Publications
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Martin G, Pettengell C, John I, et al., 2018, What Do Patients Want to Know About Their Surgeon? Stakeholder Views of Surgeon-Specific Mortality Data, 45th Annual VEITHSymposium, Publisher: MOSBY-ELSEVIER, Pages: E161-E161, ISSN: 0741-5214
Doyen B, Bicknell CD, Riga CV, et al., 2018, Evidence Based Training Strategies to Improve Clinical Practice in Endovascular Aneurysm Repair, EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, Vol: 56, Pages: 751-758, ISSN: 1078-5884
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Rao AM, Bottle A, Bicknell C, et al., 2018, Trajectory modelling to assess trends in long-term readmission rate among abdominal aortic aneurysm patients, Surgery Research and Practice, Vol: 2018, ISSN: 2356-7759
Introduction. The aim of the study was to use trajectory analysis to categorise high-impact users based on their long-term readmission rate and identify their predictors following AAA (abdominal aortic aneurysm) repair. Methods. In this retrospective cohort study, group-based trajectory modelling (GBTM) was performed on the patient cohort (2006-2009) identified through national administrative data from all NHS English hospitals. Proc Traj software was used in SAS program to conduct GBTM, which classified patient population into groups based on their annual readmission rates during a 5-year period following primary AAA repair. Based on the trends of readmission rates, patients were classified into low- and high-impact users. The high-impact group had a higher annual readmission rate throughout 5-year follow-up. Short-term high-impact users had initial high readmission rate followed by rapid decline, whereas chronic high-impact users continued to have high readmission rate. Results. Based on the trends in readmission rates, GBTM classified elective AAA repair () patients into 2 groups: low impact (82.0%) and high impact (18.0%). High-impact users were significantly associated with female sex () undergoing other vascular procedures (), poor socioeconomic status index (), older age (), and higher comorbidity score (). The AUC for c-statistics was 0.84. Patients with ruptured AAA repair () had 3 groups: low impact (82.7%), short-term high impact (7.2%), and chronic high impact (10.1%). Chronic high impact users were significantly associated with renal failure (), heart failure (P = 0.01), peripheral vascular disease (), female sex (P = 0.02), open repair (), and undergoing other related procedures (). The AUC for c-statistics was 0.71. Conclusion. Patients with persistent high readmission rates exist among AAA population; however, their readmissions and mortality are not related to AAA repair. They may benefit from optimization of their medical management of comorbiditie
Judah G, Darzi A, Vlaev I, et al., 2018, Financial disincentives? A three-armed randomised controlled trial of the effect of financial Incentives in Diabetic Eye Assessment by Screening (IDEAS) trial, British Journal of Ophthalmology, Vol: 102, Pages: 1014-1020, ISSN: 0007-1161
OBJECTIVE: Conflicting evidence exists regarding the impact of financial incentives on encouraging attendance at medical screening appointments. The primary aim was to determine whether financial incentives increase attendance at diabetic eye screening in persistent non-attenders. METHODS AND ANALYSIS: A three-armed randomised controlled trial was conducted in London in 2015. 1051 participants aged over 16 years, who had not attended eye screening appointments for 2 years or more, were randomised (1.4:1:1 randomisation ratio) to receive the usual invitation letter (control), an offer of £10 cash for attending screening (fixed incentive) or a 1 in 100 chance of winning £1000 (lottery incentive) if they attend. The primary outcome was the proportion of invitees attending screening, and a comparative analysis was performed to assess group differences. Pairwise comparisons of attendance rates were performed, using a conservative Bonferroni correction for independent comparisons. RESULTS: 34/435 (7.8%) of control, 17/312 (5.5%) of fixed incentive and 10/304 (3.3%) of lottery incentive groups attended. Participants who received any incentive were significantly less likely to attend their appointment compared with controls (risk ratio (RR)=0.56; 95% CI 0.34 to 0.92). Those in the probabilistic incentive group (RR=0.42; 95% CI 0.18 to 0.98), but not the fixed incentive group (RR=1.66; 95% CI 0.65 to 4.21), were significantly less likely to attend than those in the control group. CONCLUSION: Financial incentives, particularly lottery-based incentives, attract fewer patients to diabetic eye screening than standard invites in this population. Financial incentives should not be used to promote screening unless tested in context, as they may negatively affect attendance rates.
