European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, Jan 30, 2018
The objective of this study was to examine the impact of an integrated system of stroke care on s... more The objective of this study was to examine the impact of an integrated system of stroke care on symptom to surgery times, cost-effectiveness, and quality of life measures in patients with symptomatic carotid stenosis. Patients who underwent carotid endarterectomy (CEA) in a regional vascular centre between April 1, 2011, and March 31, 2016, were identified from the National Vascular Registry (NVR). Risk of stroke on medical therapy for each patient was calculated using the Oxford stroke risk calculator. Symptom to surgery times were compared among patients referred from a stroke service providing an integrated stroke care and the stroke service in an adjacent NHS trust which provides standard urgent referral pathway. A decision analytic Markov process model was constructed to determine the cost-effectiveness of CEA versus medical treatment in patients who followed the standard and integrated pathways. This model examined the lifetime costs and health benefits of CEA through each pat...
European Journal of Vascular and Endovascular Surgery, 2019
testing purposes. This model e when fully developed and evaluated e will give an excellent traini... more testing purposes. This model e when fully developed and evaluated e will give an excellent training model as well. We collected CT data of 26 patients with abdominal aortic aneuryms after informed consent. The CT scans were segmented and 3D computer models oft he aorta and its main branches were created in cooperation with Fraunhofer MEVIS institute. Based on this we could print 3D models in cooperation with Fraunhofer EMB, using a Connex 500Ô 3D printer. Some oft the models were covered with a silicone layer to improve the resistance and impermeability. The 3D printed vessels were set into the model of a human torso which contains the spine and the pelvis as anatomical landmarks. It is metal free and can be easily xrayed. The vascular model is perfusable when connected to a pump. Results-The torso was build by the company Human X according to our requirements. The first patient specific vessel model was 3D-printed and covered by silicone afterwards, then integrated into the torso and fixed at the spine and the pelvis. The vascular model can be easily exchanged, which gives the opportunity of testing and training under different anatomical conditions. We could then start the first testings by performing fluoroscopy and CT scans. The bony structures of the model have a density similar to that of real bones. For better visibility of the vascular model, we filled it with a mixture of water and contrast agent. A relation of 1:40 was appropriate to get a sufficient contrast. The first attempts of perfusion of the model showed some points of leakage, which led to tests with other materials. At the time of abstract submission, this problem was not sufficiently solved. Conclusion-It is feasible to create a close-to-reality training environment for endovascular aortic procedures for testing purposes as well as for training, although the development of our model is not yet complete. A unique feature of our model is the interchangeability of the vascular models and the fact that these are based on real patient data. Further patient specific vascular models will be produced and further testing of printing materials is necessary. The perfect material should be as flexible and resistant as realistic vessels without any leakages under perfusion. Another hitch is the reusability of vascular models after implantation of an aortic stentgraft. We will face this challenge in the near future.
European Journal of Vascular and Endovascular Surgery, 2019
Introduction-Prior randomized trials have demonstrated that carotid endarterectomy (CEA) can redu... more Introduction-Prior randomized trials have demonstrated that carotid endarterectomy (CEA) can reduce stroke risk in asymptomatic patients. However, subsequent improvements in medical management have challenged this notion. The aim of our study was to describe surgeon-specific CEA rates for asymptomatic versus symptomatic patients in the United States, and to identify factors associated with potential overuse of asymptomatic CEA. Methods-We studied all patients undergoing an initial CEA in the Medicare Claims database between 01/2014 e 12/ 2016. The database includes National Provider Identification
The Health and Social Care Act 2012 (HSCA2012) has altered the operational and business environme... more The Health and Social Care Act 2012 (HSCA2012) has altered the operational and business environment in which NHS trusts in England operate. The Shelford group is one of the leading multi-specialty NHS trusts in England. The aim of this study was to assess the impact of HSCA2012 on the quality of care provided by the group. Annual quality of accounts produced by each of the Shelford group trusts for financial years (FYs) 2012–13, 2013–14 and FY 2014-15 were reviewed. The key performance indicators (KPIs) for each organisation were collected and classified in line with NHS Quality and Outcomes Framework (QOF). KPIs for the period just prior to enactment of HSCA2012 (FY2012–13) were compared with the corresponding values for the period after the enactment of HSCA2012. The benchmarking model used in the study was validated against the Hospital Intelligent Monitoring Report used by the Care Quality Commission. The clinical services provided by the group increased year on year by 7.5%, 6....
