Vascular Anaesthesia Society of Great Britain and Ireland Annual Scientific Meeting Abstracts for

49 Pages·2015·1.24 MB·English

Vascular Anaesthesia Society
of Great Britain and Ireland

Annual Scientific Meeting

Abstracts for
Sheffield Meeting

7th and 8th September 2015

City Campus
Sheffield Hallam University
Howard Street
Sheffield
S1 1WB
VASCULAR ANAESTHESIA SOCIETY
Monday 7th September 2015

Session 1

11.10 - 11.45 "Day Case EVAR"
Dr Mark Regi, Sheffield (Abstract not provided)

11.45 - 12.20 "Carotid endarterectomy"
Professor Ross Naylor, Leicester

12.20 - 12.55 "Lower limb reperfusion"
Mr Tawqeer Rashid, Manchester (Abstract not provided)

Session 2

2.00 - 2.35 "Cirrhosis"
Professor Mark Bellamy, Leeds (Abstract not provided)

2.35 - 3.10 "Aortic stenosis (TAVI)"
Dr Chris Malkin, Leeds

3.10 - 3.45 "Heart failure"
Dr A Al-Mohammad, Sheffield

Session 3

4.30 - 5.30 "Mountain Rescue: vascular emergencies on the
mountain side"
Dr Steve Rowe, Sheffield
"Carotid Endarterectomy: Where are we now?"

A. Ross Naylor MD, FRCS
Professor of Vascular Surgery, Leicester Royal Infirmary

The management of carotid disease remains one of the most enduringly controversial subjects in
medicine. In one of the first examples of evidence-based medicine being used to guide practice,
carotid endarterectomy (CEA) was shown to be superior to best medical therapy (BMT) alone in the
management of patients with symptomatic carotid disease. Thereafter, further randomised trials
(RCTs) showed that CEA conferred a small but significant benefit in asymptomatic patients. Despite
level I evidence, however, there remain a number of unresolved (and new) issues relating to the
performance of CEA and these will be the theme of this lecture. Key issues to be discussed include;
(i) locoregional vs general anaesthesia, (ii) the role of carotid sinus blockade, (iii) is it safe to reverse
heparin after CEA? (iv) which symptomatic patients are ‘high risk for stroke’, (v) why is it so
important to intervene rapidly after onset of symptoms and (vi) the Leicester experience of reducing
stroke after CEA.

Locoregional (LRA) vs general anaesthesia: A meta-analysis of 41 non-randomised studies (25,000
CEAs) showed that LRA was associated with a 40% relative risk reduction in peri-operative
stroke/death, plus significant reductions in cardiopulmonary complications1. However, a 2013
Cochrane Review of 14 RCTs (4596 CEAs) showed no evidence that type of anaesthesia influenced
the procedural risk2. Surgeons and anaesthetists can, therefore, use whichever type of anaesthesia they
prefer without any risk of uncritical medico-legal censure.

Carotid sinus nerve blockade (CSNB): The rationale that CSNB reduces peri-operative haemo-
dynamic instability is based on intuitive reasoning than evidence. A systematic review and meta-
analysis of 4 RCTs (432 patients) showed no evidence that it conferred any benefit, but overall study
quality was poor3. To date, there is no compelling evidence supporting its routine use.

Protamine reversal of heparin: A recent systematic review and meta-analysis showed that heparin
reversal with protamine conferred a significant reduction in peri-operative wound haematomas with
no evidence of a significant increase in procedural stroke4. With the move towards using dual
antiplatelet therapy prior to CEA, anecdotal evidence suggests that prolonged suture hole bleeding is
probably not due to additional antiplatelet activity, but seems to be more likely to be due to heparin.

Which symptomatic patients are high risk for stroke?: Because the landmark RCTS were so large, it
has been possible to undertake meaningful subgroup analyses. Clinically significant predictors of an
increased risk of stroke on BMT include; increasing age, very recent symptoms, male gender,
hemispheric vs ocular symptoms, cortical vs lacunar stroke and increasing medical co-morbidity.
Clinically relevant imaging predictors include; irregular vs smooth plaques, increasing stenosis
severity (but not subocclusion), contralateral occlusion, tandem intracranial disease and no
recruitment of intracranial collaterals5.