Rao A, Bicknell C, Bottle R, et al., 2018, Common sequences of emergency readmissions among high-impact users following AAA repair, Surgery Research and Practice, Vol: 2018, ISSN: 2356-7759
IntroductionThe aim of the study was to examine common sequences of causes of readmissions among those patients with multiple hospital admissions, high-impact users, after abdominal aortic aneurysm (AAA) repair and to focus on strategies to reduce long-term readmission rate. MethodsThe patient cohort (2006-2009) included patients from Hospital Episodes Statistics, the national administrative data of all NHS English hospitals, and followed up for 5 years. Group-based trajectory modelling and sequence analysis were performed on the data. ResultsFrom a total of 16,973 elective AAA repair patients, 18% (n=3055) were high-impact users. The high-impact users among rAAA repair constituted 17.3% of the patient population (n=4144). There were 2 subtypes of high-impact users, short-term (7.2%) with initial high readmission rate following by rapid decline and chronic high-impact (10.1%) with persistently high readmission rate. Common causes of readmissions following elective AAA repair were respiratory tract infection (7.3%), aortic graft complications (6.0%), unspecified chest pain (5.8%), and gastro-intestinal haemorrhage (4.8%). However, high-impact users included significantly increased number of patients with multiple readmissions and distinct sequences of readmissions mainly consisting of COPD (4.7%), respiratory tract infection (4.7%) and ischaemic heart disease (3.3%).ConclusionA significant number of patients were high-impact users after AAA repair. They had a common and distinct sequence of causes of readmissions following AAA repair, mainly consisting of cardiopulmonary conditions and aortic graft complications. The common causes of long-term mortality were not related to AAA repair. The quality of care can be improved by identifying these patients early and focusing on prevention of cardiopulmonary diseases in the community.
Murray AC, Markar S, Mackenzie H, et al., 2018, An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK, Surgical Endoscopy, Vol: 32, Pages: 3055-3063, ISSN: 0930-2794
BACKGROUND: Evidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood. METHODS: In this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998-2012) and USA (National Inpatient Sample 1998-2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England. RESULTS: Patients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; p < 0.001). Pre-treatment (1 vs. 2 days; p < 0.001) and total ( 4 vs. 7 days; p < 0.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; p < 0.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission. CONCLUSION: This study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.
Li MM, Hamady MS, Bicknell CD, et al., 2018, Flexible robotic catheters in the visceral segment of the aorta: advantages and limitations, JOURNAL OF CARDIOVASCULAR SURGERY, Vol: 59, Pages: 317-321, ISSN: 0021-9509
Chi W, Liu J, Rafii-Tari H, et al., 2018, Learning-based endovascular navigation through the use of non-rigid registration for collaborative robotic catheterization, INTERNATIONAL JOURNAL OF COMPUTER ASSISTED RADIOLOGY AND SURGERY, Vol: 13, Pages: 855-864, ISSN: 1861-6410
PurposeEndovascular intervention is limited by two-dimensional intraoperative imaging and prolonged procedure times in the presence of complex anatomies. Robotic catheter technology could offer benefits such as reduced radiation exposure to the clinician and improved intravascular navigation. Incorporating three-dimensional preoperative imaging into a semiautonomous robotic catheterization platform has the potential for safer and more precise navigation. This paper discusses a semiautonomous robotic catheter platform based on previous work (Rafii-Tari et al., in: MICCAI2013, pp 369–377. https://doi.org/10.1007/978-3-642-40763-5_46, 2013) by proposing a method to address anatomical variability among aortic arches. It incorporates anatomical information in the process of catheter trajectories optimization, hence can adapt to the scale and orientation differences among patient-specific anatomies.MethodsStatistical modeling is implemented to encode the catheter motions of both proximal and distal sites based on cannulation data obtained from a single phantom by an expert operator. Non-rigid registration is applied to obtain a warping function to map catheter tip trajectories into other anatomically similar but shape/scale/orientation different models. The remapped trajectories were used to generate robot trajectories to conduct a collaborative cannulation task under flow simulations. Cross-validations were performed to test the performance of the non-rigid registration. Success rates of the cannulation task executed by the robotic platform were measured. The quality of the catheterization was also assessed using performance metrics for manual and robotic approaches. Furthermore, the contact forces between the instruments and the phantoms were measured and compared for both approaches.ResultsThe success rate for semiautomatic cannulation is 98.1% under dry simulation and 94.4% under continuous flow simulation. The proposed robotic approach achieved smoother cathete
