Table Of ContentVascular Surgery: Current Questions
Edited by
Α. Α. Β. Barros D'Sa
Vascular Surgery Unit, Royal Victoria Hospital, Belfast, UK
P. R. F. Bell
The Leicester Royal Infirmary, Department of Surgery, Leicester, UK
S. G. Darke
Department of Surgery, Royal Bournemouth Hospital, Bournemouth, UK
P. L. Harris
Vascular Surgery Unit, Broadgreen Hospital, Liverpool, UK
[ Ml J T T E R W O R TH
Ε I Ν Ε Μ Α Ν Ν
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British Library Cataloguing in Publication Data
Vascular Surgery: Current questions.
I. Barros D'Sa, Α. Α. Β. II. Bell, P. R. F.
617.4
ISBN 0 7506 1381 5
Library of Congress Cataloging in Publication Data
A CIP catalogue record for this book is available from the
Library of Congress.
Filmset by Latimer Trend & Company Ltd.
Printed and bound in Great Britain by
Bath Press Ltd, Bath, Avon.
Foreword
Vascular surgery is a relatively young speciality and the whole scope of its widespread
clinical application is easily encompassed within the career of one surgeon. The
pioneers of vascular surgery, in the 1930s particularly, and during its rapid growth
during the late 1950s, established a speciality which will continue to expand until
atheroma can be prevented or treated by medical means rather than by surgery. The
first generation of vascular surgeons was sustained by the excitement of technical
advances and increasingly successful operations. With mounting expertise and
familiarity the duration of operations decreased, mortality fell and results improved.
Advances in surgical technique were paralleled by considerable evolution in anaesthe-
tic service, intensive care and the investigation of vascular disease using improved
forms of angiography and, in particular, non-invasive assessment.
The second generation of vascular surgeons needs to take a colder, harder look at
their chosen speciality. There are very few controlled trials available in the vast
literature on the results of vascular surgical operations and adjuvant treatment. When
compared with the established specialities of gastroenterology and oncological
surgery, vascular surgery seems a poor and unscientific relation. The reasons for the
lack of good objective scientific data to support our clinical decisions are not hard to
find. Each individual vascular surgeon does not perform sufficient operations per
annum to achieve an adequate controlled trial within a limited period. The trial which
runs on for several years tends to be abandoned through a general waning of interest
and the natural feeling that the answer will have been found by some other means
before the trial is completed. The casual, multicentre trial has equally serious
problems: it is very difficult to persuade surgeons to co-operate on an ad hoc basis,
data collection is usually incomplete, many surgeons fail to co-operate having
shown an initial willingness to participate and the final collection and follow-up of
patients is usually less than ideal.
After preliminary discussions, a group of thirteen British consultant vascular
surgeons, who also happen to be friends, held a meeting hosted by Tony Chant in
Southampton on 25 March 1983 to form the Joint Vascular Research Group of the
United Kingdom. The concept of the JVRG UK was originally attributable to Simon
Darke who must be congratulated for his foresight. The prime objective of this
collaborative group is to try to enter as many patients as possible into multicentre
controlled trials of vascular operations and their complications, as well as studies of
the natural history of vascular disease. Their success may be judged from the contents
of this book. The members agreed to attempt to standardize their collection of data,
to meet twice a year and at these meetings to propose new protocols and reassess the
V
vi Foreword
results of current trials. Each trial becomes the responsibility of one member of the
group, but that member is assisted by a full-time research co-ordinator.
JVRG UK is a registered charity, which is entirely self-supporting and relies upon
donations to cover the cost of research assistance and trial analysis. The group has
grown, with some minor changes in membership, to a total of twenty-one members to
date and the principles involved in its original inception have been very successful.