The Health and Social Care Act of 2012 (HSCA2012) has transformed the operational and business en... more The Health and Social Care Act of 2012 (HSCA2012) has transformed the operational and business environment within which NHS trusts in England operate. The Shelford Group is the leading multi-specialty NHS trusts in England. The aim of this study was to assess the impact of HSCA2012 on the financial position of the Shelford Group of NHS trusts. The annual account statements produced by each of the trusts for financial years (FY) 2011–12; 2012–13; 2013–14 and 2014–15 were reviewed and the key financial indicators (KFIs) for each organisation were collected. KFIs for the period just prior to enactment of HSCA2012 (FY2011–12, FY2012–13) were compared with the corresponding values for the period after the enactment of HSCA2012. The clinical services provided by the Shelford Group increased year on year by 10.6%, 7.5% and 4% respectively as did their combined annual income. In FY2014–15, the Shelford Group collectively provided 14 735 000 patient care episodes and reported a combined annu...
Background: Duplex ultrasound (DU) remains the gold standard for identification and grading of in... more Background: Duplex ultrasound (DU) remains the gold standard for identification and grading of infrainguinal vein graft stenosis. However, DU-based graft surveillance remains controversial. The aim of this study was to develop a decision tree to identify high-risk grafts which would benefit from DU-based surveillance. Methods: Consecutive patients undergoing infrainguinal vein graft bypass were enrolled in a DU surveillance program. An early postoperative DU was performed at a median of 6 weeks (range 4e9). Based on the findings of this scan and 4 established risk factors for graft failure (diabetes, smoking, infragenicular distal anastomosis, revision bypass surgery), a classification and regression tree (CART) was created to stratify grafts into grafts which are at high and low risk of developing severe stenosis or occlusion. The accuracy of the CART model was evaluated using area under receiver operator characteristic curve (ROC). Results: Of 796 vein graft bypasses performed (760 patients), 64 grafts were occluded by the first surveillance visit and 732 vein grafts were entered into surveillance program. The CART model stratified 299 grafts (40.8%) as low-risk and 433 (59.2%) as high-risk grafts. One hundred twenty-six (17.2%) developed critical vein graft stenosis. Overall, 30-month primary patency, primary-assisted and secondary patency rates were 76.2%, 83.6%, and 85.3%, respectively. The area under ROC curve for the CART model was 0.88 (95% confidence interval 0.81e 0.94). Primary graft patency rates were higher in low-risk versus high-risk grafts (log rank 186, P < 0.0001). Amputation rates were significantly higher in the high-risk grafts compared with low-risk ones (log rank 118, P < 0.0001). Conclusion: A clinical decision rule based on readily available clinical data and the findings of significant flow abnormalities on an early postoperative DU scan successfully identifies grafts at high risk of failure and will contribute to safely improving the efficacy of infrainguinal vein graft surveillance services.
