trainees--1-50 CEA's (n=11); 3: consultant vascular surgeons - > 50 CEA's (n=10)] consented two patients (trained actors) for a local anaesthetic CEA. The performance was assessed at post hoc video review by two independent assessors using a validated rating scale and checklist of risk factors.

RESULTS

There was no difference in performance between the junior and senior trainees (1: median 91 range 64-121; 2: median 100.5 range 66-125; p=0.118 1 vs. 2 Mann-Whitney). There was a significant improvement between senior trainees and consultant surgeons (3: median 120 range 89-1 142; p=0.001 2 vs. 3). Few junior (1/11) and senior (2/11) trainees, and most (8/11) consultants, were competent. Inter-rater reliability was high (alpha=0.832). Consultant surgeons were significantly more likely to discuss cranial nerve injuries (p<0.0001 Chi-square test) as well as personal or hospital specific stroke risk (p<0.0001) than their junior counterparts. They were less likely to discuss infection (p<0.0001).

CONCLUSION

Senior trainees, despite being able to perform a CEA, were not competent in consent. The majority of consultant surgeons had developed competence in consenting even though they had no formal training.

Self-assessment of technical skill in surgery: the need for expert feedback

INTRODUCTION

Technical skill has been formally assessed in the Fellow of the European Board of Vascular Surgery Examinations (FEBVS) since 2002. The aim of this study was to examine the relationship between expert assessment and trainee self-assessment.

MATERIALS AND METHODS

Forty-two examination candidates performed a saphenofemoral junction (SFJ) ligation and an anterior tibial anastomosis on a synthetic simulation. Each candidate was rated by two examiners using a validated rating scale for their generic surgical skill for both procedures. Candidates then anonymously rated their own performance using the same scale. Parametric tests were used in the statistical analysis; a P-value < 0.05 was considered significant.

RESULTS

The maximum mark in each assessment was 40; 24 was considered a competent score. The interobserver correlation for examiners marks were high (SFJ ligation, alpha = 0.68; distal anastomosis, alpha = 0.76). Examiners' marks were averaged. The mean examiner score for the SFJ ligation station was 27.8 (SD = 4.1) with 36 candidates (85.8%) attaining a competent score. The mean self-assessment score for this station was 30.7 (SD = 4.66). The mean examiners' marks for the distal anastomosis station was 29.2 (SD = 4.2); 39 candidates (92.8%) attained a competent score. The mean self-assessment score was 32.1 (SD = 4.0). There was no correlation between examiner and self-assessment scores in either station (Pearson's correlation coefficient: SFJ, r = 0.045, P = NS); distal anastomosis, r = 0.089, P = NS). Bland and Altman plots assessed the agreement between examiner and self-assessment. These showed candidates marked themselves higher than examiners with a mean difference of 2.9 marks in each station.

CONCLUSIONS

Candidates' self-assessment and expert independent assessment correlate poorly. Trainees overestimate their ability according to independent assessment; regular technical feedback during training is, therefore, essential.

Thorascopic sympathectomy performed using laser

INTRODUCTION

Thorascopic sympathectomy is accepted as an effective treatment for palmar hyperhidrosis, facial blushing and to a lesser extent for digital ischaemia and axillary hyperhidrosis.

PATIENTS AND METHODS

Data were collected retrospectively on patients undergoing thorascopic sympathectomy at St Peter's Hospital between 1987 and 2006. Patients were followed up by telephone interview.

RESULTS

A total of 233 thorascopic sympathectomy procedures were performed by a single operator in 123 patients. Ages ranged from 9-71 years and 75 were women. In patients, 105 had a bilateral and 13 a unilateral procedure, 5 patients had a bilateral procedure performed in two stages. In 6 upper limbs, the procedure could not be done. Overall, 110 patients (90%) had the procedure performed for palmar hyperhidrosis, 8 (6%) for facial blushing and in 5 (4%) patients the operation was performed for digital ischaemia with tissue loss. There were no deaths and all patients were discharged on day 1 following the procedure. Complications included bleeding (2), pulmonary oedema (1) and failed procedure (2); however, no incidences of Horner's syndrome occurred. Only 40 of 123 (32.5%) patients gave follow-up information. Of this small group, 33 of 40 (83%) were cured, 4 of 40 (10%) were better, 2 of 40 (5%) were unchanged and 1 patient was worse. Only 22 out of 40 (55%) of these patients were troubled by compensatory sweating, with only 4 of 40 (10%) reporting this as a major problem.

CONCLUSIONS

Thorascopic sympathectomy is safe and can be carried out as a single bilateral procedure in the majority of cases. The laser allows the use of a single port, requires less dissection than surgical or clipping techniques, is more precise than diathermy and may be less likely to cause a Horner's syndrome.

Simulated anaesthetists in high fidelity simulations for surgical training: feasibility of a training programme for actors

BACKGROUND

High fidelity simulations within the operating theatre (OT) require physical infrastructure and a full OT team. Such teams place heavy demands on clinical service. Research and training programmes in our surgical department were often compromised by the late cancellation of anaesthetists.

AIMS

This paper describes and evaluates a training programme in which actors were trained as simulated anaesthetists.

METHODS

The training programme was developed, piloted and implemented in a surgical education programme. Evaluation consisted of interviews with actors after the series of simulations. Surgical participants were not informed that the anaesthetist was an actor until after the simulation when they completed an interview and a 10-point authenticity scale (1 = not at all to 10 = highly authentic).

RESULTS

Three actors played the role of anaesthetists in 34 scenarios with 17 surgeons in simulations of carotid endarterectomy. Although initially anxious about their role, actors found the training programme valuable and came to feel confident. Mean ratings of anaesthetist authenticity was 8.1 (Range 2-10). Surgeons' comments showed that in most scenarios they found the anaesthetist's performance highly authentic.

CONCLUSIONS

Although this study demonstrates the feasibility of using actors as anaesthetists in high fidelity surgical simulations, there are also limitations. Factors contributing to success included: selective actor recruitment; written training materials; formal OT orientation, audio link between the control room and the actor; the opportunity to rehearse; and, structured observations.

Competence assessment of senior vascular trainees using a carotid endarterectomy bench model

Background

Competency-based assessment is being introduced to surgical training. The value of bench-top technical skills assessment using a synthetic carotid endarterectomy (CEA) model was evaluated in vascular trainees and consultants.

Methods

Forty-one surgeons (13 junior trainees, 15 senior trainees and 13 experienced consultants with experience of more than 50 CEAs) performed a three-throw knot-tying exercise on a jig and a CEA on the bench model. A composite score for knot-tying was calculated, incorporating electromagnetic motion analysis. CEA technical skill was assessed using validated rating scales by blinded video analysis.

Results

Senior trainees performed better than junior trainees in knot-tying (P = 0·025) as well as generic (P &lt; 0·001) and procedural (P &lt; 0·001) skills on CEA model assessment. There was no difference between senior trainees and consultants on any of these measures. The CEA model interobserver reliability was high for all rating scales (generic α = 0·974, procedural α = 0·952, end-product α = 0·976).

Conclusion

Senior trainees achieved the same score as consultants, suggesting a similar level of basic technical skill and knowledge required to perform CEA, and were significantly better than junior trainees. Performance on the bench model could provide an early assessment for suitability to proceed to operative training in a competency-based training and assessment programme.