The agreed format of common recording techniques and a general co-ordinator
greatly facilitate the collection of accurate data during a rapid controlled clinical trial
and the speed with which the trial can be completed maintains the interest and
enthusiasm of the members. The membership is not static and younger surgeons join
older ones, who drop out as they become less productive members of the group, and it
is hoped that the current enthusiasm and productiveness of this research will
continue.
Crawford Jamieson
Preface
'... but when we have stuffed
These pipes and these conveyances of our blood
With wine and feeding, we have suppler souls
Than in our priest-like fasts
Coriolanus V.l
Over a period of approximately three decades vascular surgery has matured within
the broad spectrum of general surgery into a speciality responsible for the treatment
of serious vascular diseases. It is a field which has grown enormously, not only in the
numbers of patients receiving surgical treatment, but also in the range and complexity
of procedures undertaken. A large proportion of this patient population is burdened
by intercurrent and sometimes generalized arterial and other diseases, the care of
which calls for participation by clinicians in other medical disciplines. Invariably,
some operations carry a risk of complications, a few of which are potentially fatal.
Amidst the proliferating volumes and reference texts covering a multitude of
vascular surgical subjects there appears to be a need to explore specific topics which
are not only of practical interest but also arouse controversy and provoke debate. In
an attempt to fulfil this end, the path chosen here is one which endeavours to avoid a
didactic approach or an indulgence in restating well-worn answers. This book does
not aim to be a comprehensive review of every conceivable subject within the arena of
vascular surgery. Rather, its purpose is to raise current questions in a manner which
will induce the reader to scrutinize established and newer modes of therapy, and to re-
examine surgical practices in order to develop fresh perspectives in management.
Prompted by such objectives, a number of surgeons actively involved in teaching,
training and collaborative research, and representing the membership of the Joint
Vascular Research Group UK, were called upon to make a contribution. Inevitably,
each of the topics covered in this book will bear the personal stamp of the author
concerned. The subjects were presented at a major vascular symposium held in Belfast
on 9 May 1991.
The areas addressed are those which confront us all - in outpatient clinics, on the
wards, in the operating theatre and in the intensive care unit. Throughout the book,
attention is focused on diagnostic accuracy, judgement in challenging clinico-
pathological situations, selection of patients for various modalities of treatment,
assessment of surgical techniques and interventional procedures, prevention of
serious complications, and finally, an objective appraisal of outcome. The contents
vii
viii Preface
are of interest to consultant and trainee vascular and general surgeons and other
specialists who share in the overall management of patients with vascular problems.
On behalf of the editors, I would like to place on record my appreciation to the
membership of the Joint Vascular Research Group UK for their contributions, my
co-editors for their assistance, Mrs Andrea Chetcuti, our research co-ordinator, for
her initial help, Dr June Greig-Smith and Miss Deena Cook of Butterworth-
Heinemann for their expertise in processing this book through to publication in the
limited time available, and above all Miss May Weiler for secretarial excellence which
became evident in so many ways throughout the preparation of this book.
