June 2022 | Issue 94
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Ukraine ESVS takes steps to support vascular surgery colleagues
Profile: Alexander Zimmermann
Launch Pad: Trainee perspective from Claire Dawkins
page 18
page 25
Perioperative outcomes of carotid endarterectomy not improved on dual versus single antiplatelet therapy At the time of carotid endarterectomy (CEA), surgeons should consider single antiplatelet therapy (SAPT) rather than dual antiplatelet therapy (DAPT). This is the conclusion of a new meta-analysis—reportedly the largest conducted on the topic to date—published in the European Journal of Vascular and Endovascular Surgery (EJVES).
Community-focused approach required to tackle global issue of unnecessary amputations A roundtable discussion at the recent 2022 Charing Cross (CX) International Symposium (26–28 April, London, UK) recognised a need to discover patients with a “hurting leg” sooner. Experts from across the globe also highlighted the importance of raising awareness and improving access—with approaches that are specific to individual communities—in order to tackle what the panel and audience agreed is a global and pressing issue.
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nchor Roger Greenhalgh (Imperial College, one thing was clear, however, and that was the fact that half London, UK) highlighted a “very concerning” of all major amputees do not have diabetes. “Amputation trend of amputations taking place “without any inequality extends beyond diabetes,” the presenter stated. investigation whatsoever”. The aim of the CX roundtable, While he stressed that few detailed inequality data he stated, was to tackle this problem head on. have been published over the last seven years, a paper Naseer Ahmad (Manchester University Foundation by Ahmad et al gives an insight into 10 years of hospital Trust, Manchester, UK), who joined virtually, opened data for the period 2003–2013. The study included 42,294 the roundtable discussion with a presentation on major and 52,535 minor amputations, as well 255,545 inequalities in the epidemiology of amputations across revascularisations and described variations across England, England. The vascular surgeon highlighted regional, Ahmad told CX attendees. He reported that the amputation gender, and ethnic variations, and also underlined rate in those aged 50 and over was 26.3/100,000 the importance of looking beyond diabetes when across England, but noted that the average discussing amputation. varied across the country; in London it was He first outlined a 2019 paper by Maria below the national average, in the Midlands Davies (Bolton NHS Foundation Trust, it was around the same, and in the north of Bolton, UK) titled “The epidemiology England, it was above the national average. of major lower-limb amputation in The investigators found the same pattern All content is now England: a systematic review highlighting with revascularisation. In addition, Ahmad available on demand. Visit methodological differences of reported trials” revealed that the overall major amputation www.cxsymposium.com based on 25 years’ worth of data. The paper rate actually went down over that same time for more information found that it was difficult to compare changes period, but that inequalities between north and access options over time, Ahmad told the CX audience, as and south and between men and women basic epidemiological data within studies remained the same. were “very poorly described”. He noted that
CX 2022
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“AT THE TIME OF CEA IN SYMPTOMATIC or asymptomatic patients with carotid stenosis, perioperative DAPT has no effect on the occurrence of the ischaemic CEA complications versus perioperative aspirin SAPT,” authors Jerry C Ku (University of Toronto, Toronto, Canada) and Shervin Taslimi (Kingston General Hospital, Kingston, USA) et al write. “However,” they note, “DAPT does result in an increase of haemorrhagic CEA complications.” These are the key findings behind the investigators’ recommendation of SAPT over DAPT at the time of CEA, although Ku, Taslimi and colleagues acknowledge that the overall quality of the available evidence is poor. In the introduction to their study, the authors highlight a lack of granularity in the available guidelines on this topic. “Consensus medical management guidelines recommend aspirin monotherapy for asymptomatic atherosclerotic carotid artery disease and DAPT with aspirin and the addition of clopidogrel or dipyridamole for symptomatic carotid artery disease,” they write. However, they stress that “it remains unclear whether the second antiplatelet agent should be withheld preoperatively and resumed after surgery to reduce bleeding risk or continued throughout the perioperative period to reduce the ischaemic complication risk in patients with symptomatic carotid stenosis.” This ambiguity is reflected in surgeons’ practice. “Surveys of surgeons who perform CEA have shown significant variations in perioperative antiplatelet prescribing patterns,” the authors communicate. “Although the vast Continued on page 6