Rolls AE, Bicknell CD, Cheshire NJ, et al., 2018, Recent developments in vascular robotics, Journal of Cardiovascular Surgery, Vol: 59, Pages: 307-309, ISSN: 1827-191X
Rudarakanchana N, Hamady M, Harris S, et al., 2018, Early outcomes of patients transferred with ruptured suprarenal aneurysm or dissection, ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, Vol: 100, Pages: 316-321, ISSN: 0035-8843
Martin G, Patel N, Grant Y, et al., 2018, Antihypertensive medication adherence in chronic type B aortic dissection is an important consideration in the management debate., Journal of Vascular Surgery, Vol: 68, Pages: 693-699, ISSN: 0741-5214
OBJECTIVE: Early aortic stenting in chronic type B aortic dissection (TBAD) may lead to long-term benefit, although the optimal treatment strategy is hotly debated. A robust comparison to outcomes seen in medically managed patients is challenging as the rate of antihypertensive medication adherence is unknown. The aims of this study were therefore to identify the rate of antihypertensive medication adherence and predictors of adherence in TBAD. METHODS: This was a cross-sectional mixed methods study of patients with TBAD. Medication adherence was assessed by the eight-item Morisky Medication Adherence Scale together with an assessment of demographic, behavioral, and psychological variables and disease-specific knowledge. RESULTS: There were 47 patients (mean age, 59 years; 81% male) who were recruited from a tertiary vascular unit. The mean total number of medications taken was 5.8 (2-14), and the mean number of antihypertensive medications was 1.9 (1-6). Of the 47 patients, 20 (43%) reported high levels of medication adherence, 17 (36%) reported moderate adherence, and 10 (21%) reported low adherence. Previous aortic surgery was associated with higher levels of adherence (β = 0.332; P = .03), as was taking a greater number of medications (β = 0.332; P = .026), perceived benefit from treatment (β = 0.486; P < .001), good memory (β = 0.579; P < .001), and low fears of side effects (β = 0.272; P < .014). CONCLUSIONS: Medical management remains the mainstay of treatment in uncomplicated TBAD; however, the majority of patients are poorly adherent to their antihypertensive medications. The merits of thoracic endovascular aortic repair in TBAD are argued, and poor adherence is an important factor in the debate; one cannot robustly compare two strategies when half of a treatment group may not be receiving the stated intervention. To develop an evidence-based treatment strategy for TBAD
Weerakkody R, Ross D, Parry DA, et al., 2018, Targeted genetic analysis in a large cohort of familial and sporadic cases of aneurysm or dissection of the thoracic aorta, Genetics in Medicine, Vol: 20, Pages: 1414-1422, ISSN: 1098-3600
PurposeThoracic aortic aneurysm/aortic dissection (TAAD) is a disorder with highly variable age of onset and phenotype. We sought to determine the prevalence of pathogenic variants in TAAD-associated genes in a mixed cohort of sporadic and familial TAAD patients and identify relevant genotype-phenotype relationships.MethodsWe used a targeted polymerase chain reaction and next-generation sequencing-based panel for genetic analysis of 15 TAAD-associated genes in 1,025 unrelated TAAD cases.ResultsWe identified 49 pathogenic or likely pathogenic (P/LP) variants in 47 cases (4.9% of those successfully sequenced). Almost half of the variants were in nonsyndromic cases with no known family history of aortic disease. Twenty-five variants were within FBN1 and two patients were found to harbor two P/LP variants. Presence of a related syndrome, younger age at presentation, family history of aortic disease, and involvement of the ascending aorta increased the risk of carrying a P/LP variant.ConclusionGiven the poor prognosis of TAAD that is undiagnosed prior to acute rupture or dissection, genetic analysis of both familial and sporadic cases of TAAD will lead to new diagnoses, more informed management, and possibly reduced mortality through earlier, preclinical diagnosis in genetically determined cases and their family members.Genetics in Medicine advance online publication, 15 March 2018; doi:10.1038/gim.2018.27.
