Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?

BACKGROUND: Vascular surgery became a new independent surgical specialty in the United Kingdom (UK) in 2013. In this matter for debate we discuss the question, is there a "shortage of vascular surgeons in the United Kingdom?" MATERIALS AND METHODS: We used data derived from the "Vascular Surgery United Kingdom Workforce Survey 2014", NHS Employers Electronic Staff Records (ESR), and the National Vascular Registry (NVR) surgeon-level public report to estimate current and predict future workforce requirements. RESULTS: We estimate there are approximately 458 Consultant Vascular Surgeons for the current UK population of 63 million, or 1 per 137,000 population. In several UK Regions there are a large number of relatively small teams (3 or less) of vascular surgeons working in separate NHS Trusts in close geographical proximity. In developed countries, both the number and complexity of vascular surgery procedures (open and endovascular) per capita population is increasing, and concerns have been raised that demand cannot be met without a significant expansion in numbers of vascular surgeons. Additional workforce demand arises from the impact of population growth and changes in surgical work-patterns with respect to gender, working-life-balance and 7-day services. CONCLUSIONS: We predict a future shortage of Consultant Vascular Surgeons in the UK and recommend an increase in training numbers and an expansion in the UK Consultant Vascular Surgeon workforce to accommodate population growth, facilitate changes in work-patterns and to create safe sustainable services.

The vascular surgery workforce: a survey of consultant vascular surgeons in the UK, 2014.

OBJECTIVE: The purpose of this study was to describe the demographics, training, and practice characteristics of consultant vascular surgeons across the UK to provide an assessment of current, and inform future prediction of workforce needs. METHODS: A questionnaire was developed using a modified Delphi process to generate questionnaire items. The questionnaire was emailed to all consultant vascular surgeons (n = 450) in the UK who were members of the Vascular Society of Great Britain & Ireland. RESULTS: 352 consultant vascular surgeons from 95 hospital trusts across the UK completed the survey (78% response rate). The mean age was 50.6 years old, the majority (62%) were mid-career, but 24% were above the age of 55. Currently, 92% are men and only 8% women. 93% work full-time, with 60% working >50 hours, and 21% working >60 hours per week. The average team was 5 to 6 (range 2-10) vascular surgeons, with 23% working in a large team of ≥8. 17% still work in small teams of ≤3. Over 90% of consultant vascular surgeons perform the major index vascular surgery procedures (aneurysm repair, carotid endarterectomy, infra-inguinal bypass, amputation). While 84% perform standard endovascular abdominal aortic aneurysm repair (EVAR), <50% perform more complex endovascular aortic therapy. The majority of vascular surgeons "like their job" (85%) and are "satisfied" (69%) with their job. 34% of consultant vascular surgeons indicated they were "extremely likely" to retire within the next 10 years. CONCLUSIONS: This study provides the first detailed analysis of the new specialty of vascular surgery as practiced in the UK. There is a need to plan for a significant expansion in the consultant vascular surgeon workforce in the UK over the next 10 years to maintain the status quo.

Remodelling of vascular (surgical) services in the UK.

The last few years have seen major changes in the delivery of vascular services in the UK. An increasingly elderly population with greater expectations from their medical services has challenged established methods. It also became apparent that outcomes for low volume, high risk index vascular interventions such as abdominal aortic aneurysm repair were poor in the UK compared to the rest of Europe. Other ongoing challenges were the introduction of a national aortic aneurysm screening programme and the development of vascular surgery as a separate speciality. This article details the approach taken to modernise vascular services in the UK, using a quality framework agreed by vascular specialists, which drove the structural change to move vascular interventions into fewer, higher volume centres. The introduction of modern networks is designed to maintain services in surrounding hospitals without on site vascular inpatient services. The initial effects of this service remodelling are positive, with elective aortic aneurysm mortality rates falling nationally from 7.5 to 2.4 per cent.

Descending thoracic endovascular aneurysm repair: antegrade approach via ascending aortic conduit.

Challenging access situations continue to arise in endovascular aneurysm repair, despite evolving arterial access techniques. We report a modified access approach, where an ascending aortic conduit was successfully used for antegrade delivery of a thoracic endograft to repair a descending thoracic aortic aneurysm, in a patient with previous surgical ligation of the infra-renal aorta.

Impact on renal function after endovascular aneurysm repair with uncovered supra-renal fixation assessed by serum cystatin C.