Increased internal carotid artery peak systolic velocity is associated with presence of significant atherosclerotic plaque instability independent of degree of ICA stenosis
Intérêt de la surveillance des pontages veineux de faible diamètre
Annales de Chirurgie Vasculaire, 2009
ABSTRACT Nous avons évalué l&#39;impact du diamètre préopératoire des veines sur le taux de r... more ABSTRACT Nous avons évalué l&#39;impact du diamètre préopératoire des veines sur le taux de réintervention et les résultats après pontage veineux sous-inguinal. Les pontages veineux sous-inguinaux faits de janvier 2001 à décembre 2006 ont été revus. Tous les patients ont eu une mesure préopératoire du diamètre de la veine (DV). Les greffes ont été classées selon que le DV était &lt;3,5 mm ou ≥3,5 mm. Tous les patients ont été enrôlés dans un programme de surveillance duplex. Le lien entre le DV et le taux de réintervention a été évalué. Les taux de perméabilité et d&#39;amputation ont été comparés. Il y avait 377 pontages suivis avec une médiane de 23 mois (extrêmes 8-67). Le DV de139 greffes était &lt;3,5 mm (36,9%) et celui de238 greffes était ≥3,5 mm (63,1%). Une proportion plus élevée de plus petites greffes veineuses (32,3%) a nécessité une réintervention pour maintenir la perméabilité par comparaison avec les greffes plus larges (20,2%) (χ2 = 7,7, p &lt; 0,001). Le DV (odds ratio [OR] = 2,87, intervalle de confiance à 95% [IC] 1,63-3,81; p &lt; 0,001), le tabagisme (OR = 1,83, IC 95% 1,39-3,20; p = 0,02), et le type de pontage (OR = 1,86, IC 95% 1,49-2,47; p = 0,02) étaient des variables liées à un taux plus élevé de réintervention. Il n&#39;y avait aucune différence de perméabilité des greffes (p = 0,13) ou des taux d&#39;amputation (p = 0,35) entre les deux groupes. L&#39;utilisation de plus petites greffes veineuses était associée à un taux plus élevé de réintervention. À condition que ces greffes soient surveillées et réparées si nécessaire, l&#39;utilisation de plus petites greffes veineuses est efficace et augmente la disponibilité des conduits autogènes pour les reconstructions artérielles sous-inguinales.
We assessed the impact of preoperative diameter of the venous conduit on reintervention rate and ... more We assessed the impact of preoperative diameter of the venous conduit on reintervention rate and outcome following infrainguinal vein graft bypass. Consecutive infrainguinal vein bypasses between January 2001 and December 2006 were reviewed. All patients underwent preoperative measurement of vein graft diameter (VGD). Grafts were classified into those with VGD <3.5 mm and those with VGD > or =3.5 mm. All patients were enrolled in a duplex surveillance program. The association between VGD and reintervention rate was assessed. Graft patency and amputation rates were compared. There were 377 bypasses followed up for a median of 23 months (range 8-67). VGD was <3.5 mm in 139 grafts (36.9%) and > or =3.5 mm in 238 grafts (63.1%). A higher proportion of smaller vein grafts (32.3%) required reintervention to maintain graft patency compared with larger conduits (20.2%) (chi(2) = 7.7, p < 0.001). VGD (odds ratio [OR] = 2.87, 95% confidence interval [CI] 1.63-3.81; p < 0.001...