Of these, the most important is to perform CEA as soon as possible after onset of symptoms. Natural
history studies show that the early risk of stroke is much higher than previously thought and that CEA
can be performed during this hyperacute time period without incurring an excess risk of stroke. There
are, however, important lessons to be learned from operating at this time with the emphasis being to
avoid embolisation. There is also evidence that starting dual antiplatelet therapy once parenchymal
haemorrhage has been excluded on CT/MRI reduces recurrent events prior to expedited CEA without
increasing peri-operative bleeding complications6.

Reducing the risks of peri-operative stroke: The Leicester experience: Over a 21 year period, a
series of themed research/audit projects has addressed each of the major causes of intra- and post-
operative stroke7. Intra-operative stroke was virtually abolished through intra-operative TCD (warning
of embolisation during carotid dissection, ensuring shunt is working and that MCAV is >15cm/sec
and to warn of embolisation during wound closure) plus completion angioscopy (primarily to identify
and remove residual thrombus prior to flow restoration). Early post-operative thrombotic stroke was
abolished via the use of selective Dextran therapy (now unavailable), superseded by dual antiplatelet
therapy (DAP) started pre-operatively. Finally, the combination of DAP and the preparation of
guidelines for managing post-CEA hypertension saw an immediate and sustained reduction in MI,
ICH and the hyperperfusion syndrome. In Leicester, 90%+ CEA patients do not go to either ITU or
HDU after CEA. The principle reason for requiring higher level care is persisting or recurrent
hypertension.
REFERENCES

1. Rerkasem K, Bond R, Rothwell PM. Local versus general anaesthesia for carotid
endarterectomy. Cochrane Database Syst Rev 2004; (2); CD000126

2. Vaniyapong T, Chongruksut W, Rerkasem K. Local versus general anaesthesia for carotid
endarterectomy. Cochrane Database Syst Rev 2013; Issue 12; CD000126. DOI:
10.1002/14651858

3. Tang TY, Walsh SR, Gillard JH, Varty K, Boyle JR, Gaunt ME. Carotid sinus nerve
blockade to reduce blood pressure instability following carotid endarterectomy: a
systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 34 (2007) 304-11

4. Kakisis J . European Society of Vascular Surgery Guidelines for the treatment of
extracranial carotid and vertebral artery disease. Eur J Vasc Endovasc Surg (IN
PREPARATION)

5. Naylor AR, Sillesen H, Schroeder TV. Clinical and imaging features associated with an
increased risk of late stroke in patients with symptomatic carotid disease. European Journal
of Vascular and Endovascular Surgery 2015;49:513-23

6. Batchelder AJ, Hunter J, Robertson V, Sandford R, Munshi A, Naylor AR. Dual antiplatelet
therapy prior to expedited carotid surgery reduces recurrent events prior to surgery without
increasing peri-operative bleeding complications. Eur J Vasc Endovasc Surg 2015 (IN
PRESS)

7. Naylor AR, Sayers RD, McCarthy MJ, Bown MJ, Nasim A, Dennis MS et al. Closing the
loop: A 21-year audit of strategies for preventing stroke and death following carotid
endarterectomy. Eur J Vasc Endovasc Surg 2013;46:161-70
"Cirrhosis"

Professor Mark Bellamy, Leeds
(Abstract not provided)

Biography
I have been a consultant in Anaesthesia and intensive care in Leeds since 1993. In that time, I have
been very involved in the liver transplant program, and in particular, intensive care for patients with
liver failure. I was for many years the lead anaesthetist for liver transplantation, and took a lead role
in setting up living related transplantation in Leeds and the UK. I anaesthetised Europe's first live
related small bowel transplant, and set up the theatre and intensive care protocols for live related
bowel and liver transplantation. My research interests centred predominantly around major
haemorrhage and ischaemia reperfusion injury, and the critical care management of patients with
sepsis and acute liver failure.
"Aortic Stenosis (TAVI)"

Dr Christopher Malkin
Consultant in Interventional Cardiology, Leeds Teaching Hospitals

The last 10 years has seen a revolution in the treatment of aortic stenosis (AS) with the advent of
catheter delivered valves implanted into a beating heart. Although surgical valve replacement (SAVR)
remains the standard of care, many patients are unsuitable or high risk for sternotomy. Trans-catheter
Aortic Valve implantation (TAVI) was developed in animals in the late 1990s and the first in man
procedure was performed in 2002. The techniques and technology have been refined such that TAVI
is now a frequently performed treatment with a high level of success and demand worldwide.
In the UK TAVI is commissioned nationally and delivered from 30 centres, although there is
considerable variation in patient referral and access by geographic area. All UK centres offer
treatment through a framework of a heart team including cardiologists and cardiac surgeons and all
contribute to a mandatory UK registry.