Perera AH, Rudarakanchana N, Monzon L, et al., 2018, Cerebral embolization, silent cerebral infarction and neurocognitive decline after thoracic endovascular aortic repair, British Journal of Surgery, Vol: 105, Pages: 366-378, ISSN: 1365-2168
BACKGROUND: Silent cerebral infarction is brain injury detected incidentally on imaging; it can be associated with cognitive decline and future stroke. This study investigated cerebral embolization, silent cerebral infarction and neurocognitive decline following thoracic endovascular aortic repair (TEVAR). METHODS: Patients undergoing elective or emergency TEVAR at Imperial College Healthcare NHS Trust and Guy's and St Thomas' NHS Foundation Trust between January 2012 and April 2015 were recruited. Aortic atheroma graded from 1 (normal) to 5 (mobile atheroma) was evaluated by preoperative CT. Patients underwent intraoperative transcranial Doppler imaging (TCD), preoperative and postoperative cerebral MRI, and neurocognitive assessment. RESULTS: Fifty-two patients underwent TEVAR. Higher rates of TCD-detected embolization were observed with greater aortic atheroma (median 207 for grade 4-5 versus 100 for grade 1-3; P = 0·042), more proximal landing zones (median 450 for zone 0-1 versus 72 for zone 3-4; P = 0·001), and during stent-graft deployment and contrast injection (P = 0·001). In univariable analysis, left subclavian artery bypass (β coefficient 0·423, s.e. 132·62, P = 0·005), proximal landing zone 0-1 (β coefficient 0·504, s.e. 170·57, P = 0·001) and arch hybrid procedure (β coefficient 0·514, s.e. 182·96, P < 0·001) were predictors of cerebral emboli. Cerebral infarction was detected in 25 of 31 patients (81 per cent) who underwent MRI: 21 (68 per cent) silent and four (13 per cent) clinical strokes. Neurocognitive decline was seen in six of seven domains assessed in 15 patients with silent cerebral infarction, with age a significant predictor of decline. CONCLUSION: This study demonstrates a high rate of cerebral embolization and neurocognitive decline affecting patients foll
Hamady MS, Sharma P, Patel R, et al., 2017, Hybrid endovascular repair of aneurysmal right-sided aortic arch and Kommerell’s diverticulum using a two-vessel branched stent graft; Case report and review of literature, SAGE Open Medical Case Reports, Vol: 5, ISSN: 2050-313X
Right-sided aortic arches are rare, affecting approximately 0.1% of the population. They are a result of abnormal developmentof the primitive aortic arches and may present later in life with later life with aneurysmal expansion of the aberrant leftsubclavian artery ‘Kommerell’s diverticulum’. These can be challenging to treat effectively. We report a rare case presentingwith mild dysphagia and right-sided aneurysmal aortic arch with aneurysmal aberrant left-sided. The patient underwenthybrid endovascular repair incorporating bilateral carotid–subclavian bypasses and dual-arch-branch endograft placement tothe left and right common carotid arteries. Although endovascular approaches have been described, there are no reports ofbranched endografts in this scenario. Right-sided aneurysmal aortic arch and the aneurysmal aberrant left subclavian arteryare rare and represent a significant therapeutic challenge. Endovascular repair in conjunction with extra-anatomical bypassutilising a custom-made branched thoracic endograft is feasible.
Rolls AE, Riga CV, Rahim S, et al., 2017, Video motion analysis in live coronary angiography differentiates levels of experience and provides a novel method of skill assessment, Eurointervention, Vol: 13, Pages: E1460-E1467, ISSN: 1774-024X
Aims: Video motion analysis (VMA) uses fluoroscopic sequences to derive catheter and guidewire movement, and is able to calculate 2D catheter-tip path length (PL) on the basis of frame-by-frame pixel coordinates. The objective of this study was to validate VMA in coronary angiography as a method of skill assessment.Methods and results: Forty-seven coronary interventions performed by 10 low- (<1,000 cases; group A), five medium- (1,000-4,000; group B) and six high- (>4,000; group C) experience-volume cardiologists were prospectively recorded and analysed using VMA software. Total PL was calculated and procedure, fluoroscopy times, and radiation dose were recorded. Comparisons of PL were made between groups of experience. Groups A, B and C performed 24, 14 and 6 paired (right and left coronary) cannulations, respectively. Calculation of PL was possible in all recorded cases and significantly correlated with procedure (p=<0.001, rho=0.827) and fluoroscopy times (p=<0.001, rho=0.888). Median total path length (combined right and left coronaries) was significantly shorter in group C which used 3,836 pixels of movement (IQR: 3,003-4,484) vs. 10,556 (7,242-31,408) in group A (p=<0.001) and 8,725 (5,187-15,150) in group B (p=0.013).Conclusions: VMA in coronary angiography is feasible and PL is able to differentiate levels of experience.
