Peripheral Vascular Disease and Management
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- Melina McLaughlin
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1 Peripheral Vascular Disease and Management Professor Andrew W. Bradbury BSc MB ChB MD MBA FRCSEd Sampson Gamgee Professor of Vascular Surgery College of Medical and Dental Sciences, University of Birmingham and Consultant Vascular Surgeon, Heart of England NHS Foundation Trust Annual Clinical Negligence Conference June 2012 Hilton Brighton Metropole
2 The Circulation Heart (boiler and hot water pump) Arteries (hot water pipes) High pressure / flow Wear and tear narrow (atherosclerosis) Block suddenly (gunk! embolus) Dilate and burst (aneurysms) Tissues (radiators) Brain Guts Kidneys Arms and legs Veins (cold water pipes) Low pressure / low flow / valves Block (deep vein thrombosis) Blood flows the wrong way (VV) Vascular Surgeon at Work! (regular maintenance)
3 How do Vascular Surgeons work? Take referrals from primary (GP, nurses) and secondary care (A&E, specialists) (letter, fax, , telephone) Elective (planned) Communication and Documentation Medical (e.g. aspirin, statins) Urgent (semi-planned) History and Examination Investigations Diagnosis MDT Treatment Interventional (e.g. angioplasty, stent) After and continuing care Emergency (unplanned) Timeliness Targets Expectations Surgery (e.g. bypass) (back to GP, onward specialist referral, limited follow-up and surveillance)
4 What do Vascular Surgeons do? Take referrals from primary (GP, nurses) and secondary care (A&E, specialists) (letter, fax, , telephone) Elective (planned) Communication and Documentation Medical (e.g. aspirin, stains) Urgent (semi-planned) History and Examination Investigations Diagnosis Treatment Interventional (e.g. angioplasty, stent) Emergency (unplanned) Timeliness Targets Expectations Surgery (e.g. bypass) Aftercare (back to GP, onward specialist referral, limited follow-up and surveillance)
5 What do Vascular Surgeons do? Arteries Carotid (stroke) Arms (atherosclerosis, embolus) Aorta (aneurysm, dissection, trauma) Thoracic Abdominal Kidneys (dialysis access) Intestines (ischaemic bowel) Legs (10X > arms) Atherosclerosis (smoking) Diabetes (+ neuropathy) Trauma (bleeding, compartment syndrome) Veins Varicose veins, leg ulcers DVT/PE
6 Control of bleeding service anywhere, anytime! Trauma Post-partum haemorrhage
7 Legs all shapes and sizes Just looking tells you a lot about their owners!
8 Legs all shapes and sizes!
9 Legs - anatomy Bipedal: pros and cons Outgrown blood supply (10:1) Pressure too high Arterial segments Aorto-iliac (abdomen and pelvis) Femoro-popliteal (thigh and knee) Infra-popliteal (below knee) Smaller and so harder to treat as you go down the leg
10 Risk factors for peripheral arterial disease (PAD) Smoking (pack years) Diabetes (type 2 > type 1) High cholesterol High blood pressure Obesity (poor diet and sedentary life-style) Alcohol Old age (Genes, ethnicity?) Usually multi-factorial Psychological factors Socio-economic factors
11 Diabetes High blood sugar High blood fats Nephropathy (kidneys) Retinopathy (eyes) Neuropathy (nerves, longest first) Arteriopathy (blood vessels) Heart Legs Brain Type 1 Adolescent Insulin Genes Type 2 Middle age +/- Insulin Obesity
12 PAD: classification and frequency (65y) No significant disease (80%) Disease but no symptoms (15%)* Intermittent Claudication (IC) (4%)* Pain (in calf) on walking Critical (Severe) Limb Ischaemia (CLI/SLI)*** Pain (in foot) all the time worse at night Tissue loss (ulcers, gangrene) 2/52 rule *Peripheral Arterial Disease (PAD) is a powerful marker of overall cardiovascular (CV) risk (+/- symptoms)
13 Intermittent Claudication (relatively uncommon cause of litigation in my experience)
14 Critical (severe) limb ischaemia (CLI/SLI) (without intervention the limb will likely be lost)
15 Critical (severe) limb ischaemia (CLI/SLI) The largest single subject of my ML reports Especially in diabetes Breach of duty failure to: Examine Diagnose Refer Intervene Consent appropriately Complications Causation but for the failure: Pain and suffering Minor and major amputation Death Primary care GP / DN / PN / podiatry / chiropody Secondary care
16 The diabetic foot Ischaemia lack of blood supply Neuropathy (Charcot s) sensory, motor and autonomic Neuro-ischaemia - both Contributory negligence? Smoking, non-compliance with treatment Poor prognosis anyway Clinical negligence or natural history? Quantum Effect of disability, QoL, life expectancy
