thoracic outlet syndrome commissioning and organisation of vascular services david gerrard
TRANSCRIPT
Thoracic Outlet SyndromeCommissioning and Organisation of Vascular
Services
David Gerrard
Thoracic Outlet Syndrome
• Cervical Rib• Fibrous bands• Idiopathic• Iatrogenic• Physiological– Exercise– Work related
Anatomy
• Compression of neurovascular structures exiting the neck
• Varying pattern of symptoms• Purely Neurological• Purely Arterial
– Embolic or thrombotic
• Purely Venous– Usually thrombotic
• Mixed
Diagnosis
• High Clinical Suspicion• By Exclusion• Examination– Cervical spine/shoulder MS exam– Inspection– Pulse – BP in each arms– Adson’s Test– Roos’ Test
Investigations
• Thoracic Outlet X-Ray• Venous/Arterial Duplex• Cervical MRI/CTA• Venography• Nerve Conduction Studies
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome
Treatment
• 3-6 months physiotherapy• Adjust lifestyle• Job• Venoplasty• Surgery
Surgical Approaches
Commissioning of Vascular Services
• Varicose Veins
• Hyperhidrosis
• Complex AAA repair
Commissioning of Vascular Services
• Varicose Veins
– Based upon CEAP classification
CEAP classification
• Clinical classification • Etiology classification • Anatomic classification • Pathophysiological
CEAP classification• Clinical classification
– C0: no visible or palpable signs of venous disease– C1: telangiectasies or reticular veins– C2: varicose veins– C3: edema– C4a: pigmentation or eczema– C4b: lipodermatosclerosis or athrophîe blanche– C5: healed venous ulcer– C6: active venous ulcer– S: symptomatic, including ache, pain, tightness, skin irritation,
heaviness, and muscle cramps, and other complaints attributable to venous dysfunction
– A: Asymptomatic
CEAP classification
• Etiology classification
– Ec: congenital– Ep: primary– Es: secondary– En: no venous cause identified
CEAP classification
• Anatomic classification
– As: superficial veins– Ap: perforating veins– Ad: deep veins– An: no venous location identified
•
CEAP classification
• Pathophysiological
– Pr: reflux– Po: obstruction– Pr,o: reflux and obstruction– Pn: no venous pathophysiology identifiable
Commissioning of Vascular Services
• Varicose Veins
– Differing policies in Surrey, Hampshire & Berkshire
Commissioning of Vascular Services
• Varicose Veins
– Surrey• CEAP 3
• Otherwise IFR required
Commissioning of Vascular Services
• Varicose Veins
– N Hampshire• CEAP 6
• Otherwise IFR required
Commissioning of Vascular Services
• Varicose Veins
– Berkshire• Prior authorisation
Commissioning of Vascular Services
• Hyperhidrosis– Botox– Cervical Sympathectomy
• Common Policies– Not funded outside IFR
• Commissioning of Vascular Services
Complex AAA repairF-EVAR
‘Nellix’
Organisation of Vascular Services
• Pre-2012– Network with ASPH
• S Central Review 2011– Separate hubs– Separation agreement
• Screening Programme
Current Situation
• Surrey and Sussex commissioners wish to retain 2 hub model– ? Timeframe– Outside pressures to Centralise even further• Expertise, surgical, anaesthetic, nursing• Expense• Training• Outcomes
The Future
• FHFT– Basingstoke, +/- RSCH
• ASPH– +/- Epsom, +/- RSCH, +/- East Surrey
• One Vascular Centre
FHFT Clinics
FHFT Contact Details• VASCULAR DEPARTMENT CONTACT DETAILS• • • Contact details:• • Frimley Park Hospital main switchboard 01276 604604• • • Medical Secretaries for:• • Mr P W Leopold & Mr M Cleanthis: 01276 604291 (Tracy Cullen)• • Mr D J Gerrard & Mr N Dastur: 01276 604772 (Eileen Kean)• • Mr P F S Chong: 01276 522141 (Sally Dolman)• • Miss S Sonnenberg: 01256 313569 (Laura Dobson / Sally Dolman)•
FHFT Contact Details• Vascular Specialist Nurses • • Claire Martin • Jean Nixon • Tracey Craig • Andrea Croucher • Amy Dickenson (NHH) 07799 862858• • Direct Dial 01276 526302 or Bleep 407 / 349 / 452• • Email: [email protected]• • Vascular Support Secretary 01276 522555 (Joanne Briggs)• • • Vascular Office Fax Number: 01276 526516• • Vascular Specialist Registrars Bleep 020 / 014• • Senior House Officer Bleep 170• • House Officer Bleep 019