Search

Introduction In 2012, the Rouleaux Club published their survey claiming large deficits in venous training. Since then vascular surgery has become its own specialty with a dedicated section of the curriculum for superficial venous intervention. The aim of this study was to assess whether the introduction of the new curriculum has improved current Rouleaux Club members training in superficial venous intervention. Method A trainee designed survey was developed and distributed to UK vascular surgery trainees in summer 2017. Results We received 55 (41.0%) responses. Training in endovenous procedures was available to 100% of trainees, and open surgery was only available to 43.2% of trainees; 86.5% of centres used endovenous procedures as the default intervention Only 75.7% of respondents were timetabled for dedicated superficial venous intervention lists; 72.7% have not received any formal training in duplex ultrasonography. Higher self-reported procedural competence was associated with greater numbers of procedures rather than training grade seniority. Conclusion It seems that despite a separate curriculum there are still self-reported trainee deficits in competence and skills. Low respondent levels (41%) should be considered but there is a potential problem for future venous practice.

Objectives Venous thromboembolism is a potentially fatal complication of superficial endovenous treatment. Proper risk assessment and thromboprophylaxis could mitigate this hazard; however, there are currently no evidence-based or consensus guidelines. This study surveyed UK and Republic of Ireland vascular consultants to determine areas of consensus. Methods A 32-item survey was sent to vascular consultants via the Vascular and Endovascular Research Network (phase 1). These results generated 10 consensus statements which were redistributed (phase 2). ‘Good’ and ‘very good’ consensus were defined as endorsement/rejection of statements by >67% and >85% of respondents, respectively. Results Forty-two consultants completed phase 1. This generated seven statements regarding risk factors mandating peri-procedural pharmacoprophylaxis and three statements regarding specific pharmacoprophylaxis regimes. Forty-seven consultants completed phase 2. Regarding venous thromboembolism risk factors mandating pharmacoprophylaxis, ‘good’ and ‘very good’ consensus was achieved for 5/7 and 2/7 statements, respectively. Regarding specific regimens, ‘very good’ consensus was achieved for 3/3 statements. Conclusions The main findings from this study were that there was ‘good’ or ‘very good’ consensus that patients with any of the seven surveyed risk factors should be given pharmacoprophylaxis with low-molecular-weight heparin. High-risk patients should receive one to two weeks of pharmacoprophylaxis rather than a single dose.

Summary Background The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p

Objective Published in July 2013, National Institute for Health and Care Excellence Clinical Guideline 168 (CG168) recommended that people with bleeding varicose veins be referred immediately to a vascular service. We have examined the impact of CG168 on referral practice for patients with bleeding varicose veins from primary to secondary care in a local National Health Service setting. Methods Referrals to a local vascular service in the 6 years before (group 1) and 6 years after (group 2) publication of CG168 were analyzed to assess patients' management after a bleed, with particular reference to a patient's initial presentation and delays in referral to the vascular service. This was done by retrospective electronic database and case note interrogation of patients presenting with bleeding varicose veins. Relevant data were collected onto an Excel spread sheet (Microsoft, Redmond, Wash) in relation to demographic information, comorbidities, clinical presentation, and treatment pathway. Results During the period studied, 73 patients presented with bleeding varicose veins. Their mean age was 66 years, and 56% were men. Their mean body mass index was 28 kg/m2. Of note, 33 patients (45%) initially self-treated before going to see their general practitioner; another 18 (25%) went to the emergency department. In 51 patients (70%), the underlying superficial disease involved the great saphenous vein, and most patients (73%) were treated with foam sclerotherapy with or without truncal thermal ablation; 45 patients (group 1) were treated in the 6 years before publication of CG168, and 28 patients, allowing 6 months for dissemination, were treated in the 6 years after CG168 publication (group 2). Mean time from index bleed to referral to the vascular service was faster after publication of CG168 (84 days before and 20 days after publication of CG168; P = .00842). Publication of CG168 was also associated with reduced mean bleed to intervention times (194 vs 60 days; P = .00097). Conclusions Publication of UK National Institute for Health and Care Excellence guideline CG168 has been associated with a significant reduction in the delay to referral of patients presenting with bleeding varicose veins; however, the goal of immediate referral to a vascular service is not being met. CG168 is likely to have been a significant component of the factors that have led to the improvements seen thus far.

