Jeanette Robey reports from the Vascular Society Spring Meeting on 11 March

The Vascular Society Spring Meeting was held in conjunction with the Midland Vascular Society, and ran in parallel with a Tissue Viability symposium. The Meeting was the highlight of the Circulation Foundation’s ‘Vascular Disease Awareness Week’.

The twin themes were Critical Limb Ischaemia (CLI) and major Lower Extremity Amputation (LEA). Gerry Stansby outlined the difficulties in estimating the extent of the problem of CLI for which there is no ICD code and where there is lack of consistency in definitions, and limitations in follow-up from limited life/limb expectancy. HES data suggest there are over 5000 LEAs per year in England, implying a population with CLI three to four times higher.

Cliff Shearman emphasised that diabetes, already present in 40% of patients with PAD, is set to become the commonest vascular condition treated. This theme of diabetes and its risk of LEA was highlighted by most speakers and illustrated with some startling facts: lifetime LEA risk >15%; 15-24 fold likelihood of LEA, 50% of all LEA and, worldwide, a limb is removed every 30 seconds for diabetic vascular disease.

The Southampton multidisciplinary foot protection team have, using a protocol driven approach, reduced levels of primary amputation by 60%. Such multidisciplinary teams do not require any additional personnel and could be organised to run as parallel, but independent clinics enabling immediate specialist opinion. However, the drive to commission services in primary rather than secondary care and failure to recognise multiple professional input
in a single clinic visit could jeopardise this model. William Jeffcoate added that amputation rates also reflect the effectiveness of management of the patient’s entire diabetic history and not just the specialist end-stage care that occurs in hospital. He highlighted the ‘putting feet first’ initiative by Diabetes UK (www.diabetesuk.org).

Andy Weale described data on LEA from the NVD. Vascular surgeons have been poor at capturing major LEA on the NVD (2095 per year compared with 5000 by using the HES data), with only 30% having a complete dataset. Analysis of this limited dataset demonstrates an overall 30 day mortality of 6.5% after below knee and 12.8% after above knee amputation. Denise O’Connell reminded the delegates of the importance of a patient-led LEA counselling service before amputation, for which there is at best patchy national availability, in dealing with the psychological and emotional consequences of LEA. She emphasised pre-operative counselling and gradual introduction of amputation as a particularly important role that could not always be achieved on busy acute wards.

Bruce Braithwaite held a Q&A session with three patients who had undergone LEA. Because of opiate analgesia, the patients who needed urgent LEA had little recall of any peri-operative details. The validity of the consent process under these conditions was open to challenge. Jonathan Beard suggested increasing the use of epidurals in patients to allow a more lucid and valid consent process.

Jeanette Robey,

Chief Executive, The Vascular Society

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