Cheltenham Vascular Unit


The Incidence of endovenous foam induced thrombosis (EFIT) in 1000 legs in a single vascular centre.
Kulkarni SR, Messenger DE, Slim FJA, Emerson LG, Bulbulia RA, Whyman MR, Poskitt KR
Cheltenham General Hospital, Cheltenham, UK

Aims: The incidence of deep vein thrombosis (DVT) following ultrasound-guided foam sclerotherapy (UGFS) varies from 0 to 5.7%. The aim of this study was to assess the incidence of DVT following UGFS in a single vascular centre.

Methods: Consecutive patients undergoing UGFS between December 2005 and September 2011 attended within 2 weeks of treatment for quality control duplex imaging, performed by a senior vascular scientist independent of the operator. DVT when present was labelled as ‘Endovenous Foam Induced Thrombosis’ (EFIT) type 1 when thrombus was lining <25% of the lumen of the deep vein; type 2 when thrombus extension was 25-50%; type 3 when thrombus extension was 50-99% and type 4 when the deep vein was occluded.

Results: A total of 1166 UGFS treatments were performed in 1000 legs (776 patients); following which 17 DVTs were detected (1.5%). No DVTs were detected in legs undergoing multiple treatments. Seven DVTs were EFIT type 1, two were type 2, two were type 3 and five were type 4. One DVT was seen in the gastrocnemius vein alone. Two of 1166 treatments (0.2%) resulted in a symptomatic DVT, both of which were EFIT type 4. On regression analysis, there was an increase in the risk of DVT when =10mls of foam was injected (OR=4.58, 95% CI=1.42-14.8; p=0.01).
Conclusions:  The incidence of duplex detected DVT following foam sclerotherapy is low and may be associated with the injection of high foam volumes. However, the rationale for routine post-procedure duplex imaging is debatable, given that clinically significant DVTs are rare.

Eighty laparoscopic aortic aneurysm repairs from 3 UK vascular centres.
Coulston JE, Howard A, Davenport R, Gordon A, Bachouse C, Bulbulia RA, Whyman MR, Poskitt KR.
Departments of Vascular Surgery,
Colchester General, Wexham Park and Cheltenham General Hospitals.

Aims: Laparoscopic aortic surgery is an alternative or adjunct to open or endovascular repair and may confer certain advantages. Our experience of laparoscopic aortic aneurysm surgery is reported.

Methods: Prospectively collected data was recorded on patients undergoing elective laparoscopic assisted or total laparoscopic aortic surgery from three vascular centres. 

Results: Eighty patients with 54 aortic and 26 aortoiliac (7 juxtarenal, 1 suprarenal + renal graft) aneurysms underwent surgery. Seventy eight were male with a median age of 72 years (IQR 67-75). Forty seven patients had laparoscopic assisted and 33 had total laparoscopic surgery. Median aortic clamp time was 85 minutes (IQR 75-120) with an operative time of 330 minutes (IQR 300-390). Epidural requirement was 1 day (range 0-3); time to solid diet was 1 day (range 1-6) and time to mobilisation was 1 day (range 1-4). Postoperative stay was 5 days (IQR 3-7). Early complication rate was 19% and 30 day mortality rate was 1.3%. Follow-up at 5 years showed 4 late but no graft-related complications.

Laparoscopic aneurysm surgery was performed with a low perioperative mortality and good early durability.  Operative times were long, epidural usage was limited, recovery of gut function and mobility was early and length of stay was short.

Poor prognostic factors in venous ulceration: Analysis of 7481 ulcers.
Coulston JE1, Davies CE2, Bulbulia RA1, Poskitt KR1, Whyman MR1
Department of Vascular Surgery1 and Gloucestershire Leg Ulcer Service2
Cheltenham General Hospital, United Kingdom.

Aims: Identification of risk factors for prolonged healing and early recurrence is vital to identify a high risk population who may benefit from early intensive treatment.

Methods: Data were collected from a prospective database over a 16 year period under a specialist leg ulcer service. Kaplan-Meier survival analysis calculated 24 week healing and 12 month recurrence rates. Risk factors were assessed using cox regression multivariate analysis.

Results: Overall 24 week healing was 79% increasing from 63% (1995-98) to 81% (2007-10) over the study period (p<0.01). The twelve month recurrence rate decreased from 20.1% (1995-8) to 13.5% (2007-10) with an overall rate of 19% (p<0.01). Eighteen risk factors were identified for analysis. Rheumatoid arthritis was an independent risk factor for prolonged healing (p<0.01). The range of ankle movement was independently associated with an increased risk of early recurrence (p<0.05).
Poor mobility, ulcer size and chronicity were all associated with both prolonged healing (p<0.01, <0.01, <0.01) and early recurrence (p<0.01, <0.01, <0.05).

Conclusions: Poor mobility, ulcer size and ulcer chronicity are all associated with a poor outcome.