Background Thermal ablation, usually performed with tumescent local anaesthesia (TLA), is the preferred method for varicose veins treatment. Tumescent local anaesthesia is always cited; however, little detail of the procedure is presented in publications. This retrospective audit of clinical tumescent local anaesthesia practice aims to provide detailed information on an important aspect of endovenous practice. Methods Patients who underwent three types of endothermal treatment (Venefit, Radiofrequency Induce Thermal Therapy and Endovenous Laser Ablation) to a single saphenous trunk using tumescent local anaesthesia were assessed. Differences in tumescent local anaesthesia volume per unit length of treated vein were assessed for the followings: type of saphenous trunk, length of vein treated, effect of additional phlebectomy and bilateral versus interval unilateral treatment for bilateral veins. Descriptive data are reported as mean and standard deviation, and groups were compared using the one-way ANOVA test. Results Between 2008 and 2014, single-saphenous-trunk ambulatory TLA thermal ablation was performed in 979 patients, mean age was 54 years. A total of 1229 limbs had truncal ablations and synchronous phlebectomy was performed in 470 limbs. No tumescent local anaesthesia-related complications occurred. There was no significant difference in standardised tumescent local anaesthesia volume per centimetre (ml) used for the three devices. Tumescent local anaesthesia volume per centimetre (ml) differed significantly between saphenous trunks. On average, a standard 10–12 ml/cm of tumescent local anaesthesia was used for saphenous trunks. Mean total tumescent local anaesthesia volume per patient, when treating the great saphenous vein alone, was 931 ml for bilateral and 425 ml for unilateral treatment. Conclusion This report of over 1000 endovenous procedures demonstrates safe performance of laser and radiofrequency treatments using tumescent local anaesthesia. Although no attempt was made to determine minimum volume requirements, a mean tumescent local anaesthesia volume of 10–12 ml/cm administered to the perivenous space provides adequate anaesthesia for truncal saphenous ablation.

Objective Management of pelvic vein disorders possibly contributing to leg varicose veins remains variable and controversial. This survey investigated practice in the UK. Methods Email questionnaire to 328 members of the Vascular Society. Results One hundred and four (32%) questionnaires were returned. Of 100 respondents treating varicose veins, 9% do not recognise pelvic vein reflux and 11% never investigate or treat it. Indications for investigation include labial (94%) and buttock/upper thigh (70%) varicose veins: 46% use magnetic resonance venography and only 16% transvaginal duplex. Treatments used are coil embolization (89%), sclerotherapy via thigh veins (47%) and transcatheter sclerotherapy (26%). Thirty-four per cent treat only ovarian veins (not internal iliac tributaries). Follow-up is by clinical response (100%): only 14% use duplex. Only 5% treat >10 patients annually. Conclusions There is substantial variation in the management of pelvic vein reflux in the UK. There is need for further consensus and good clinical trial evidence to guide practice.

This randomized clinical trial uses data from the Early Venous Reflux Ablation trial to evaluate the long-term clinical and cost benefits of combined early endovenous ablation and compression compared with compression therapy alone and deferred ablation for treating superficial venous reflux of the leg., Key Points Question In patients with venous leg ulceration and superficial reflux, what is the clinical and cost-effectiveness of early endovenous ablation of reflux? Findings In this 450-patient, multicenter, randomized clinical trial, early endovenous ablation with compression accelerated venous ulcer healing, reduced the overall incidence of ulcer recurrence, and was highly cost-effective compared with compression with deferred intervention. Meaning To deliver clinical and cost benefits, leg ulcer care pathways should be revised to include early assessment and treatment of superficial venous reflux., Importance One-year outcomes from the Early Venous Reflux Ablation (EVRA) randomized trial showed accelerated venous leg ulcer healing and greater ulcer-free time for participants who are treated with early endovenous ablation of lower extremity superficial reflux. Objective To evaluate the clinical and cost-effectiveness of early endovenous ablation of superficial venous reflux in patients with venous leg ulceration. Design, Setting, and Participants Between October 24, 2013, and September 27, 2016, the EVRA randomized clinical trial enrolled 450 participants (450 legs) with venous leg ulceration of less than 6 months’ duration and superficial venous reflux. Initially, 6555 patients were assessed for eligibility, and 6105 were excluded for reasons including ulcer duration greater than 6 months, healed ulcer by the time of randomization, deep venous occlusive disease, and insufficient superficial venous reflux to warrant ablation therapy, among others. A total of 426 of 450 participants (94.7%) from the vascular surgery departments of 20 hospitals in the United Kingdom were included in the analysis for ulcer recurrence. Surgeons, participants, and follow-up assessors were not blinded to the treatment group. Data were analyzed from August 11 to November 4, 2019. Interventions Patients were randomly assigned to receive compression therapy with early endovenous ablation within 2 weeks of randomization (early intervention, n = 224) or compression with deferred endovenous treatment of superficial venous reflux (deferred intervention, n = 226). Endovenous modality and strategy were left to the preference of the treating clinical team. Main Outcomes and Measures The primary outcome for the extended phase was time to first ulcer recurrence. Secondary outcomes included ulcer recurrence rate and cost-effectiveness. Results The early-intervention group consisted of 224 participants (mean [SD] age, 67.0 [15.5] years; 127 men [56.7%]; 206 White participants [92%]). The deferred-intervention group consisted of 226 participants (mean [SD] age, 68.9 [14.0] years; 120 men [53.1%]; 208 White participants [92%]). Of the 426 participants whose leg ulcer had healed, 121 (28.4%) experienced at least 1 recurrence during follow-up. There was no clear difference in time to first ulcer recurrence between the 2 groups (hazard ratio, 0.82; 95% CI, 0.57-1.17; P = .28). Ulcers recurred at a lower rate of 0.11 per person-year in the early-intervention group compared with 0.16 per person-year in the deferred-intervention group (incidence rate ratio, 0.658; 95% CI, 0.480-0.898; P = .003). Time to ulcer healing was shorter in the early-intervention group for primary ulcers (hazard ratio, 1.36; 95% CI, 1.12-1.64; P = .002). At 3 years, early intervention was 91.6% likely to be cost-effective at a willingness to pay of £20 000 ($26 283) per quality-adjusted life year and 90.8% likely at a threshold of £35 000 ($45 995) per quality-adjusted life year. Conclusions and Relevance Early endovenous ablation of superficial venous reflux was highly likely to be cost-effective over a 3-year horizon compared with deferred intervention. Early intervention accelerated the healing of venous leg ulcers and reduced the overall incidence of ulcer recurrence. Trial Registration ClinicalTrials.gov identifier: ISRCTN02335796