Pancreatic necrosectomy remains an important treatment modality for the management of infected pa... more Pancreatic necrosectomy remains an important treatment modality for the management of infected pancreatic necrosis but is associated with significant mortality. The aim of this study was to identify factors associated with mortality following pancreatic necrosectomy. Patients who underwent pancreatic necrosectomy from January 1995 to December 2004 were reviewed. The association between admission, preoperative and postoperative variables, and mortality was assessed using logistic regression analysis. A total of 1248 patients presented with acute pancreatitis, of whom 94 (7.5%) underwent pancreatic necrosectomy (51 men, 43 women). The preoperative median Acute Physiology, Age, and Chronic Health Evaluation (APACHE II) score was 9 (range 2-19). The median cumulative organ dysfunction score was 2 (0-9) preoperatively and 4 (1-11) postoperatively. In all, 23 patients (24.5%) died. Those who died were older than the survivors; the ages (median and range) were 69 years (40-80 years) versus 52 years (19-79 years) (p < 0.05). They also had higher admission APACHE II scores (median and range): 14 (12-19) versus 9 (2-22) (p < 0.001). There were significant associations between preoperative (p < 0.01) and postoperative (p < 0.01) Marshall scores and mortality following pancreatic necrosectomy. The presence of the systemic inflammatory response syndrome (SIRS) during This study was presented at the 39th annual congress of the European Pancreatic Club,
The Selective Use of Magnetic Resonance Cholangiopancreatography in the Imaging of the Axial Biliary Tree in Patients with Acute Gallstone Pancreatitis
Pancreatology, 2008
Magnetic resonance cholangiopancreatography (MRCP) is an emerging modality in the management of a... more Magnetic resonance cholangiopancreatography (MRCP) is an emerging modality in the management of acute gallstone pancreatitis (AGP). The aim of this study was to assess the impact following the introduction of MRCP in the management of AGP in a tertiary referral unit. Patients presenting with AGP from January 2002 to December 2004 were reviewed to assess the impact of the introduction of MRCP in June 2003. The indication for MRCP was suspected common bile duct (CBD) stones in the absence of biliary sepsis. Definitive treatment for AGP was laparoscopic cholecystectomy, with endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy reserved for patients unfit for cholecystectomy and those with biliary sepsis. 249 patients were identified of whom 36 (14.5%) underwent ERCP and sphincterotomy as definitive treatment. 96 patients with a non-dilated CBD and normal or resolving liver function tests proceeded to laparosocopic cholecystectomy and intraoperative cholangiogram (IOC), 8 (8.5%) of whom had CBD stones intraoperatively. Eleven patients underwent cholecystectomy during pancreatic necrosectomy. Of those undergoing preoperative diagnostic biliary tract imaging, ERCP was undertaken in 57 patients and MRCP in 49 patients. There was no significant difference in serum bilirubin levels [ERCP 43 mmol/l (18-204) vs. MRCP 39 mmol/l (24-180), p = NS] or the proportion of patients with CBD stones [ERCP 10 (17.5%) vs. MRCP 7 (14.2%), p = NS] between the two groups. Patients who underwent MRCP had a shorter median hospital stay [MRCP 5 days (range: 3-14) vs. ERCP 9 days (range: 4-20), p &amp;amp;lt; 0.01] and higher rate of cholecystectomy during the index admission (MRCP 83.3% vs. ERCP 67.2%, p &amp;amp;lt; 0.05). There was a high degree of correlation between preoperative MRCP results and findings of subsequent IOC or therapeutic ERCP (area under ROC curve: 0.94). MRCP is an accurate modality for imaging the axial biliary tree in patients with AGP. Selective use of MRCP reduces the need for ERCP and results in shorter hospital stay. and IAP.
Introduction: Axillary artery injury is a rare but severe complication of fractures of the surgic... more Introduction: Axillary artery injury is a rare but severe complication of fractures of the surgical neck of the humerus. Case presentation: We present a case of axillary artery pseudoaneurysm secondary to such a fracture, in a 82-year-old white woman, presenting 10 weeks after the initial injury, successfully treated with subclavian to brachial reversed vein bypass together with simultaneous open reduction and internal fixation of the fracture. We discuss the use of a Javid™ shunt during combined upper limb revascularisation and open reduction and internal fixation of the fractured humerus. Conclusion: This case highlights the usefulness of a Javid™ shunt, over other forms of vascular shunts, in prompt restoration of blood flow to effect limb salvage. It can be considered as a temporary measure whilst awaiting definitive revascularisation which can be performed following fracture fixation.