Patient selection remains the single most important component. Untreated severe AS has a poor
prognosis but there is major potential for co-morbidities or frailty to nullify the haemodynamic
advantage of valve intervention. Symptomatic severe aortic stenosis remains the principle indication
for aortic valve intervention, the requirement for intervention in asymptomatic patients is rare but may
be considered in the presence reduced LV function and if major non-cardiac surgery is required.
Many patients are candidates for SAVR or TAVI; some are suitable for both or neither. Stand-alone
balloon aortic valvuloplasty can be used to bridge critically ill patients to definitive valve intervention
or as a trial of treatment in diagnostic doubt. ‘Missed’ aortic stenosis in patients with low flow low
gradient states may deny patients effective therapy and untreated symptomatic aortic stenosis is
associated with significant risk of harm. Preliminary evidence suggest TAVI is should be considered
in patients inoperable for surgical valve replacement or whom are at high risk due to co-morbidity or
previous cardiac surgery. On-going trials are exploring the efficacy of TAVI in intermediate risk
populations.

General anaesthesia for major non-cardiac surgery in patients with aortic stenosis can be challenging,
around 10-15% referrals to UK TAVI MDTs include patients found to have aortic stenosis during a
workup for unrelated non-cardiac surgery. The decision to offer valve intervention depends on risk of
anaesthesia and surgery; the symptomatic and haemodynamic effects of the stenosed valve and
reversibility or potential for ‘cure’ or relief from non-cardiac surgery.
TAVI is a major vascular procedure and is associated with a range of complications including
bleeding, stroke, dissection, pacemaker requirement and death. The most contemporaneous registries
in intermediate to high-risk populations report a 30-day death rate of 2%. General anaesthesia is still
widely used but with smaller delivery catheters, pre-procedural cross-sectional imaging and
introduction of re-positionable valves use of conscious sedation and local anaesthesia has become
more prevalent. In ‘non-GA cases’ anaesthetic support remains important with fragile patients
requiring careful levels of sedation and the immediate management of occasional (sometimes
unpredictable) haemodynamic embarrassment. Cardiac anaesthetists in TAVI centres will be familiar
with anticipating haemodynamic support required during pacing, or slow valve deployment with self
expanding valves. ‘Suicide ventricle’ – a phenomenon of transient pulseless electrical activity treated
effectively by cardiac massage is not uncommon in patients with poor LV function or with low stroke
volume.

Major TAVI publications.
Partner A: Smith et al. NEJM; 2011, 364(23): 2187-2198
Partner B: Leon et al. NEJM; 2010, 363(17):1597-1607
Pivotal US Corevalve Trial. Adams et al. NEJM; 2014, 370(19): 1790-1798
Notion Study: Thyregod et al. JACC; 2015, 65(20):2184-2194
Sapien 3 registry: Most recent up to real-world data, oral presentation ACC March 2015.
(STS: ‘Society of Thoracic Surgeons’ a risk score of 30-day mortality)
Study Patients (n) STS Randomisation Outcome / death at 1 Comment
30-day groups yr
death
Partner B Inoperable- 11.6 TAVI v medical 30% v 50% TAVI is better
extreme risk than nothing
(n=358)
Partner A Operable 11 TAVI v SAVR 24.2% v 26.8% Equivalence
high risk
(n=699)
Pivotal Operable 7.3 TAVI v SAVR 14.2% v 19.2% Planned as non-
Corevalve high risk inferiority trial of
study (795) TAVI, showed
superiority
Notion All comers 3 TAVI v SAVR 4.9% v 7.5% Not significant:
age>70 trend to TAVI
(280)
Sapien 3 High risk TAVI *30-day mortality* Non-randomised
registry (583) 8.6 (2.2%) very low event
From Intermediate rates for TAVI
partner 2 risk (1076) 5.3 (1.1%)
trial

Biography
I trained in Sheffield and completed a fellowship in Adelaide, South Australia.
I have been a consultant in Leeds for 3 years and perform high volume coronary intervention and
trans-catheter aortic valve implantations.