OBJECTIVE: Supra-renal fixation in endovascular aneurysm repair (SR-EVR) is used to improve the proximal seal of aortic stent grafts and appears to have minimal effect on serum creatinine. Serum cystatin C (CC) is a more sensitive marker of renal injury and, unlike creatinine, is unaffected by non-renal influence. The aim of this study was to assess the true renal effect of SR-EVR using this superior renal index. METHODS: Consecutive patients undergoing SR-EVR were prospectively recruited and compared to control groups undergoing open aneurysm repair (OR) and colorectal resection (CR). Serum CC and creatinine clearance (CrC) were determined pre-operatively and at 3, 6 and 12 months post-surgery. Renal function was compared using analyses of covariance (ANCOVA). RESULTS: Sixty-five patients (M:F; 52:13, median age 74 years) were enrolled (24 SR-EVR, 28 OR, 13 CR). Pre-operative renal function and risk factors were comparable (CC 1.04mg/l, SR-EVR; 0.96mg/l, OR; 0.97mg/l, CR). Adjusting for baseline renal function, there was no significant difference in CC or CrC between study and both control groups at 3, 6 or 12-months post-operatively. CONCLUSION: Using cystatin C as a more sensitive renal index, there was no detectable evidence of kidney dysfunction at up to one-year following EVR with uncovered bare-metal supra-renal fixation.

Comment on "Atlantic and Pacific multidecadal oscillations and Northern Hemisphere temperatures".

Steinman et al. (Reports, 27 February 2015, p. 988) argue that appropriately rescaled multimodel ensemble-mean time series provide an unbiased estimate of the forced climate response in individual model simulations. However, their procedure for demonstrating the validity of this assertion is flawed, and the residual intrinsic variability so defined is in fact dominated by the actual forced response of individual models.

Primary squamous cell carcinoma of the caecum.

A case of primary squamous cell carcinoma of the caecum arising in a tubulo-villous adenoma is described. This rare lesion develops following genomic derangement of the multipotential colonic stem cells. The literature is reviewed and factors contributing towards squamous cell differentiation discussed.

Isolated tibial vessel disease: treatment options and outcome.

Tibial vessel disease is an important cause of limb ischaemia, particularly in diabetics. Revascularisation by angioplasty and bypass is increasingly feasible. The aim of this study was to review treatment and outcome in patients with this patterns of disease. We have performed 25 procedures in 20 patients since September, 1989. Six patients (5 diabetic) underwent 9 tibial angioplasties for stenotic lesions causing critical ischaemia or short-distance claudication. In 6 procedures there was single vessel run-off. Eight angioplasties were radiologically successful with a median increase in ankle-brachial index (ABI) of 0.15 [range: 0.00-0.44] at a median follow-up of 9 months. A further 4 patients (3 diabetic) with critical ischaemia underwent popliteal-distal, in-situ vein bypass for tibial occlusions. Distal anastomosis was onto the dorsalis pedis artery or distal anterior artery. Three grafts remain patent with successful limb salvage and ABI's greater than 1.0. Angioplasty is also useful for distal disease progression following femoro-popliteal bypass. Six patients with "at-risk" grafts underwent 8 tibial angioplasties for stenotic lesions in distal run-off. Radiologically, 6 procedures were successful with a median increase in ABI of 0.21 [range: 0.00-0.38] at a median follow-up of 7 months. There were less favourable results when a "graft-distal" bypass performed to salvage an occluded femoro-popliteal graft with diseased run-off vessels. Three of 4 grafts reoccluded within 3 months, 2 patients requiring amputation. We advocate an aggressive policy towards localised distal disease causing foot ischaemia.

A dual strategic approach to mega-aortic aneurysms.

Staged resection of mega-aortas with Borst's two-stage elephant trunk (ETK) is the gold standard but has a higher mortality and morbidity compared to single-segment repair. We report the first case of combined surgical and covered-stent approach in Europe. Location and dilatation of the proximal landing zone accounts for the majority of failures in covered-stenting but an ETK is stable, easy to localise and gives an excellent seal. In high-risk cases where surgical resection is not offered, stenting is an option. The lack of a thoracotomy is an advantage in often-frail patients recovering from stage-I and shortens ITU-stay. Therefore, a combined approach is an acceptable alternative in selected individuals.

An objective comparison of four stress tests in the assessment of "at risk" femoro-distal grafts.

