The Canadian Society for Vascular Surgery (CSVS) has released a list of specific tests, treatments or procedures that are commonly ordered but not always necessary in vascular surgery as part of the Choosing Wisely Canada campaign. The list identifies five targeted, evidence-based recommendations that can support conversations between patients and physicians about what care is really necessary.
The Canadian Society for Vascular Surgery’s list identified the following five recommendations:
Do not perform percutaneous interventions or bypass surgery as first line therapy in patients with asymptomatic peripheral arterial disease (PAD) and in most patients with claudication. PAD is a marker of a systemic disease and patients with PAD may have atherosclerotic disease in other vascular beds, including the carotid and coronary circulation. Patients with mild to moderate PAD have a higher five-year risk of stroke, myocardial infarction or cardiovascular death than amputation. Initial therapy should include smoking cessation and risk factor modification, medical therapy and a walking programme. Lower extremity bypass surgery and endovascular therapy should be reserved for patients with limb-threatening ischaemia or truly disabling claudication.
Do not perform carotid endarterectomies or stenting in most asymptomatic high risk patients with limited life expectancy. The purpose of carotid artery surgery and stenting is to prevent stroke and, when combined with appropriate medical therapy, is a successful strategy in selected, mainly symptomatic, patients. Medical therapy alone is an effective alternative in many asymptomatic patients and safer in those who are elderly or at high risk for surgery and stenting and do not have the life expectancy to benefit from such a prophylactic procedure.
Do not perform open or endovascular repair in most asymptomatic patients with small abdominal aortic aneurysms (
Do not perform endovascular repair of abdominal aortic aneurysms in most asymptomatic high risk patients with limited life expectancy. Repair of asymptomatic abdominal aortic aneurysms is recommended when the risk of rupture exceeds the risk of repair and is performed in patients with sufficient life expectancy to allow them to benefit from such a prophylactic procedure. Most elderly, or medically high risk patients, have insufficient life expectancy and are at higher risk of complications following endovascular repair to warrant intervention.
Do not perform unnecessarily frequent ultrasound examinations in asymptomatic patients with small abdominal aortic aneurysms. Aneurysms smaller than 4.5cm in diameter should undergo ultrasound surveillance every 12 months. Regular ultrasound examination of asymptomatic patients with small abdominal aortic aneurysms is essential to document aneurysm growth and decide when intervention is warranted. The interval between examinations is dictated by the size of the aneurysm and its expected growth rate. Too frequent examinations can cause undue patient anxiety and are not cost effective.
The Canadian Society for Vascular Surgery says that its Choosing Wisely Canada list was developed after months of careful consideration and review, using the most current evidence about management and treatment options. “As responsible physicians we must continuously question the need and appropriateness of tests and interventions and this list will help our members and their patients have a conversation regarding these issues,” says CSVS president Thomas Forbes.
“Conversations about what care patients truly need are a shared responsibility among all members of the health care team”, said Wendy Levinson, chair of Choosing Wisely Canada. “The Canadian Society for Vascular Surgery’s list will help vascular surgeons across the country engage their patients in a dialogue about what care is best for them, and what we can do to reduce waste and overuse in our health care system.”
To date nearly 100 national and provincial medical specialty societies, regional health collaboratives and patient and community partners have joined the conversations about appropriate care. With the release of these new lists, the campaign will have covered more than 150 tests and procedures that the specialty society partners say are overused and inappropriate, and that physicians and patients should discuss.