Lear R, Godfrey AD, Riga C, et al., 2017, Surgeons' Perceptions of the Causes of Preventable Harm in Arterial Surgery: A Mixed-Methods Study, European Journal of Vascular and Endovascular Surgery, Vol: 54, Pages: 778-786, ISSN: 1078-5884
BackgroundSystem factors contributing to preventable harm in vascular patients have not been previously reported in detail. The aim of this exploratory mixed-methods study was to describe vascular surgeons' perceptions of factors contributing to adverse events (AEs) in arterial surgery. A secondary aim was to report recommendations to improve patient safety.MethodsVascular consultants/registrars working in the British National Health Service were questioned about the causes of preventable AEs through survey and semi-structured interview (response rates 77% and 83%, respectively). Survey respondents considered a recent AE, indicating on a 5 point Likert scale the extent to which various factors from a validated framework contributed toward the incident. Semi-structured interviews were conducted to obtain detailed accounts of contributory factors, and to elicit recommendations to improve safety.ResultsSeventy-seven surgeons completed the survey on 77 separate AEs occurring during open surgery (n = 41) and in endovascular procedures (n = 36). Ten interviewees described 15 AEs. The causes of AEs were multifactorial (median number of factors/AE = 5, IQR 3-9, range 0–25). Factors frequently reported by survey respondents were communication failures (36.4%; n = 28/77); inadequate staffing levels/skill mix (32.5%; n = 25/77); lack of knowledge/skill (37.3%; n = 28/75). Themes emerging from interviews were team factors (communication failure, lack of team continuity, lack of clarity over roles/responsibilities); work environment factors (poor staffing levels, equipment problems, distractions); inadequate training/supervision. Knowledge/skill (p = .034) and competence (p = .018) appeared to be more prominent in causing AEs in open procedures compared with endovascular procedures; organisational structure was more frequently implicated in AEs occurring in endovascular procedures (p = .017). To improve safety, interviewees proposed team training programmes (5/10 interview
Chi W, Rafii-Tari H, Payne CJ, et al., 2017, A learning based training and skill assessment platform with haptic guidance for endovascular catheterization, 2017 IEEE International Conference on Robotics and Automation (ICRA), Publisher: IEEE, Pages: 2357-2363, ISSN: 1050-4729
Increasing demands in endovascular intervention have motivated technical skill training and competency-based measures of performance. However, there are no well-established online metrics for technical skill assessment; few studies have explored operator behavioral patterns from catheter motion and operator hand motions. This paper proposes a platform for active online training and objective assessment of endovascular skills, through learning optimum catheter motions from multiple demonstrations. An ungrounded hand-held haptic device for providing intuitive haptic guidance to novice users based on this learnt information is also proposed. Statistical models are implemented to extract the underlying catheter motion patterns, and utilize them for performance evaluation and haptic guidance. The results show significant improvements in endovascular navigation for inexperienced operators. Finer catheter motions were achieved with the provided haptic guidance. The results suggest that the proposed platform can be integrated into current clinical training setups, and motivate the improvement of endovascular training platforms with better realism.
Ramjeeawon A, Sharrock AE, Morbi A, et al., 2017, Exploring the effect of a structured debrief on measurable performance outcomes during endovascular surgery simulation, International Congress of the Association-of-Surgeons-of-Great-Britain-and-Ireland, Publisher: WILEY, Pages: 41-42, ISSN: 0007-1323
Desender LM, Van Herzeele I, Rancic Z, et al., 2017, Patient-specific simulation of endovascular thoracic aortic repair: initial experience, Annals of Thoracic Surgery, Vol: 104, Pages: 336-341, ISSN: 0003-4975
Purpose:Endovascular thoracic aortic repair (TEVAR) has become the treatment modality of diverse aortic pathology. We report the use of patient-specific simulation using a dedicated PROcedure Rehearsal Studio (PRS) platform (Simbionix USA Corp, Cleveland, OH) before TEVAR and evaluate the feasibility and realism of this technology.Description:Virtual three-dimensional models of the patient’s relevant anatomy were reconstructed from computed tomography data. PRS was used in 2 patients before TEVAR. In a multicenter retrospective study, we evaluated how PRS compares with real TEVAR.Evaluation:PRS before TEVAR was feasible and demonstrated good correlation with the actual procedure. In the retrospective study, 16 patients were reconstructed (median duration, 26 minutes; interquartile range, 21 to 36 minutes). The realism of the simulated angiographies was rated highly (median, 4; interquartile range, 3 to 4). Final angiography revealed type I endoleak in 2 simulated cases and 1 real case.Conclusion:Patient-specific rehearsal before TEVAR is feasible and permits the creation of realistic case studies; however, software updates are required to improve face validity and to foster implementation in clinical practice.
