get rid

The Rouleaux Club

hello and welcome to this british

journal of surgery podcast I'm Wendy

Barnaby and this is a podcast with the

difference it's for members of the rule

oak lub of trainee vascular surgeons

we're having a conference call with

three of them dotted around the country

they are mr. Simon Hobbs at New Cross

Hospital Wolverhampton mr. Fehmi ocean

from the Royal Liverpool Hospital and

mr. Robert Hinchcliffe absent George's

Vascular Institute in London they've

chosen some bjs papers that they think

would be of particular interest to their

fellow trainees each of them has picked

up two papers that they'd like to

recommend so first of all let's hear

from mr. Simon Hobbs at New Cross

Hospital in Wolverhampton salmon what's

your first choice well first we've got

is a case-controlled comparison of

profunda plasti and femoropopliteal soo

particular bypass for peripheral

arterial disease and is by cos the only

at AU from Bond University Medical

School we are looking at in this paper

at the sort of situation that smokers

can find themselves in with hardening of

the arteries when the superficial

femoral artery is blocked and surgeons

have to restore circulation and so they

have two different options they can

operate on the profunda femoral artery

to reconstruct it do a profunda plasti

which is a short operation or they can

bypass the occluded segment of the

superficial femoral artery in other

words do a fem row to above the knee

popliteal surgery and that's the

treatment of choice isn't it but it's

longer and riskier than the profunda

plasti so do you think profunda plasti

has a role in 2010 yes I I think it does

have a role but i think it's it's

difficult to define and this study may

not be sort of have all the answers the

final puzzle can be used on its own or

certain my clinical practice more often

in conjunction with other techniques

such as in flow procedures femoral

endarterectomy zor with the distal

bypasses certainly as a sole treatment

it may well have a role in subjects who

perhaps not suitable for as you said the

gold standard bypass perhaps those

without a decent vein and impacting

those who are unfit or needs a simple

procedure under local anesthetic for

example so you wouldn't think it's a

question of either or as this study sets

it up I don't think so and I mean

certainly in my practice I would tend to

use both of them in conjunction I

suppose that's one area that this study

doesn't help to clarify it sounds it

doesn't actually help to define the role

of these different procedures or by

themselves no I guess I guess there are

a number of issues with this study it's

not a a randomized control study which

are so it recognizes the better quality

studies it is a retrospective case

control which has some merits but also

does introduce a number of biases it's

also not entirely clear of the exact

inclusion criteria used to define which

patients got which treatment certainly I

would like to see as well evidence that

yes or looking at both of the treatments

in combination and this paper suggests

that both treatments have some efficacy

but does combining both treatments can

improve that Africa's efficacy well tell

us about your second paper the second

paper is this time is a randomized

controlled file and it's a randomized

clinical trial of distal anastomotic

interposition vein cuff in infra ingre

nawl polytetrafluoroethylene bypass

grafting and it's by Griffis a towel on

behalf of the the joint vascular

research group right now this is about a

decision that arises in bypass surgery

above or below the knee when the surgeon

is using a prosthetic bypass graft and

the question is whether to use a miller

cuff a two to three millimeter length of

vein material where the bypass graft

joins the artery again why do you think

one might use a prosthetic lower limb

bypass well plus I think if I was a use

for many reasons and generally when

there is no adequate vain to use for a

conventional buy passes away with vein

in my opinion prosthetic bypasses should

be reserved solely for limb Salvage

procedures in subjects who do not have

sufficient autologous vein in the leg or

or in the arm and perhaps where no other

treatment options for example

angioplasty you are available so really

when you're in a pretty extreme

situation I think so yes although that

there are other groups who would be more

sort of free in their use of prosthetic

material do you think it should be

routine to use the cuff at the join

between the prosthetic graft and the

artery I think on the basis of this

paper it appear that cuffing should not

necessarily be routine for prosthetic

bypasses to the above knee popliteal

artery but perhaps should be routine for

why person's going below the knee joint

to the Bologna popliteal artery I guess

a caveat to this statement is thus

although cuffing appears to

significantly improve patency rates of

Bologna graphs this did not necessarily

translate into improved limb Salvage

rates this might simply be a reflection

of reasonably small numbers of patients

in this in the study but I think should

be borne in mind furthermore the study

only assess PTFE graphs whilst the

result probably we would be transferable

to other prosthetic materials this has

not necessarily been investigated in

this study how do you think we can

minimize the number of prosthetic

bypasses that are done I think for the

most important factor is to perform

these procedures in special sensors with

surgeons who have a specific interest in

these forms of bypasses I think these

surgeons will probably probably take a

more aggressive policy of using vein

wherever possible and reserving

prosthetic material for those cases

where that is not not possible I think

there's a strong argument for good

preoperative assessment of patients in

terms of vein mapping to try and find

the most suitable vein in

preoperative periods and the final

things I think there would be an

increasing role for endovascular

treatment are you doing angioplasties

rather than perhaps additional surgery

which may or minimize or reduce the need

for doing open surgical procedures vary

your papers are about varicose veins