Background Venous ulceration is a common and costly health-care issue worldwide, with poor healing rates greatly affecting patient quality of life. Compression bandaging has been shown to improve healing rates and reduce recurrence, but does not address the underlying cause, which is often superficial venous reflux. Surgical correction of the reflux reduces ulcer recurrence; however, the effect of early endovenous ablation of superficial venous reflux on ulcer healing is unclear. Objectives To determine the clinical effectiveness and cost-effectiveness of compression therapy with early endovenous ablation of superficial venous reflux compared with compression therapy with deferred endovenous ablation in patients with venous ulceration. Design A pragmatic, two-arm, multicentre, parallel-group, open randomised controlled trial with a health economic evaluation. Setting Secondary care vascular centres in England. Participants Patients aged ≥ 18 years with a venous leg ulcer of between 6 weeks’ and 6 months’ duration and an ankle–brachial pressure index of ≥ 0.8 who could tolerate compression and were deemed suitable for endovenous ablation of superficial venous reflux. Interventions Participants were randomised 1 : 1 to either early ablation (compression therapy and superficial endovenous ablation within 2 weeks of randomisation) or deferred ablation (compression therapy followed by endovenous ablation once the ulcer had healed). Main outcome measures The primary outcome measure was time from randomisation to ulcer healing, confirmed by blinded assessment. Secondary outcomes included 24-week ulcer healing rates, ulcer-free time, clinical success (in addition to quality of life), costs and quality-adjusted life-years (QALYs). All analyses were performed on an intention-to-treat basis. Results A total of 450 participants were recruited (224 to early and 226 to deferred superficial endovenous ablation). Baseline characteristics were similar between the two groups. Time to ulcer healing was shorter in participants randomised to early superficial endovenous ablation than in those randomised to deferred ablation [hazard ratio 1.38, 95% confidence interval (CI) 1.13 to 1.68; p = 0.001]. Median time to ulcer healing was 56 (95% CI 49 to 66) days in the early ablation group and 82 (95% CI 69 to 92) days in the deferred ablation group. The ulcer healing rate at 24 weeks was 85.6% in the early ablation group, compared with 76.3% in the deferred ablation group. Median ulcer-free time was 306 [interquartile range (IQR) 240–328] days in the early ablation group and 278 (IQR 175–324) days in the deferred endovenous ablation group (p = 0.002). The most common complications of superficial endovenous ablation were pain and deep-vein thrombosis. Differences in repeated measures of Aberdeen Varicose Vein Questionnaire scores (p p = 0.03) and Short Form questionnaire-36 items body pain (p = 0.05) over the follow-up period were observed, in favour of early ablation. The mean difference in total costs between the early ablation and deferred ablation groups was £163 [standard error (SE) £318; p = 0.607]; however, there was a substantial and statistically significant gain in QALY over 1 year [mean difference between groups 0.041 (SE 0.017) QALYs; p = 0.017]. The incremental cost-effectiveness ratio of early ablation at 1 year was £3976 per QALY, with a high probability (89%) of being more cost-effective than deferred ablation at conventional UK decision-making thresholds (currently £20,000 per QALY). Sensitivity analyses using alternative statistical models give qualitatively similar results. Limitations Only 7% of screened patients were recruited, treatment regimens varied significantly and technical success was assessed only in the early ablation group. Conclusions Early endovenous ablation of superficial venous reflux, in addition to compression therapy and wound dressings, reduces the time to healing of venous leg ulcers, increases ulcer-free time and is highly likely to be cost-effective. Future work Longer-term follow-up is ongoing and will determine if early ablation will affect recurrence rates in the medium and long term. Trial registration Current Controlled Trials ISRCTN02335796. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 24. See the NIHR Journals Library website for further project information.

