In addition to the Multi-centre Aneurysm Screening Study (MASS) (reported in Vascular News issue 16, November 2002), the 37th Annual Meeting of the Vascular Surgical Society of Great Britain and Ireland (VSSGBI) featured an eminent international faculty who spoke on Challenging Vascular Emergencies.
Among the speakers at the VSSGBI meeting were Hazim Safi (University of Texas Medical School), Raymond Dawson (Rand Mutual Hospital, Johannesburg), Kenneth Boffard (Johannesburg Hospital and University of Witwatersrand), Eric Frykberg (University of Florida), Linda Reilly (University of California), Ramon Berguer (Harper University Hospital Wayne State University and Detroit Medical Center), Jacobus van Marle (Pretoria Heart Hospital and Unitas Hospital), Wilhelm Sandmann (Heinrich Heine University), Michael Dake (Stanford University Medical Center), Peter Taylor (Guy’s and St Thomas’Hospital) and Brian Hopkinson (University of Nottingham School of Medicine).
Ramon Berguer talked on vascular emergencies of substance abuse. According to him, over 21 million Americans have tried cocaine. Over 50% of his clinic’s acutely injured patients test positive for cocaine, heroine or both, with obvious implications for resuscitation. Cocaine in any form causes myocardial infarction, stroke, visceral artery complications and aortic dissection. The latter is also seen in methamphetamine and ecstasy users. Complications of heroin abuse are related to vessel injury, bacterial contamination and chemical irritation from substances including strychnine, talc powder, lidocaine, quinine, sugar and starch making up “mixed jive”used to “cut down”the heroine before street use. Shared needles and the search for better central injection sites result in pneumothorax, empyema, abscess and cellulitis mostly yielding MRSA and gram-negative coli.
HIV/AIDS-related Vascular emergencies
Jacobus van Marle told the audience that the spectrum of vascular diseases related to HIV/AIDS include fibro-obliterative disease, necrotising vasculitis, aneurysms and complications of hypercoagulability. In known AIDS patients the least invasive procedure to preserve life and if possible limb should be performed, said van Marle.
Whereas elective surgery is influenced by the patient’s immune state, surgery for vascular emergencies is performed regardless of HIV status, because this information is often only available at a later stage. Many of the patients present with end-stage disease. According to van Marle, there is no documentation that surgery has adverse outcomes in patients with HIV.
A word on reporting
Outgoing president Aires Baros D’Sa commented on Dr Foster’s Hospital Consultant Guide report that appeared in The Times just prior to the VSSGBI meeting. He said that it served as a reminder that surgeons’results are in the public domain and comparisons and league tables are becoming the norm. D’Sa said, “It should be our information, we should all contribute to the national vascular database. The data could then be risk adjusted and allowances made for case mix. Crude data are likely to penalise centres and surgeons who operate on high-risk patients
Iatrogenic vascular injuries
The John Kinmonth Memorial Lecture, this year, was given by Professor David Bergqvist of Uppsala, Sweden, and was entitled “Management of iatrogenic vascular injuries. He looked at vascular injuries caused by treatment or diagnostic procedures carried out by clinicians other than vascular specialists. He said that those caused by vascular specialists would be “a chapter on its own.
He said that attention needs to be given to iatrogenic vascular injuries because:
Bergqvist said that iatrogneic vascular injuries are difficult to deal with because the definition is not that clear and reporting procedures are sometimes very poor. If there is an iatrogenic injury caused by a surgeon and he can deal with it then sometimes it is not even reported.
“In the Swedish Vascular Registry,”said Bergqvist, “we have tried to at least give a pragmatic definition of the iatrogenic vascular injuries – injuries caused during diagnosis or therapy that are reported as iatrogenic or that lead to some form of intervention or causes the patients death.
“If we look at SWEDVASC [the Swedish Vascular Registry] we have about 10 vascular injuries per million a year. We are 9 million people that means about 100 vascular injuries a year. Of these, one-third are blunt, one-third are penetrating and one-third are iatrogenic.
Bergqvist identified several factors that are important in contributing to iatrogenic vascular injuries:
He said that although the patients can never be blamed, sometimes an explanation for the injury can be found in the patient – either variations in their anatomy from the norm or sometimes previous therapy can be a problem.
Every speciality, with the exception of psychiatry, has iatrogenic injuries, for example bleeding associated with varicose veins and laproscopic procedures, and ischaemia associated with knee/hip surgery or prolonged leg support.
Bergqvist then went on to present several cases to illustrate the type of iatrogenic vascular injuries that can occur.
In his summing up, Bergqvist said: “The best way to deal with iatrogenic vascular injuries is to avoid them. He called for improved communication, discussion, reporting and competence from all surgeons.
In the closing of the VSSGBI meeting, the Society’s presidency was passed to Kevin Burnand.