What you need to know to pass the FRCS Vascular Surgery

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					What you need to know to pass
the FRCS – Vascular Surgery
         David Mitchell

                           Rule 1:
                           Stay awake
• Keep it simple stupid
  – Listen to the question with
  – “Surgical pause”
  – Tell them what you know,
    don’t make it up on the
  – Its easy to kill the unfit
    with an operation
• Don’t get lost in minutiae
  unless you are expert
• Core                        • Specialist
  – Aneurysms                   – Carotid in detail
     • Aortic                        • Trial data
     • Popliteal                     • Techniques and
  – PAD                                justification
     • Medical                  – Juxta-renal &Thoraco-
     • Surgery/Intervention       abdominal aneurysms
  – Amputation                       • Debranching
  – Venous                      –   TOS
     • VVs
                                –   Hyperhidrosis
     • Ulcers
  – Vascular access             –   Vasculitic syndromes
  – Carotid                     –   Lymphoedema
                                –   Vascular malformations
               Evidence base
• You need to be able to talk
  sensibly about this
  – Detail for the committed
• Aortic aneurysms
  – What size to intervene
    (small AAA trial)
  – Benefits of EVAR (EVAR 1 &
    2, DREAM)
  – Screening, why should we do
• Small aneurysm trial
   – RCT surgery vs watch & wait 4.0 – 5.5.cm
       • No benefit from early surgery, watch and wait is safe
       • Mortality rates about 6%
                                                              Lancet 1998 Nov 21;352(9141):1649-55

• EVAR trials (AAA of 5.5 cm or more)
   – EVAR 1 RCT in fit patients, EVAR vs OR. 1082 pts
       • Mortality 1.6% (EVAR) vs 4.6% (OR) at 30 days
                                                             Lancet 2004 Sep 4-10;364(9437):843-8
   – EVAR 2 RCT in unfit, EVAR vs no intervention. 338 pt
       • 9% op mortality (EVAR). No difference in mortality or AAA mortality at 4
         years between EVAR or no intervention
                                                       Lancet 2005 Jun 25-Jul 1;365(9478):2187-92

• DREAM – Dutch RCT EVAR vs OR 345 pts
   – >5cm AAA. 30 day mortality, EVAR 1.2% vs 4.6% in OR
                                                          N Engl J Med 2004 Oct 14;351(16):1607-18
   – At 2 years mortality EVAR 2.1% vs 5.7% OR
       • All difference accounted for by peri-op difference
                                                         N Engl J Med 2005 Jun 9;352(23):2398-405
         Screening for AAA         0·

• DoH is introducing national screening
  programme, throughout England by 2013
• Evidence base
  – MASS trial 67,770 men 65-74 randomized to
    screening (with fu surveillance for those with AA)
    or control
     • 155 vs 296 AA related deaths over 10 years (48% RR)
     • £7600 per life year gained.
                                        BMJ 2009 Jun 24;338:b2307
• Surgery for symptomatic disease
  – Clear benefits in those with tight ipsilateral
    ICA stenosis
                                       NASCET & ECST trials

  – Significant benefit in asymptomatic with tight
                                                 ACST trial

  – Trend to better outcome with local
                                                 GALA trial

  – Stenting not safer than surgery
                                      ICSS & CAVATAS trials