Even in my relatively short consultant career the pattern of clinical work has changed significantly.
The coronary intervention I perform is now almost exclusively for acute coronary syndromes and
particularly STEMI. I review and report more aortic CT scans than coronary angiograms and I now
participate in multiple sub-specialty heart team MDT meetings a week. I have performed increasing
numbers of elective aortic valve interventions (TAVI and balloon aortic valvuloplasty) year on year
(135 in 2014) with a projected growth of 20% per annum. Our centre is now the largest trans-catheter
valve implanting centre in the UK and we are constantly trying to innovate to improve patient
outcome using novel valve technologies, cerebral protection devices, alternate vascular access and
non-GA procedures.

I am a proctor for the Medtronic Evolut valve and Boston Lotus valve system and I have led on
developing a physician training programme with lectures, virtual reality simulators and catheter
laboratory implants in silicon models to allow new centres a head start with second generation valve
technology.

I am very active with clinical research and have published papers on the use of balloon aortic
valvuloplasty in the TAVI pathway and the impact of reduced ejection fraction and paradoxical low
trans-aortic gradient on outcome from TAVI. Our centre has contributed heavily to TAVI research
including SURTAVI and DEFLECT-3 and I am the local principle investigator for UK TAVI.

Outside of work in am keen on the great outdoors particularly skiing and cycling.

Some of the information above has been sourced from the British Cardiovascular Society.
"Heart Failure"

Dr A Al-Mohammad
Sheffield Teaching Hospitals NHS Foundation Trust

Heart failure is a major co-morbidity amongst patients with vascular disease and could pose a
significant risk to these patients undergoing surgical interventions.

I will discuss:
 The epidemiology of heart failure
 Types of heart failure
 Pharmacological and non-pharmacological interventions to treat heart failure
 The time-scale for the effects of the interventions in heart failure

I will explore the evidence behind certain interventions in patients with vascular disease that may be
suitable for patients with heart failure.

I will address the role of testing pre-operatively of patients with established heart failure, as opposed
to testing patients with vascular disease for heart failure.

I will explore post-operative management of patients with heart failure.

Biography
Dr. Abdallah Al-Mohammad, is a consultant cardiologist to Sheffield Teaching Hospitals NHS
Foundation Trust. He is also an honorary senior lecturer at the University of Sheffield. He has
interests in heart failure, non-invasive imaging and endocarditis. He is a fellow of the Royal College
of Physicians of Edinburgh (2003), a fellow of the Royal College of Physicians of London (2005),
and a fellow of the European Society of Cardiology (2012). He is regional adviser in Trent for the
Royal College of Physicians of Edinburgh 2012-2017.

He has contributed to work into the NICE Guidelines on myocardial perfusion scintigraphy 2003, on
chronic heart failure 2010 and on acute heart failure 2012. He contributed to the work on chronic
heart failure quality standards 2011, and is a member of the expert panel advising on their update in
2015. He is currently co-opted as a cardiology expert to the guidelines development groups into two
NICE guidelines on carding for the dying adult and on pre-operative testing.
He has published on the topics of heart failure diagnosis and therapy, imaging of the heart using
echocardiography, myocardial perfusion scintigraphy, positron emission tomography and cardiac
MRI.
"Mountain Rescue: Vascular Emergencies on the Mountainside"

Dr Steve Rowe
Medical Officer Edale Mountain Rescue Team
Consultant Anaesthetists Sheffield teaching Hospitals NHS Trust

This lecture will cover the day to day work of UK mountain rescue teams, and how the interface
between pre-hospital and in-hospital services works to benefit the patients. It will cover some of the
challenges to providing high quality medical care including terrain, access, resources and weather,
and demonstrate how we as a team overcome these challenges. It will include video footage from
incidents, and an insight into the operational challenges of being a doctor on the hills!