Aires A.B. Barros D'Sa
Contributors
Roger Ν. Baird, BSc ChM FRCS FRCS(Ed)
Consultant Surgeon, Royal Infirmary, Bristol; Senior Clinical Lecturer in Surgery,
Department of Surgery, University of Bristol
Aires A. B. Barros D'Sa, MD FRCS FRCS(Ed)
Consultant Vascular Surgeon, Vascular Surgery Unit, Royal Victoria Hospital,
Belfast; Honorary Lecturer in Surgery, The Queen's University of Belfast
Jonathan D. Beard, ChM FRCS
Consultant Vascular Surgeon, Department of Surgery, Royal Hallamshire Hospital,
Sheffield; Honorary Clinical Lecturer in Vascular Surgery, University of Sheffield
Peter R. F. Bell, MD FRCS
Professor of Surgery, Department of Surgery, Leicester Royal Infirmary, Leicester;
Professor of Surgery and Head of Department, University of Leicester
W. Bruce Campbell, MS MRCP FRCS
Consultant in Vascular and General Surgery, Department of Surgery, Royal Devon
and Exeter Hospital, Exeter
John Chamberlain, FRCS(Ed)
Consultant Surgeon, Department of Surgery, Freeman Hospital, Newcastle-upon-
Tyne; Clinical Lecturer in Surgery, University of Newcastle-upon-Tyne
Anthony D. B. Chant, BA BSc MS FRCS
Consultant Vascular Surgeon, Department of Vascular Surgery, Royal South Hants
Hospital, Southampton; Honorary Clinical Lecturer, University of Southampton
Charles A. C. Clyne, MS FRCS(Ed) FRCS(Eng)
Consultant Vascular and General Surgeon, Torbay Hospital, Torquay
Simon G. Darke, MS FRCS
Consultant Vascular and General Surgeon, Royal Bournemouth Hospital, Bourne-
mouth; Honorary Lecturer, University of Southampton
John M. D. Galloway, ChM FRCS(Ed)
Consultant Surgeon, Department of Surgery, Hull Royal Infirmary, Hull
Peter L. Harris, MD FRCS
Consultant Vascular Surgeon, Vascular Surgery Unit, Broadgreen Hospital, Liver-
pool; Lecturer in Surgery, University of Liverpool
Michael Horrocks, MS FRCS
Consultant Surgeon, Surgical Unit, Bristol Royal Infirmary, Bristol; Honorary
Lecturer in Surgery, University of Bristol
ix
χ Contributors
Paul Lieberman, FRCS
Consultant Surgeon, Department of Surgery, Glasgow Royal Infirmary, Glasgow
John A. Mûrie, MA BSc MD FRCS
Consultant Vascular Surgeon, Department of Surgery, The Royal Infirmary, Edin-
burgh; Honorary Senior Lecturer in Surgery, University of Edinburgh
Simon D. Parvin, MD FRCS
Consultant General and Vascular Surgeon, Department of Surgery, Royal Bourne-
mouth Hospital, Bournemouth
P. Michael Perry, MS FRCS
Consultant Surgeon, Department of Surgery, Queen Alexandra Hospital, Ports-
mouth; Honorary Clinical Lecturer, University of Southampton
C. Vaughan Ruckley, ChM FRCS(Ed)
Consultant Vascular Surgeon, Vascular Surgery Unit, Royal Infirmary, Edinburgh;
Reader in Surgery, University of Edinburgh
Denis C. Wilkins, MD FRCS
Consultant Vascular Surgeon, Department of Surgery, Derriford General Hospital,
Plymouth
Colin C. Wilmshurst, MRCS LRCP
Associate Specialist in General and Vascular Surgery, Torbay Hospital, Torquay
John Η. N. Wolfe, MS FRCS
Consultant Vascular Surgeon, Department of Vascular Surgery, St Mary's Hospital,
London; Honorary Senior Lecturer, St Mary's Medical School and Royal Postgradu-
ate Medical School, Hammersmith, London
Chapter 1
The clinical vascular laboratory -
requirements and recommendations
Michael Horrocks
Clinical vascular laboratories have gradually appeared over the last 30 years and are
now an established department in many hospitals. They arose originally in teaching
hospitals where there was interest in non-invasive measurement of blood flow and
blood pressure in patients with vascular disease. In the last decade new techniques
have evolved, necessitating the purchase of very expensive equipment. With the
increase of new technology and enthusiasm it becomes increasingly important to
reflect on the value of these investigative techniques and to attempt to assess the cost-
effectiveness of many of the procedures advocated. As long ago as 1976 the
Intersociety Commission for Heart Disease Resources issued a report on medical
instrumentation in peripheral vascular disease and stated that a vascular laboratory is
desirable in any institution which is performing angiography of the peripheral
vascular, coronary or cerebral vessels[l]. The report also emphasized the value of
vascular laboratory assessment in the management of trauma patients, in those
undergoing arterial reconstruction and in the care of patients suffering from venous
thromboembolic disease. It was clear from that time that vascular laboratories would
be required in most large hospitals but this has not come about, largely because of the
failure to provide the necessary finance.