what's the first one the first one that

I'm going to talk about is the

randomized is a randomized clinical

trial of radiofrequency ablation or

conventional high ligation and stripping

of the great saphenous varicose veins

and this is a paper by subramanya Etta

oh and mr. Tim Lee's and it comes from

kingsmill hospital and northern vascular

center in Newcastle this is about the

best way to treat varicose veins isn't

it whether it's better to use

conventional surgery or radiofrequency

ablation that technique that uses

electrodes to generate heat which which

closes the vein first of all what are

the indications for treating varicose

veins when do they need treatment

varicose veins are largely benign

disease however they can eventually lead

to discoloration and thickening of the

skin condition called lipo demato

sclerosis ultimately may result in

ulcers these veins may also subject to

clots as well which can result in the

brightest or inflammation of the veins

and it is really that the spectrum of

the lastly three things that I talked

about rid of the ulcers the skin changes

and also the summer for bitis that's

triggers treatment but as is well known

the majority of veins aren't treated for

cosmetic reasons really and I gather

there are some problems with

conventional surgery what are they well

you've got to remember the conventional

surgery is an invasive procedure and

when we talk about conventional surgery

we're usually talking about the ligation

and stripping of the great saphenous

vein in order to achieve this one needs

to sort of needs to perform an incision

in the groin in order to disconnect it

from disconnect the superficial vein

from the deep venous system

and then physically remove the great

saphenous vein by stripping it out so

this is in itself a fairly brutal

procedure which can result in sim

bleeding and like all surgical

procedures is also prone to wound

infections following the initial

procedure another problem with stripping

of the great saphenous vein is the fact

that you have some cutaneous nerves

which run in close proximity to the vein

and these may be damaged during the

procedure and lead to altered sensation

or a complete loss of sensation in the

worst-case scenario so do you think that

a radiofrequency ablation is the answer

I think radiofrequency ablation

certainly from this trial and other

trials has demonstrated that these

potential outcomes which are related to

open surgery may be avoided the

certainly reduced incidence of wound

infection and this trial has

demonstrated like others that people

return to work quicker possibly because

they do not have to deal with the same

level of post-operative pain however

like all types of endovascular

procedures the main limitation is

patient's Anatomy and in this sort of

procedure one needs a fairly straight

great saphenous vein in order to in

order to treat the patient however that

is not always the case and I think that

they're you know they're still will be a

place for open surgery in some instances

so it sounds as though radiofrequency

ablation could be a good technique in

many cases but not all no certainly not

all the other alternative perhaps is you

know another form of Venus ablation

which uses chemical therapy and using a

sclerosing in such cases so the end of

Venus treatment is those possibility but

there is limited experience with using

foam sclerotherapy for the great

saphenous vein it's not something that

some people are comfortable doing now

family what what's your second choice

this is also about varicose vein surgery

yes I second choice

is a randomized clinical trial of

co-amoxiclav versus no antibiotic

prophylaxis in varicose vein surgery and

this is a paper by macaco and it's a

towel from Hull and this is about

whether it's a good idea to give

antibiotics prophylactically for

varicose vein surgery or not the idea

being to reduce the rate of groin wound

complications following the surgery

that's correct what are the main results

of this trial then well I mean this

trial essentially demonstrates that in

patients in whom prophylactic

antibiotics were given preoperatively

the incidence of wounded fashion as

determined by a validated a sepsis wound

score was lower and it was also an

association between increasing body mass

index and concurrent smoking with poorer

wound outcomes after the initial

procedure is it a particularly well

designed study I think was a very

well-designed study I mean it's plus

points are that it is a randomized

controlled trial and the the the primary

outcome measure was clear and also the

way in which the primary can measure was

determined as in username validated

scoring method and were there any

confounding factors well I think the

main concern of factor was that was the

study was well designed the outcome

measures were determined by the

patient's themselves in that determining

whether a lottery wound appeared to be

infected was determined by each patient

having a a diary in which they recorded

the appearances of the wound and using

the patient's own observations the score

was given to each wound a problem with

that is that even amongst trained

individuals there's a degree of

subjectivity looking at wound but this

is much less with medically trained

personnel and so the validity of the

differences between the two groups may

be called into question

particularly as 14 days afterwards when

everybody was reviewed by somebody who

has medically trained there were no

statistically significant differences

between the two groups still I mean the

results saying that the antibiotic

should be given routinely especially if

patients are obese or or a current

smokers it sounds reasonably convincing

doesn't it would you use prophylaxis

routinely then in future on the basis of

this I think the main thrust of this

paper was to determine whether or not

prophylactic antibiotics should be used

in clean surgery where the incidence of

wound infection is very low to begin

with certainly what they have

demonstrated is that it is associated

with smoking and increased body mass

index and one perhaps have to think that

an increase in body mass index equates