Background Day case surgery may reduce inpatient bed requirements, and varicose surgery may be an... more Background Day case surgery may reduce inpatient bed requirements, and varicose surgery may be an ideal operation to test the functioning of a day surgery service. Aims To evaluate retrospectively the feasibility of day case varicose vein surgery in all-corners, and to identify the risk factors for admission. Methods Over a three-year period from July 1995 to July 1998, all patients requiring varicose vein surgery had their procedure performed as a day case. A standard technique of sapheno-femoral ligation with below-knee stripping of the long saphenous vein and multiple stab avulsions of varicosities was performed. All limbs were dressed with wool in crepe bandage and were reviewed post-operatively at six weeks. Results Five hundred and forty two patients underwent varicose vein surgery, of whom 26% had bilateral varicose veins, 88% had primary varicose veins and 22% had recurrent disease. The procedure was performed under general anaesthesia in 86% of cases and under spinal anaesthesia in the rest. There was no perl-operative mortality. Ten patients (1.9%) developed post-operative complications. Seventy two per cent of patients were discharged on the day of surgery, a further 25% required admission for one night due to minor anaesthetic complications and patient preference. Four per cent required admission for more than 24 hours. The need for overnight admission was associated with the age of the patients (p<O.0001), bilateral varicose vein surgery (p<0.005) and the use of spinal anaesthesia (p<0.O1). Conclusion Although varicose vein surgery is safe, acceptable and cost-effective as a day case procedure, if attempted in all-corners, overnight admission will be required in a significant proportion. Pre-operative selection is advised.
National Scientific Medical Meeting 1994 Abstracts
Irish Journal of Medical Science, 1994
ANAESTHESIOLOGY AN ALTERNATIVE FACE MASK FOR PRE-OXYGENATION - A STUDY OF PATIENT PREFERENCE KD C... more ANAESTHESIOLOGY AN ALTERNATIVE FACE MASK FOR PRE-OXYGENATION - A STUDY OF PATIENT PREFERENCE KD Carson St. Vincent&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#x27;s Hospital, Elm Park, Dublin 4. Pre-operative stress is well documented and multifactorial in aetiology. Anxious patients often show ...
European Journal of Vascular and Endovascular Surgery, 2009
Background: We sought to evaluate the role of balloon angioplasty as the primary modality in the ... more Background: We sought to evaluate the role of balloon angioplasty as the primary modality in the management of vein graft stenoses. Methods: Patients who underwent infrainguinal vein graft bypass from January 2002 to December 2007 were enrolled into a surveillance program. Grafts which developed critical stenoses were identified and underwent urgent angiography with a view to angioplasty of the stenotic lesion. Lesions which were deemed unsuitable for angioplasty underwent urgent surgical repair. Results: Four hundred and eleven grafts were followed up for a median of 19 months (range: 2e61). Ninety-six grafts (22.6%) developed critical stenosis. Twelve grafts occluded prior to repair and one was not intervened upon electively. Eight grafts underwent primary surgical repair. Seventy-six grafts underwent 99 endovascular procedures. Technical success was achieved in 60 grafts (78.9%). Of the grafts in which technical success had not been achieved, eight underwent repeat angioplasty and three were surgically repaired. Twenty-four grafts underwent repeat angioplasty for re-stenosis with a technical success rate of 71%. No difference was observed in graft patency (P Z 0.08) or amputation rates (P Z 0.32) between the grafts requiring intervention to maintain patency, and grafts which did not. Smoking [OR: 2.61 (95% CI: 1.51e4.53), (P Z 0.006)], diabetes [OR: 2.55 (95% CI: 1.49e4.35), (P Z 0.006)], renal failure [OR: 1.89 (95% CI: 1.19e3.38), (P Z 0.040)] and recurrent stenosis [OR: 3.22 (95% CI: 1.63e4.69), (P < 0.001)] were risk factors for graft occlusion. Conclusions: Balloon angioplasty of failing infrainguinal vein bypass grafts is safe and can be performed with an acceptable medium term patency rate, albeit with a significant risk of re-stenosis which can be successfully treated in most patients using repeat endovascular intervention.
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Papers by Reza Mofidi