Different hospitals vary in their requirements such as their need for personnel and
equipment. Where the laboratory should be sited and how it should be financed are
other unanswered problems. In recent years the vast majority of young vascular
surgeons who have been trained in teaching hospitals where vascular laboratories are
available have become familiar with the techniques and the advantages that vascular
laboratories can offer. They are therefore understandably dissatisfied on appointment
to a definitive consultant post to find neither the facilities nor the funding to provide
even the minimum equipment and staffing for a vascular laboratory. It is the author's
opinion that this question needs to be addressed urgently so that minimum standards
of non-invasive diagnostic support are available for all surgeons practising arterial
reconstruction.
The purpose of the clinical vascular laboratory
The primary purposes are clinical and research. Although most laboratories provide a
wide variety of diagnostic services they are also a good source of clinical research. The
two are usually inseparable. Although most vascular laboratories are located at the
core of a hospital there are a few which can be found in outpatient facilities or
ι
2 The clinical vascular laboratory - requirements and recommendations
interdisciplinary clinics which, for instance are shared by diabetic physicians,
neurologists and vascular surgeons. The hospital-based laboratory appears to offer
the best compromise of availability and access to multiple disciplines. The primary
function of the laboratory is to provide objective physiological measurements to
facilitate the diagnosis of all kinds of vascular disease. Basic requirements are the
ability to assess occlusive disease in the legs, to evaluate extracranial cerebrovascular
disease, to diagnose deep venous thrombosis and to study vasospastic syndromes of
the upper arm. Other functions may include investigation of normal structures such
as veins prior to bypass and more sophisticated evaluation of mesenteric and renal
blood flow. In addition there may be facilities for intraoperative blood flow
measurement and for postoperative evaluation and monitoring following reconstruc-
tion[2].
In addition the vascular laboratory may give important information about the
natural history of the disease which in turn could lead to a change in management
policy. Vascular laboratories have taken on the responsibility of postoperative
surveillance of grafts, particularly femoropopliteal and femorodistal grafts as these
have a high early attrition rate and lend themselves to such a programme. Further-
more, the database acquired may be the basis of a full audit of the outpatient and
inpatient functions of a unit or hospital, providing precise information on the results
of surgery or demographic data as required.
A few of the more well equipped laboratories can study the pathophysiology of
vascular disease and give information about blood flow in normal and diseased
vessels.
Which studies?
A large number of different tests have been described for the diagnosis of vascular
disease. For the sake of brevity and clarity only those which the author feels are likely
to be helpful in a general vascular laboratory are considered here.
Peripheral occlusive disease of the legs
All vascular laboratories should be capable of measuring ankle pressures at rest and
after exercise if required. The measurement of resting ankle pressures provides an
excellent screen for patients with pain in the legs on walking and the addition of some
form of stress test, usually in the form of walking on a treadmill, is ideal for
identifying those patients who have a non-vascular cause for their leg pain. In the vast
majority of patients this is all that is required to make the diagnosis and to confirm
the severity of the disease. In those patients with rest pain or gangrene stress tests are
unhelpful.
In patients where the diagnosis is less certain waveform analysis, segmental
plethysmography, and segmental pressures may all be helpful in delineating the site
and extent of disease. Many laboratories have set up sophisticated methods to try and
quantify and localize disease but my own feeling is that the decision to proceed to
angiography can be made on the basis of resting ankle pressures, distance walked and
post-exercise ankle pressures where any doubt remains. In patients with rest pain or
gangrene Doppler studies are often of little value as flow in the peripheral arteries of
the ankle is exceedingly poor. In these cases even angiography may seriously
underestimate the extent of disease, and the vascular laboratory can play a valuable