• Claudication
       – No one dies of it. The treatment is
         medical in the first instance.
       – Stop smoking, take anti-platelets and
         statins, exercise
  – Evidence
    • Mild to moderate symptoms
       – MIMIC trial 93 pts RCT of PTA vs
         supervised exercise
           » At 24 months better AWD for
             PTA in both fem-pop and aorto-
             iliac groups
       Eur J Vasc Endovasc Surg 2008 Dec;36(6):680-8
• Severe limb ischemia
  – If low ankle pressure (60 mmHg),
    limb loss more likely
• Critical limb ischemia
  – Need to be able to define: Limb loss
    very likely or inevitable
     • BASIL trial, 452 pts RCT Surgery first
       vs PTA first, endpoint was amputation
       free survival
           » At 6 months no difference in end point
             with PTA first being cheaper
                     Lancet 2005 Dec 3;366(9501):1925-34
• Summary
 – Medical treatment is good for all:
   • Prevention of secondary problems (MI/CVA etc)
   • Preventing deterioration in symptoms
 – Intervention for:
   • Those with threatened livelyhood
   • Severe symptoms
   • Those with threatened limb
• Done when:
  – Limb unsalvageable and:
    • To relieve pain
    • To remove useless/harmful limb
    • To improve mobility
• Avoid amputation in the dying
• Varicose veins
  – Treatment shifting from surgery to
     • VNUS, radiofrequency ablation, heat vein to 120oC
     • LASER, same process using light
     • Foam sclerotherapy, sclerosant mixed with air to
       create foam, larger surface area treated
  – Local anaesthesia, ablation similar success to
    surgery in destroying GSV without groin
  – Foam – about 75 – 85% success, side effects
    include visual disturbance. Concerns about CVA
                     Venous ulcers
• Beware, can find out weak candidate
   – Leg, usually venous, some other rare
   – Foot, arterial/diabetes
• Work from first principles
   – What is the arterial supply – Doppler
   – Scan veins
   – Compress those with ABPI >0.8
• Surgery – ESCHAR Trial
   – Does not heal ulcers, reduces recurrence over
     compression alone in SVI/mixed SV/DVI
                           Lancet 2004 Jun 5;363(9424):1854-9
                                 BMJ 2007 Jul 14;335(7610):83
              Vascular Access
• Fastest growing surgical procedure in
  Western World (? Competition from lap
   – Providing access to circulation for:
      • Dialysis
      • Plasma filtration (hypercholesterolaemia, auto
        antibodies etc)
   – Join end of vein to side of artery
      • Use non-dominant limb, do it 6 months pre-
      • Synthetic grafts have higher revision rates and
        more sepsis prone
      • Central venous catheters carry highest sepsis
   – Key point for patient care
      • Need well organised team approach to deliver
        efficient service
       Sub speciality areas
• Carotid
  – You will be expected to give a detailed
    interpretation of current trials.
• Thoraco-abdominal aneurysms
  – Understanding of issues around suitability
    for EVAR, role of hybrid procedures,
    debranching procedures for arch placement
    of stents
      Thoracic outlet syndrome
• Lots of confusion
  – Arterial, rare
     • Abnormal pulses, stenosis and
       post stenotic dilatation X-ray
       and scan
  – Neurological more common
     • History, X-ray for C Rib. Roos
  – Venous, also common
     • Physically active, venous
       thrombosis, may benefit from
       early thrombolysis and 1st rib
• Talk coherently
  – keep away from detailed
    management issues unless
    familiar with them.
• Medical management is
  – Surgery/interventional
    approach reserved for those
    with severe complications
    (bleeding/necrosis) and
    quiescent disease (PTA/bypass
    in Takayashu’s arteritis)
            The unusual
• Even experts ask for help when faced
  with something unusual
• Primary
  – Occurs without obvious cause, may present in
    adult life
    • Relative absence of lymphatic drainage
       – Manage with compression, MLD and support groups,
         surgery for severe cases
• Secondary
  – Most commonly after cancer surgery or due to
    nodal recurrence
  – Infective causes in subtropical areas
    • Treatment aimed at eradicating cause, plus as for
     Vascular malformations
• Complex area
  – Try and identify if primarily:
    • High flow (i.e. Significant arterial component)
    • Low flow (mainly venous)
    • Lymphatic component
• Management
  – Need well organised MDT
    • Avoid intervening in those who do not need it.
    • Beware the high flow ones, can be
      extraordinarily complex and difficult to manage
• Most questions will focus on core
• Exploration of sub-speciality areas
  when core subjects covered
  – Or if candidate invites it!
• Stay focussed
  – Think of the patient and avoiding

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