Femoro-distal vein grafts for limb salvage have a 30% failure rate at 6 months. Graft surveillance may enable the "at risk" grafts to be recognised and corrected, but there remains the need for a simple test to identify these patients. The ankle pressure response to exercise and reactive hyperaemia has been investigated prospectively in 40 "at risk" femoro-distal non-reversed grafts (median age 73 years, range 51-87 years, M/F = 33:7), defined as those with a resting ankle brachial index less than 0.9 or a drop of greater than 0.2 following a stress test. Four different stress tests have been assessed; active ankle plantar-dorsiflexion for 2 minutes (I), occlusive calf cuff 50 mmHg above systolic pressure for 2 minutes (II), treadmill exercise test for 1 minute, slope = 10%, at 3 km/hr (III) and 4 km/hr (IV). Ankle brachial indices (ABI's) were recorded before and immediately following each test and expressed as mean % drop +/- standard error of mean. Test I was only tolerated by 45% of patients whereas 55% and 50% could complete tests III and IV respectively. By contrast, 85% of patients could tolerate occlusive cuff hyperaemia (test II). Test I produced a significantly lower mean percentage drop in ABI when compared with each of the others (p less than 0.02, Mann U Whitney). There was an excellent correlation between test II and both the 3 km/hr (r = 0.77, p less than 0.001) and 4 km/hr (r = 0.84, p less than 0.001) exercise tests.(ABSTRACT TRUNCATED AT 250 WORDS)

Femorotibial bypass: the learning curve.

Femorotibial bypass is still infrequently performed in many district hospitals, because it is time consuming and the risk of failure is high, especially during the learning curve. This article reviews the results of a single consultant surgeon and his team after starting femorotibial bypass de novo in a district general hospital. During the period 1987 to 1992, 85 femorotibial grafts were performed in 76 patients for ulceration and gangrene (57), rest pain (19) and severe claudication (9). Sixty-six were autogenous vein, 15 were PTFE with distal vein cuff, two were composites and two were umbilical vein. Overall, 22 grafts (26%) failed within the first 30 days (two were salvaged) and 21 amputations were required (five despite patent grafts). There were three early deaths (mortality 3.9%). At the end of 1993, 39 limbs had been amputated and 24 patients had died (eight with amputations). Twenty-three (44% of survivors) were alive with patent grafts. These disappointing early results were due to an initial technical learning curve, after which increased confidence may have led to reconstructing some patients with inadequate distal arteries. A more selective approach is now used. Limb salvage can be achieved in a worthwhile proportion of these patients and 3-year primary patency rates are similar to those of teaching hospitals in this country.

Theatre delay for emergency general surgical patients: a cause for concern?

The delay involved in operating on emergency general surgical patients is often excessive. This problem has been examined prospectively in a district general hospital with a catchment population of 450,000. Over a 16-week period, the details of 204 consecutive general surgical emergency operations were recorded and analysed. Following essential resuscitation, the median delay in operating on emergency general surgical patients was 3 h. Eighty-eight patients had to wait in excess of 1 h, with 15% experiencing a delay of over 6 h. In only 10% of cases was a theatre required after midnight, yet 26% of all emergency general surgical operating was performed between midnight and 8 am. The majority of delays were due to a combination of factors; theatre delay was mentioned in 47% of cases, anesthetic delay in 30% and the overrunning of routine lists in 14% of cases. Our results suggest that unnecessary theatre delay results in an unacceptable number of emergency general surgical operations occurring after midnight. It is important that routine afternoon lists do not overrun, as this contributes directly to evening theatre delay. If both theatre and anaesthetic availability could be ensured in the afternoon and early evening, the after midnight workload could be cut from 26% to 10%, and staff sleep deprivation reduced.

The malignant potential of colorectal Crohn's disease.

Six patients developed colorectal carcinoma in association with Crohn's disease. The cancer was diagnosed at a mean age of 46 years and a mean 19 years after the onset of Crohn's disease. Five carcinomas arose in the chronically inflamed segment of bowel, while a sixth arose in caecum previously bypassed for Crohn's ileitis. Four carcinomas were mucinous, four presented with fistula and four were treated by complete removal of the large intestine. Three patients have died of residual or recurrent cancer. The data support an aetiological link between Crohn's proctocolitis and carcinoma.

Peripheral seeding of mycotic aneurysms from an infected aortic stent graft.

Aortic stent graft infection is rare and there are no reported cases of seeded peripheral mycotic aneurysms complicating this condition. We describe the case of a 54 year old man who developed a late stent graft infection at three years, resulting in the peripheral seeding of three mycotic aneurysms with two incidents of rupture. He was successfully treated with extra-anatomic bypass of the aorta and both surgical and endovascular repair of his peripherally seeded mycotic aneurysms.

