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2. Q&A with Professor Michael P Jenkins, VS President

 

Professor Michael P Jenkins, VS President - discusses the

NICE AAA guidelines & EVAR

 

Q: Following publication of NICE guidance for Repair of AAA this March 2020, how do you think this will change practice in the UK and effect patient outcomes? Will you change your practice?

A: Yes. There has already been a change in practice (as evidenced by NVR), since the release of the draft guidelines. I think there may be a further shift to both some more open surgery and some (at the more frail/elderly end of the spectrum) being managed conservatively.

 

Q: Will there be an impact on vascular surgical trainees?

A: Yes. This is not as bad in the UK as in the US where some areas are >90% EVAR. It is predicted that in some Fellowship programmes that trainees will be appointed having done <5 open repair aneurysms. Not quite so bad in the UK, but the previous thinking 0f “all will be EVARs in the future so no need to learn open repair” is now being re-evaluated.


Q: Can you comment on the recommendation for monitoring post EVAR?

1.7 Monitoring for complications after endovascular aneurysm repair

1.7.1 Enrol people who have had endovascular aneurysm repair (EVAR) into a surveillance imaging programme.

1.7.2 Base the frequency of surveillance imaging on the person's risk of EVAR-related complications.

1.7.3 Consider contrast-enhanced CT angiography or colour duplex ultrasound for assessing abdominal aortic aneurysm (AAA) diameter and EVAR device limb kinking.

1.7.2 Base frequency of surveillance imaging on the persons risk of EVAR related complications 
1.7.5 do not exclude endo leak based on negative colour Doppler 

A: Surveillance is a complex area. Original draft guidance suggested it should all be by CT, but subsequent data has suggested an increased cancer risk post EVAR and there are worries about radiation doses. Pragmatically what really counts is sac diameter, and if this is shrinking, likely to be all good. This could be assessed by simple ultrasound (like NAAASP), but for those on the increase more exacting imaging is needed. CT not necessarily the gold standard though as the phase dictates how easily an end-leak is seen. In some cases, a good duplex may be better and we use both modalities +/- angio as needed. The guidelines have therefore become a bit more pragmatic to take into account local skill sets.

 

Q: We have good data for the surveillance of AAAs from NAAASP, but no consensus for surveillance scanning post EVAR. How do you base your surveillance scanning?

A: Yes - frequency of scanning depends a bit on anatomy and proximity to IFU. Accepted that an individualised approach for a specific patient is probably best. There is data on surveillance frequency, but no one agrees! An increase of 5mm is significant, but also no growth is seen as “stable” and OK. Personally, I think we should only be satisfied with sac shrinkage and anything less than this is not very satisfactory. We are currently trying to run the DETECT study in London looking at the utility of simple ultrasound diameter (portable probe attached to an iPhone with imaging app).

 

Q: How do you think the cited increased mortality rate (5% in patients with cardiovascular disease and 7.3% in those with diabetes) among patients with cardiovascular disease will affect services for vascular patients over the next 12-18months?

R.Ferrari, G. Di Pasquale et C. Rapezzi ‘Commentary: What is the relationship between Covid-19 and cardiovascular disease? International Journal of Cardiology

A: All our AAA and PVD patients are in a higher risk group. We are involved in an international study (COVER via Vern) looking at this question. Data from April/May suggested that vascular patients becoming positive in the post-operative period had a 40% mortality so really important. We have also seen people presenting very late as they were worried about attending hospital so people in their 30s and 40s coming in with gangrenous feet needing amputations.

 

 

Q: Will vascular patients be able to access treatment over the coming months?

A: GIRFT (with VS input) has just released a document looking at the implications of the next phase. Most of arterial surgery is either urgent and emergent so not so bad. The only NHS category 4 patients are VVs so they will probably not get NHS treatment anytime soon.