The speaker, Steve Rowe, has been an operational member of Edale Mountain rescue team for the
past 15 years, starting as a medical student. Over that time he has held a number of roles within the
team and has been the medical officer for the past 11 years. He is also the Chairman of the Peak
District Mountain Rescue Organisation Medical group, and sits on the national advisory group.
Edale Mountain Rescue Team operates within the UK's Peak District National Park as well as the
rural areas of South Yorkshire and Derbyshire.
Due to the large number of outdoor activities carried out within our area, coupled with the high
number of visitors/participants, Edale Mountain Rescue Team is one of the busiest mountain rescue
teams in the country. Since the beginning of 2000 team members have been involved in over 1000
incidents. These incidents have occurred whilst people have been partaking in nearly every outdoor
activity possible on dry land or in the air; walking, climbing, fell running, mountain biking, horse
riding, trials biking, hand gliding, paragliding, fixed wing gliding and even fishing. We also assist the
police in incidents where our skills can be utilised in more rural locations. These predominantly
involve searching for vulnerable people that have gone missing for various reasons and whose
disappearance has cause concern. Edale Mountain Rescue Team members were also heavily involved
the flood rescue operations in Sheffield during July 2007.
As with all other UK teams, the team is made up entirely of volunteers who come from all walks of
life and give up their time freely. We have 51 operational members and 12 aspirant members. Many
of our members also work for the full time emergency services and health authorities. Currently
within our ranks there are Doctors, Paramedics, Nurses, Fire-fighters and Police Officers as well as
people from a host of other professions - Tax Inspector, Blind Fitter, Academic, Student, Salesman,
Civil Engineer to name but a few!
Edale Mountain Rescue Team receives no central funding from government and we rely entirely on
donations to raise the money we need to run the team, which is generally in the region of £50,000 per
annum. All monies raised are used to improve the service we offer to the public by investing in
equipment maintenance and renewal, training for members, running our 3 response vehicles and 1
search control vehicle; as well as planning for a secure financial future for the team. The majority of
monies raised are through the hard work of team members.
For more information go to www.edalemountainrescue.co.uk
VASCULAR ANAESTHESIA SOCIETY
Tuesday 8th September 2015

Session 4

9.00 - 9.35 "Pre-assessment - the F word!"
Dr Chris Snowden, Newcastle

9.35 - 10.10 "Predicting survival - can it be done?"
Dr John Carlisle, Torbay

10.10 - 10.45 "Anaemia and why it should be corrected"
Dr Ben Clevenger, London

Session 5

11.20 - 12.20 Free Paper Session

"Comparison of vascular Intensive Care Unit (ICU) admissions
against other surgical patients: a 7 year retrospective audit"
Elizabeth Huddlestone, Royal Liverpool University Hospital

"The use of preoperative natriuretic peptides in predicting major
adverse cardiac events in patients undergoing major vascular
surgery: a prospective audit"
Amna Ghafoor, Royal Sussex County Hospital

"Monitoring heparin anticoagulation: comparison of hemochron
ACT and rapid TEG ACT with anti Xa levels in heparin spiked
blood"
Ciara Donohue, Royal Free London NHS Trust

"Can sarcopenia predict post-operative outcomes in patients
undergoing elective abdominal aortic aneurysm surgery?"
Nikhil Shah, University College London

"Management of major haemorrhage and coagulopathy during
Thoraco-Abdominal Aortic Aneurysm repair without laboratory
tests."
McGregor EC1, Moores C1, Thomson AJ1, Chalmers RTA2 & Nimmo AF1
1. Department of Anaesthesia, Royal Infirmary of Edinburgh.
2. Department of Vascular Surgery, Royal Infirmary of Edinburgh.

12.20 - 1.10 "Case Discussion: Short of breath? Have you imaged the aorta?
Real world case exhibiting real world physiology." (No abstract)

Session 6

2.00 - 2.20 "Acute kidney injury in the vascular patient, prevention and
modification"
Dr Bisher Kawar, Sheffield

2.20 - 2.40 "Antiplatelet drugs"
Dr Rob Storey, Sheffield (No abstract provided)

2.40 – 3.00 "Preventing post-operative delirium"
Dr Richard Bourne, Sheffield (No abstract provided)

3.00 - 3.20 "The introduction of ROTEM"
Dr Dan Nevin, London (No abstract provided)