Lear R, Godfrey AD, Riga C, et al., 2017, The impact of system factors on quality and safety in arterial surgery: a systematic review, European Journal of Vascular and Endovascular Surgery, Vol: 54, Pages: 79-93, ISSN: 1078-5884
ObjectiveA systems approach to patient safety proposes that a wide range of factors contribute to surgical outcome, yet the impact of team, work environment, and organisational factors, is not fully understood in arterial surgery. The aim of this systematic review is to summarize and discuss what is already known about the impact of system factors on quality and safety in arterial surgery.Data sourcesA systematic review of original research papers in English using MEDLINE, Embase, PsycINFO, and Cochrane databases, was performed according to PRISMA guidelines.Review methodsIndependent reviewers selected papers according to strict inclusion and exclusion criteria, and using predefined data fields, extracted relevant data on team, work environment, and organisational factors, and measures of quality and/or safety, in arterial procedures.ResultsTwelve papers met the selection criteria. Study endpoints were not consistent between papers, and most failed to report their clinical significance. A variety of tools were used to measure team skills in five papers; only one paper measured the relationship between team factors and patient outcomes. Two papers reported that equipment failures were common and had a significant impact on operating room efficiency. The influence of hospital characteristics on failure-to-rescue rates was tested in one large study, although their conclusions were limited to the American Medicare population. Five papers implemented changes in the patient pathway, but most studies failed to account for potential confounding variables.ConclusionsA small number of heterogenous studies have evaluated the relationship between system factors and quality or safety in arterial surgery. There is some evidence of an association between system factors and patient outcomes, but there is more work to be done to fully understand this relationship. Future research would benefit from consistency in definitions, the use of validated assessment tools, measurement of cli
Perera AH, Riga CV, Monzon L, et al., 2017, Response to commentary on "Robotic Arch Catheter Placement Reduces Cerebral Embolisation During Thoracic Endovascular Aortic Repair (TEVAR)", European Journal of Vascular and Endovascular Surgery, Vol: 54, Pages: 126-127, ISSN: 1078-5884
Judah G, Darzi A, Vlaev I, et al., 2017, Incentives in Diabetic Eye Assessment by Screening (IDEAS) trial: a three-armed randomised controlled trial of financial incentives, Health Services and Delivery Research, Vol: 5, Pages: 1-60, ISSN: 2050-4349
Background:The UK national diabetic eye screening (DES) programme invites diabetic patients aged>12 years annually. Simple and cost-effective methods are needed to increase screening uptake. This trialtests the impact on uptake of two financial incentive schemes, based on behavioural economic principles.Objectives:To test whether or not financial incentives encourage screening attendance. Secondarily tounderstand if the type of financial incentive scheme used affects screening uptake or attracts patients witha different sociodemographic status to regular attenders. If financial incentives were found to improveattendance, then a final objective was to test cost-effectiveness.Design:Three-armed randomised controlled trial.Setting:DES clinic within St Mary’s Hospital, London, covering patients from the areas of Kensington,Chelsea and Westminster.Participants:Patients aged≥16 years, who had not attended their DES appointment for≥2 years.Interventions:(1) Fixed incentive–invitation letter and £10 for attending screening; (2) probabilistic(lottery) incentive–invitation letter and 1% chance of winning £1000 for attending screening; and(3) control–invitation letter only.Main outcome measures:The primary outcome was screening attendance. Rates for control versus fixedand lottery incentive groups were compared using relative risk (RR) and risk difference with corresponding95% confidence intervals (CIs).Results:A total of 1274 patients were eligible and randomised; 223 patients became ineligible beforeinvite and 1051 participants were invited (control,n=435; fixed group,n=312; lottery group,n=304).Thirty-four (7.8%, 95% CI 5.29% to 10.34%) control, 17 (5.5%, 95% CI 2.93% to 7.97%) fixed groupand 10 (3.3%, 95% CI 1.28% to 5.29%) lottery group participants attended. Participants offered incentives were 44% less likely to attend screening than controls (RR 0.56, 95% CI 0.34 to 0.92). Examining incentivegroups separately, the lottery gr
Perera AH, Riga CV, Monzon L, et al., 2017, Robotic Arch Catheter Placement Reduces Cerebral Embolization During Thoracic Endovascular Aortic Repair (TEVAR), EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, Vol: 53, Pages: 362-369, ISSN: 1078-5884
Rafii-Tari H, Payne CJ, Bicknell C, et al., 2017, Objective Assessment of Endovascular Navigation Skills with Force Sensing, ANNALS OF BIOMEDICAL ENGINEERING, Vol: 45, Pages: 1315-1327, ISSN: 0090-6964
Despite the increasing popularity of endovascular intervention in clinical practice, there remains a lack of objective and quantitative metrics for skill evaluation of endovascular techniques. Data relating to the forces exerted during endovascular procedures and the behavioral patterns of endovascular clinicians is currently limited. This research proposes two platforms for measuring tool forces applied by operators and contact forces resulting from catheter–tissue interactions, as a means of providing accurate, objective metrics of operator skill within a realistic simulation environment. Operator manipulation patterns are compared across different experience levels performing various complex catheterization tasks, and different performance metrics relating to tool forces, catheter motion dynamics, and forces exerted on the vasculature are extracted. The results depict significant differences between the two experience groups in their force and motion patterns across different phases of the procedures, with support vector machine (SVM) classification showing cross-validation accuracies as high as 90% between the two skill levels. This is the first robust study, validated across a large pool of endovascular specialists, to present objective measures of endovascular skill based on exerted forces. The study also provides significant insights into the design of optimized metrics for improved training and performance assessment of catheterization tasks.