to patients where the operation itself

is difficult and as such i think more

attention to surgical technique is

warranted but in terms of my own

personal practice i think i probably

tend to be more selective rather than

routinely use it i don't think this

paper has provided enough evidence to

suggest routine use of prophylactic

antibiotics in the treatment of varicose

veins now let's turn to mr. Rob

hinchliffe of some George's Vascular

Institute in London Rob your two choices

are about surgery for repairing a autók

aneurysms which paper you're going to

talk about first I will talk about the

Thompson paper which is the growth rates

of small abdominal aortic aneurysms

correlate with thankful event here the

authors were analyzing data from

screening abdominal aortic aneurysms to

see if they could find any factors that

would predict when surgery would be

needed or even when the aneurysm might

rupture so what does this study tell us

that we didn't know before about the

growth of abdominal aortic aneurysms I

think it is very important and

interesting studies from the chi chester

group who have a wealth of experience

and I'm Tom alt cameras

and pride felicity we generally believed

that the natural history of abdominal

think aneurysms was to dilate and

rupture unless the patient died of

another cause however this study really

showed as a perhaps that wasn't the case

and that there may be sort of two groups

of patients one group who continued to

expand and dilate and require surgery or

rupture and another group who who really

wouldn't do that and that really sort of

change the way that we think about these

problems so what implications does it

have the screening I think the main

implication is that we may well be able

to identify cohorts of patients who

really don't require such intensive

screening and other cohorts of patients

who may well require more intense

screening to prevent their owners and

rupturing the patients who have

abdominal aortic aneurysm growth of two

millimeters per year we may well put

into a more intense schedule whereas

those patients who have a aneurysm which

grow as much less than that less than

two millimeters per year really perhaps

may not actually require which intense

surveillance and may actually not

require any further screening after the

first couple of scam and do you think

that's the most important thing to do in

the future then or does it have any

other implications for what you should

be doing I think certainly these funny

needs to be confirmed in another study

and the using the National Adam aortic

aneurysm screening program to to do some

further research on the factors which

may be associated with aneurysm growth

and and rupture would be very worthwhile

and then I seven thinking will probably

result in a prospective randomized trial

to try and identify and confirm those

findings now what about your second

paper Rob what's that that is by black

it out and that's long-term surveillance

with computed tomography after

endovascular aneurysm repair may not be

justified right so this is about the

best after care for patients whose a

orders have been repaired below the

kidney they've had a stint positions in

the

to part of the aorta and specifically

whether you need to do routine scans of

the site of the operation afterwards to

see whether it might need a bit more

attention I mean what sort of attention

might you have to give it what are the

long-term risks of endovascular stenting

but certainly endovascular and there has

been heavily scrutinized because

especially the first and probably the

second generation of aortic stanga's

there were a number of problems

including leaks around this dental what

we call vendo leaks they were spent

fractures migration of the innocence and

kinky and z of the eye that limbs so

there's a real long-term risks and

obviously there have been a problem in

the past with in the region of forty

percent five years requiring re

intervention in a large evar trial so on

the basis of this paper do you think

that we need routine scans to avoid that

I think there are several issues I think

the authors have used probably what's

been to be one of the better stent

grafts which is second or third

generation design and what they found

was that many of the interventions were

required in the first three months and

it may be with better imaging within the

first three months that the number of

these issues may have been identified

and prevented and certainly what they

also seem to suggest was that routine

surveillance of the air things Angus

didn't necessarily prevent the

complications or predict intervention

and actually only six out of the 31

people who had complications were

detected by the surveillance imaging it

doesn't sound a huge number does it I

think he's reverted to be interesting

because in most units the number of

scams and surveillance images required

are take a heavy toll on the resources

that any unit has and if we can actually

I didn't find those groups a high-risk

then that will be ideal to reduce the

amount of resources spent yeah so what

do you think the ideal surveillance

regimen would be well I think probably

they we should really be moving away

from

in CT scanning I think he's quite clear

from the paper that the vast majority of

complications appear early in the

post-operative course we should probably

be using a number of different

modalities early on and the group runs

and George's have used 3d rotation and

geography at the end of the procedure

which is very similar to CT scanning and

thatís really reduced the number of

secretary interventions and

complications within the first month

also I think long-term CT surveillance

probably now isn't warranted and a lot

of units have actually made the move

over from routine CT surveillance to

duplex ultrasound scanning and some unix

use abdominal x-rays to identify extent

fractures well thank you all very much

indeed for that and we hope that the

rule o club has enjoyed this run down of

useful papers we hope you'll come back

and listen to our future podcasts

goodbye

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