Objective To report a case of femoral vein thrombosis in a carpet fitter and to highlight this as an occupational hazard. Method Case presentation and literature review. Results An otherwise fit 21-year-old carpet fitter with no past medical history presented with acute thrombosis of his left common femoral, superficial femoral and great saphenous veins. Attempted catheter directed thrombolysis was unsuccessful. Due to severe pain and the threat of venous gangrene he was treated by emergency surgical thrombectomy with excision of chronic venous scarring and vein-patch repair that led to resolution of his symptoms. Conclusions Deep vein thrombosis is typically associated with factors such as increasing age and prolonged periods of immobility; however, certain ‘active’ occupations can increase its risk. Crouched and cramped working conditions including repetitive active movement with flexed hips and knees can predispose to increased risk of venous thromboembolism.

Objective: To assess the outcome after transthoracic endoscopic sympathectomy (TES) for upper limb hyperhidrosis. Design: Prospective cohort study. Setting: District general hospital. Subjects: Consecutive patients undergoing TES for upper limb hyperhidrosis over a fifteen month period. Interventions: One-stage bilateral TES. Main outcome measures: Change in quality of life as shown by the Short Form-36 health assessment questionnaire. Results: Sixteen patients (11 women and 5 men, median age 26 years) underwent operation without complications. At median follow-up of 6.2 months, symptomatic improvement was found in 26 of 32 limbs treated (82%). Truncal compensatory hyperhidrosis was reported by 13 patients but was severe in only three. There were significant improvements in social function (p = 0.01) and mental health (p = 0.025) as assessed by the SF-36. Conclusion: Despite a high incidence of compensatory hyperhidrosis, TES improved both the symptoms and overall quality of life in patients with upper limb hyperhidrosis. Copyright © 1998 Taylor and Francis Ltd.

The authors present a case to illustrate a possible mechanism by which gut microorgan isms may infect the aorta, and they discuss the probable etiology of the finding.

A middle-aged man with a history of Hodgkin's disease presented with loin pain and microscopic hematuria. Radiologic studies demonstrated a urinoma secondary to ureteric obstruction at the pelvic brim. Percutaneous nephrostomy was performed to decompress the collection and a ureteric stent inserted to maintain drainage. Laparotomy revealed an unsuspected rectal adenocarcinoma. A metastatic deposit compressing the ureter had produced the urinoma. Metastatic colorectal carcinoma is a rare cause of urinoma.

The presentation of change of bowel habit, weight loss, muscle wasting, ascites, and the surgical appearance of "omental cake" are almost pathognomonic of advanced gastrointestinal malignancy. In our case, these symptoms represented a unique presentation of the condition sclerosing mesenteritis. Despite its rarity, the clinician should be aware of this "sheep in wolf's clothing," the clinical importance of which lies in the condition's benign and self-limiting course and imparts to the patient a prognosis and treatment that could not be further removed from that of advanced malignancy. Investigations that may be helpful to the surgeon in distinguishing the condition from carcinomatosis and avoiding unnecessary laparotomy include preoperative colonoscopy, barium enema, cytology of any ascites, and intraoperative frozen section biopsy. Treatment of the condition is conservative unless it has caused extrinsic bowel obstruction.

Introduction: A case report of direct vancomycin irrigation as management of retroperitoneal abscess following removal of infected aortic graft. Case Report: A 63-yearold man presented nine years following aortic aneurysm repair with recurrence of aneurysm. At re-operation, aortic graft infection was diagnosed and managed with graft excision, debridement, axillo-bifemoral bypass and prolonged systemic antibiotics. The abscess failed to resolve. Direct vancomycin irrigation via percutaneous drainage catheter led to resolution of infection. Conclusion: There is little evidence to support vancomycin irrigation as treatment after removal of infected aortic grafts. Such an approach may be considered in patients failing to respond to traditional therapy.

EDITOR,—Deborah A Simon and colleagues' study provides further evidence supporting the role of community based clinics in the management of leg ulcers.1 These specialised local clinics provide skill in managing leg ulcers close to patients' homes and have influenced healing and cost effectiveness.2 Our only concern with this study is that no patient was referred for venous investigation or surgery. We, like others, have shown that superficial venous disease alone is present in about half of patients with venous ulceration. …