Secondary interventions and mortality following endovascular aortic aneurysm repair: device-specific results from the UK EVAR trials.

OBJECTIVES: To compare secondary intervention rate, aneurysm-related mortality and all-cause mortality for patients receiving elective endovascular aneurysm repair (EVAR) for large abdominal aortic aneurysms with different commercially available endografts. DESIGN, MATERIALS & METHODS: In the EVAR 1 and 2 multi-centre trials, the principal endografts used were Zenith and Talent and these are compared in 505 patients from EVAR 1 and 143 patients from EVAR 2 followed-up for an average of 3.8 years until 31st December 2005. Outcomes were analysed by Cox proportional hazards regression, with adjustments for potential confounding risk factors and centre. Gore/Excluder graft outcomes also are reported. RESULTS: Across the two trials the secondary intervention rates were 7.0 and 9.4 per 100 patient years for Zenith and Talent grafts respectively, adjusted hazard ratio 0.77 [95%CI 0.52-1.12]. Aneurysm-related mortality was 1.2 and 1.4 per 100 patient years for Zenith and Talent grafts respectively, adjusted hazard ratio 0.90 [95%CI 0.37-2.19]. All-cause mortality was 8.5 and 10.3 per 100 patient years for Zenith and Talent grafts respectively, adjusted hazard ratio 0.81 [95%CI 0.58-1.14]. The direction of all results was similar when the two trials were analysed separately. CONCLUSION: There was no significant difference in the performance of the two endografts but the direction of results was slightly in favour of patients with Zenith (versus Talent) endografts.

The mid-term effect of bare metal suprarenal fixation on renal function following endovascular abdominal aortic aneurysm repair.

OBJECTIVE: The aim of this study was to assess the mid term effect of proximal bare metal fixation design on renal function in patients undergoing endovascular repair (EVR) of abdominal aortic aneurysm (AAA). METHODS: Consecutive EVR patients for AAA from December 1995-2001 were included and grouped to either infrarenal (Group 1) or uncovered suprarenal (Group 2) fixation. Peri-operative renal function and at 6, 12 and 24 months was determined by serum creatinine (sCr mmol l(-1)) and Cockroft-Gault creatinine clearance (CrC ml min(-1)). Changes in renal function were compared using non-parametric analysis. RESULTS: Of the 179 EVR procedures during this six-year period, paired renal data was available for 135 patients at a minimal follow-up of 6 months (Gp1, n = 63; Gp2, n = 72). Median pre-EVR sCr and CrC were 113, 57 in Group 1 and 108, 58 in Group 2, p = NS. There was no significant deterioration in renal function within or between either group at 2 years post-EVR: median sCr, CrC values were 118, 56 (Group 1) and 111, 56 (Group 2), all p = NS. CONCLUSION: This study suggests mid-term renal function remains unaffected following EVR of AAA, irrespective of proximal fixation type. Designs to improve stent durability and EVR applicability do not appear to compromise renal function.

Critical and subcritical ischaemia.

OBJECTIVES: To stratify leg ischaemia into high and low risk groups with respect to outcome. METHODS: An evaluation of 20 recent publications, reporting the results of 6118 patients with critical ischaemia. Low and high risk patient groups are identified by the definition of critical ischaemia. These groups are analysed with respect to outcome of the patient and limb. MAIN OUTCOME MEASURES: Major amputation and mortality. RESULTS: From these data subcritical (rest pain and/or ankle pressure > 40 mmHg, n = 4089) and critical (tissue loss and/or ankle pressure < 40 mmHg, n = 2029) risk group of patients was identified. The 1, 3 and 5-year mortality is 26%, 44% and 56% with or without reconstruction. For patients in the low risk group, 27% did not lose their leg within the year if treated conservatively. For patients in the high risk group, amputation was required by 95% if treated conservatively, compared to 25% if treated with arterial reconstruction. CONCLUSION: Reconstructive surgery should be viewed from the following, more realistic, perspective. For patients with rest pain (and/or ankle pressure > 40 mmHg), 100% cumulative patency is equivalent to 64% resolution of symptoms at 1 year, as the rest may have improved without treatment. For high risk patients (tissue loss and/or ankle pressure < 40 mmHg), 100% cumulative patency is equivalent to 93% limb salvage at 1 year. Future reports should identify these two groups separately, as the dominant difference between outcome studies is the proportion of subcritical patients in the study rather than better surgical or radiological techniques. This stratification also has an important bearing on pharmacotherapy trials.