Desender L, Van Herzeele I, Lachat M, et al., 2017, A multicentre trial of patient specific rehearsal prior to EVAR: impact on procedural planning and team performance, European Journal of Vascular and Endovascular Surgery, Vol: 53, Pages: 354-361, ISSN: 1532-2165
OBJECTIVE: Patient specific rehearsal (PsR) prior to endovascular aneurysm repair (EVAR) enables the endovascular team to practice and evaluate the procedure prior to treating the real patient. This multicentre trial aimed to evaluate the utility of PsR prior to EVAR as a pre-operative planning and briefing tool. MATERIAL AND METHODS: Patients with an aneurysm suitable for EVAR were randomised to pre-operative or post-operative PsR. Before and after the PsR, the lead implanter completed a questionnaire to identify any deviation from the initial treatment plan. All team members completed a questionnaire evaluating realism, technical issues, and human factor aspects pertinent to PsR. Technical and human factor skills, and technical and clinical success rates were compared between the randomised groups. RESULTS: 100 patients were enrolled between September 2012 and June 2014. The plan to visualise proximal and distal landing zones was adapted in 27/50 (54%) and 38/50 (76%) cases, respectively. The choice of the main body, contralateral limb, or iliac extensions was adjusted in 8/50 (16%), 17/50 (34%), and 14/50 (28%) cases, respectively. At least one of the abovementioned parameters was changed in 44/50 (88%) cases. For 100 EVAR cases, 199 subjective questionnaires post-PsR were completed. PsR was considered to be useful for selecting the optimal C-arm angulation (median 4, IQR 4-5) and was recognised as a helpful tool for team preparation (median 4, IQR 4-4), to improve communication (median 4, IQR 3-4), and encourage confidence (median 4, IQR 3-4). Technical and human factor skills and technical and initial clinical success rates were similar between the randomisation groups. CONCLUSION: PsR prior to EVAR has a significant impact on the treatment plan and may be useful as a pre-operative planning and briefing tool. Subjective ratings indicate that this technology may facilitate planning of optimal C-arm angulation and improve non-technical skills. TRIAL REGISTRATION:
Kakkos SK, Bicknell CD, Tsolakis IA, et al., 2016, Management of secondary aorto-enteric and other abdominal arterio-enteric fistulas: a review and pooled data analysis, European Journal of Vascular and Endovascular Surgery, Vol: 52, Pages: 770-786, ISSN: 1532-2165
OBJECTIVES: To compare management strategies for secondary abdominal arterio-enteric fistulas (AEFs). METHODS: This study is a review and pooled data analysis. Medline and Scopus databases were searched for studies published between 1999 and 2015. Particular emphasis was given to short- and long-term outcomes in relation to AEF repair type. RESULTS: Two hundred and sixteen publications were retrieved, reporting on 823 patients. In-hospital mortality was 30.7%. Open surgery had higher in-hospital mortality (246/725, 33.9%), than endovascular methods (7/98, 7.1%, p < .001, OR 6.7, 95% CI 3-14.7, including staged endovascular to open surgery, 0/13, 0%). In-hospital mortality after graft removal/extra-anatomical bypass grafting was 31.2% (66/226), graft removal/in situ repair 34% (137/403), primary closure of the arterial defect 62.5% (10/16), and for miscellaneous open procedures 41.3% (33/80), p = .019. Among the subgroups of in situ repair, homografts were associated with a higher mortality than impregnated prosthetic grafts (p = .047). There was no difference in recurrent AEF-free rates between open and endovascular procedures. Extra-anatomical bypass/graft removal and in situ repair had a lower AEF recurrence rate than primary closure and homografts. Late sepsis occurred more often after endovascular surgery (2-year rates 42% vs. 19% for open, p = .001). The early survival benefit of endovascular surgery was blunted during follow-up, although it remained significant (p < .001). Within the in situ repair group, impregnated prosthetic grafts were associated with the worst overall and AEF related mortality free rates and vein grafts with the best. No recurrence, sepsis, or mortality was reported following staged endograft placement to open repair after a mean follow-up of 16.8 months (p = .18, p = .22, and p = .006, respectively, compared with patients in other groups). CONCLUSIONS:
Bicknell CD, Kiru G, Falaschetti E, et al., 2016, An evaluation of the effect of an angiotensin-converting enzyme inhibitor on the growth rate of small abdominal aortic aneurysms: A randomised placebo controlled trial (AARDVARK), European Heart Journal, Vol: 37, Pages: 3213-3221, ISSN: 1522-9645