17 NICE Guidelines 2004 The 24 hour rule Reality or aspirational?
18 Consent a surgeon s perspective Process not an event: but not always very much time Capacity: yes, but limited by being unwell, in pain, muddled, educational and intellectual status, communication barriers (hearing, language) Family: not present, not contactable, dysfunctional Doctor knows best: You re the expert, doc! Humanity: unwell, needs the operation and reluctant to increase suffering with unpleasant possibilities if you tell them they will probably consent anyway(?) ( Don t want to know ) Serious or frequent risks: how defined (1%)? Limited recall: write it all down, takes time, dictate a note Quantification of risks: Literature? Unit? Personal? One-offs?
19 Treatment options Medical Interventional Surgery End of life care (drugs and dressings) What? (angioplasty, stent) (bypass) (DNAR, LCP) Who decides? Patient? When? By whom? Where? Transfer? Who pays? Family? Doctor? FT / PCT? DoH / NICE / MRHA / EU? Evidence and data? Politics and ego? Post-code and reality? Aftercare (limited opportunity for follow-up and surveillance)
20 Angioplasty / stenting
21 Bypass operation Femoro-popliteal block
22 Complications All surgeons get complications (even experts ) Half of all hospitals and surgeons are, by definition, below average When does a complication represent negligence (severity, frequency)? When does a side-effect of surgery become a complication? Surgical bypass Immediate/ early (0-30 days) Intermediate (30days 12 months) Late (> 12 months) General (can happen after many / most operations) (Anaesthetic) Bleeding Wound infection DVT/PE Pneumonia Heart attack Poor wound healing Keloid scar (cosmetic) Specific (more or less) to particular operation Blocked graft Bleeding graft Graft stenosis Graft occlusion and failure (leading to amputation)
23 Poor Prognosis of CLI Up to 1. 50% of people with CLI may be untreatable (amputation, end of life care) 2. 20% of treatments (angioplasty, bypass) fail (within 30 days) 3. 50% of people with CLI who have initially successful treatment may lose their leg and/or die within 5 years 4. 30% will develop SLI in the other leg Breach with causation vs. natural history of the condition (quantum)
24 Compartment syndrome what is it? Ischaemia and death of tissues due to obstruction of microvascular blood flow secondary to increased tissue pressure within a confined fascial space Powerful muscles 100mmHg Leaky! (especially when damaged) 25mmHg Tightly bound in fascia (silverside) Low pressures 10mmHg
25 CS how does it happen? Trauma (bleeding) Reperfusion (embolism) Trapped (immobility, blood flow, fixed pressure on muscles)
26 CS diagnosis and management Clinical diagnosis (index of suspicion) Severe (unresponsive) pain Pain on passive movement of toes Pain on squeezing calf Calf tense Loss of pulses TOO LATE! Pressure measurements Can be helpful(?) BUT if you have thought about doing a fasciotomy. do a fasciotomy! Fasciotomy
27 What is a negligent operation? Reckless (very rare) Dishonest (cover up, also rare) Foolhardy (it was never going to work!) Careless / bad day (only human?) Unlucky (TBFTGOG go I!) Not negligent (but settled) (increasing?) Negligent (but no, or not enough, causation) Negligent (but successfully defended)
28 Clinical Negligence: final thoughts Factors of production (people, stuff, time) Communication (shift working, EWTD) Documentation (EPR) Unrealistic expectations (not just patients) Wrong treatment Wrong time, place and person Wrong (poor) technique (training, EWTD) Failure to recognise / treat complications Failure of team working and to ask for help
29 Thank you
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This information explains the advice about the care and treatment of people with stable angina that is set out in NICE clinical guideline 126.
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