Aims The AARDVARK (Aortic Aneurysmal Regression of Dilation: Value of ACE-Inhibition on RisK) trial investigated whether ACE-inhibition reduces small abdominal aortic aneurysms (AAA) growth rate, independent of blood pressure (BP) lowering.Methods and results A three-arm, multi-centre, single-blind, and randomized controlled trial (ISRCTN51383267) was conducted in 14 hospitals in England. Subjects aged ≥55 years with AAA diameter 3.0–5.4 cm were randomized 1:1:1 to receive perindopril arginine 10 mg, or amlodipine 5 mg, or placebo and followed 3–6 monthly over 2 years. The primary outcome was aneurysm growth rate (based on external antero-posterior ultrasound measurements in the longitudinal plane), determined by multi-level modelling to provide maximum likelihood estimates. Two hundred and twenty-four subjects were randomized (2011–2013) to placebo (n = 79), perindopril (n = 73), or amlodipine (n = 72). Mean (SD) changes in mid-trial systolic BP (12 months) were 0.5 (14.3) mmHg, P = 0.78 compared with baseline, −9.5 (13.1) mmHg (P < 0.001), and −6.7 (12.0) mmHg (P < 0.001), respectively. No significant differences in the modelled annual growth rates were apparent [1.68 mm (SE 0.2), 1.77 mm (0.2), and 1.81 mm (0.2), respectively]. The estimated difference in annual growth between the perindopril and placebo groups was 0.08 mm (CI −0.50, 0.65). Similar numbers of AAAs in each group reached 5.5 cm diameter and/or underwent elective surgery: 11 receiving placebo, 10 perindopril, and 11 amlodipine.Conclusion Small AAA growth rates were lower than anticipated, but there was no significant impact of perindopril compared with placebo or placebo and amlodipine, combined despite more effective BP lowering.
Ribé L, Bicknell CD, Gibbs RG, et al., 2016, Long-term results of intra-arterial onyx injection for type II endoleaks following endovascular aneurysm repair., Vascular, Vol: 25, Pages: 266-271, ISSN: 1708-5381
PURPOSE: The aim of this paper is to report our experience of type II endoleak treatment after endovascular aneurysm repair with intra-arterial injection of the embolizing liquid material, Onyx liquid embolic system. METHODS: From 2005 to 2012, we performed a retrospective review of 600 patients, who underwent endovascular repair of an abdominal aortic aneurysm. During this period, 18 patients were treated with Onyx for type II endoleaks. PRINCIPAL FINDINGS: The source of the endoleak was the internal iliac artery in seven cases, inferior mesenteric artery in seven cases and lumbar arteries in four cases. Immediate technical success was achieved in all patients and no endoleak from the treated vessel recurred. During a mean follow-up of 19 months, no major morbidity or mortality occurred, and one-year survival was 100%. CONCLUSIONS: Treatment of type II endoleaks with Onyx is safe and effective over a significant time period.
Smith R, Lee S, Bicknell C, et al., 2016, Examining the use of a novel dynamic endovascular simulator to facilitate intelligent localization and robotic technologies, The Vascular Societies’ ASM 2016
Lear R, Riga C, Godfrey AD, et al., 2016, Multicentre observational study of surgical system failures in aortic procedures and their effect on patient outcomes, British Journal of Surgery, Vol: 103, Pages: 1467-1475, ISSN: 1365-2168
BACKGROUND: Vascular surgical care has changed dramatically in recent years with little knowledge of the impact of system failures on patient safety. The primary aim of this multicentre observational study was to define the landscape of surgical system failures, errors and inefficiency (collectively termed failures) in aortic surgery. Secondary aims were to investigate determinants of these failures and their relationship with patient outcomes. METHODS: Twenty vascular teams at ten English hospitals trained in structured self-reporting of intraoperative failures (phase I). Failures occurring in open and endovascular aortic procedures were reported in phase II. Failure details (category, delay, consequence), demographic information (patient, procedure, team experience) and outcomes were reported. RESULTS: There were strong correlations between the trainer and teams for the number and type of failures recorded during 88 procedures in phase I. In 185 aortic procedures, teams reported a median of 3 (i.q.r. 2-6) failures per procedure. Most frequent failures related to equipment (unavailability, failure, configuration, desterilization). Most major failures related to communication. Fourteen failures directly harmed 12 patients. Significant predictors of an increased failure rate were: endovascular compared with open repair (incidence rate ratio (IRR) for open repair 0·71, 95 per cent c.i. 0·57 to 0·88; P = 0·002), thoracic aneurysms compared with other aortic pathologies (IRR 2·07, 1·39 to 3·08; P < 0·001) and unfamiliarity with equipment (IRR 1·52, 1·20 to 1·91; P < 0·001). The major failure total was associated with reoperation (P = 0·011), major complications (P = 0·029) and death (P = 0·027). CONCLUSION: Failure in aortic procedures is frequently caused by issues with team-wo
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