Vaux Robertson - Academia.edu (original) (raw)

Papers by Vaux Robertson

Surgery (Oxford), 2018

Abdominal Aortic Aneurysm (AAA) is a dilatation of the infra-renal abdominal aorta to greater tha... more Abdominal Aortic Aneurysm (AAA) is a dilatation of the infra-renal abdominal aorta to greater than 3 cm. Population screening is offered to men in their 65th year in the UK. Patients with small AAAs (

Hepatobiliary & pancreatic diseases international : HBPD INT, 2021

European Journal of Vascular and Endovascular Surgery, 2020

This systematic review evaluated open surgical/endovascular interventions in three groups of pati... more This systematic review evaluated open surgical/endovascular interventions in three groups of patients with proximal common carotid artery (CCA) or innominate artery (IA) disease, with/without tandem disease involving the ipsilateral internal carotid artery (ICA). The higher morbidity/mortality associated with isolated open surgical reconstructions probably reflects the invasiveness of these procedures in a cohort with a greater proportion of IA occlusive/stenotic lesions. The available data support an "endovascular first" strategy in symptomatic patients with isolated proximal CCA/IA lesions and a hybrid approach in symptomatic patients with tandem proximal CCA/IA and ICA stenoses. Recently published evidence suggests that caution should be exercised in recommending hybrid interventions in asymptomatic patients with tandem disease. Objective: To establish 30 day and mid term outcomes in patients treated for significant stenoses affecting the proximal common carotid artery (CCA) or innominate artery (IA) with/without tandem disease of the ipsilateral internal carotid artery (ICA). Methods: Systematic review of early and mid term outcomes in 1 969 patients from 77 studies (1960e2017) who underwent: (i) hybrid open retrograde angioplasty/stenting of the IA/proximal CCA plus carotid endarterectomy (CEA) in patients with tandem disease of the ipsilateral proximal ICA (n ¼ 700); (ii) isolated open surgery to the IA or proximal CCA (no CEA) (n ¼ 686); or (iii) an isolated endovascular approach to IA or proximal CCA stenoses (no CEA) (n ¼ 583). Results: In the hybrid group with tandem disease (66% involving proximal CCA), the 30 day death/stroke was 3.3%, with a late ipsilateral stroke rate of 3.3% at a median six years follow up. Late re-stenosis was 10.5% for proximal CCA/ IA and 4.1% for the ICA. In the isolated open surgery group (78% involving the IA), the 30 day death/stroke was 7%, with a late ipsilateral stroke rate of 1% at a median 12 years follow up. Late re-stenosis within aortic bypasses was 2.6%. In the isolated endovascular group (52% IA, 47% proximal CCA), the majority of procedures were done percutaneously (84%), with a 30 day death/stroke rate of 1.5%. Late ipsilateral stroke was 1% at a median four years follow up, with a re-stenosis rate of 9%. Conclusion: Procedural risks were higher following isolated open surgical interventions involving the proximal CCA/ IA, compared with proximal lesions treated by isolated angioplasty/stenting, or in tandem with CEA. This higher morbidity/mortality may, however, reflect a greater proportion of innominate (vs. proximal CCA) lesions in open surgical series, changes in patient selection, time dependent evolution of medical interventions, and publication bias. The available data were limited and related to very different patient groups and management strategies spanning 57 years. Caution is raised, particularly for open IA and CCA surgery, and for any procedures in asymptomatic patients. In symptomatic patients, the data cautiously support an "endovascular first" strategy for isolated proximal CCA/IA lesions and a hybrid approach for tandem proximal CCA/IA and ICA stenoses.

The Surgeon, 2018

Background: Simulation based training (SBT) enhances endovascular psychomotor skill acquisition a... more Background: Simulation based training (SBT) enhances endovascular psychomotor skill acquisition and is a requirement of the UK vascular surgical curriculum. We aimed to assess the provision and obstacles to the delivery of SBT within regional UK vascular surgical training programmes. Methods: An electronic survey was distributed to all UK regional vascular surgical training programme directors (TPDs) assessing SBT regional infrastructure and provision. Results: The survey response rate was 12/14 (86%). All regions incorporated SBT into regional training programmes, but with varying regularity: 50% every 6e12 months, 25% every 3e6 months and 25% bimonthly. Twenty-five percent of regions provide SBT in conjunction with vascular surgery from another region and 33% of regions combine with interventional radiology training programmes. Only seven regions possess a high-fidelity endovascular simulator and a further 2 have access to industry-sponsored facilities. The majority of SBT (92%) is delivered by consultants outside of their NHS or deanery contracts. All TPDs reported a regular reliance (>50%) on industry sponsorship for the provision of SBT and only 3 TPDs reported receiving sufficient deanery funding for the majority of SBT.

European Journal of Vascular and Endovascular Surgery, 2019

This is the largest systematic review and meta-analysis detailing the presentation, management, a... more This is the largest systematic review and meta-analysis detailing the presentation, management, and procedural complications following carotid body tumour (CBT) surgery. Although relatively rare, complications associated with CBT are not inconsiderable, especially in the more challenging Shamblin III CBTs where procedural stroke rates were about 4%, while cranial nerve injury rates approached 20%. The increasing morbidity associated with Shamblin III tumours must be considered during the consent process. Objectives: The aim was to determine the mode of presentation and 30 day procedural risks in 4418 patients with 4743 carotid body tumours (CBTs) undergoing surgical excision. Methods: This is a systematic review and meta-analysis of 104 observational studies. Results: Overall, 4418 patients with 4743 CBTs were identified. The mean age was 47 years, with the majority being female (65%). The commonest presentation was a neck mass (75%), of which 85% were painless. Dysphagia, cranial nerve injury (CNI), and headache were present in 3%, while virtually no one presented with a transient ischaemic attack (0.26%) or stroke (0.09%). The majority (97%) underwent excision, but only 21% underwent pre-operative embolisation. Overall, 27% were Shamblin I CBTs; 44% were Shamblin II; and 29% were Shamblin III. The mean 30 day mortality was 2.29% (95% CI 1.79e2.93). The mean 30 day stroke rate was 3.53% (95% CI 2.91e4.29), while the mean 30 day CNI rate was 25.4% (95% CI 24.5e31.22). The prevalence of persisting CNI at 30 days was 11.15% (95% CI 8.42e14.64). Twelve series (544 patients) correlated 30 day stroke with Shamblin status. Shamblin I CBTs were associated with a 1.89% stroke rate (95% CI 0.92e3.82), increasing to 2.71% (95% CI 1.43e5.07) for Shamblin II CBTs and 3.99% (95% CI 2.34e 6.74) for Shamblin III tumours. Twenty-six series (1075 patients) correlated CNI rates with Shamblin status: 3.76% (95% CI 2.62e5.35) for Shamblin I CBTs, 14.14% (95% CI 11.94e16.68) for Shamblin II, and 17.10% (95% CI 14.82e19.65) for Shamblin III tumours. The prevalence of neck haematoma requiring re-exploration was 5.24% (95% CI 3.45e7.91). The proportion of patients with a neck haematoma requiring re-exploration was not reduced by pre-operative embolisation (5.92%; 95% CI 2.56e13.08) vs. no embolisation (5.82%; 95% CI 2.76e11.88). Pre-operative embolisation did not reduce drainage losses (639 mL vs. 653 mL). Conclusions: This is the largest meta-analysis of outcomes after CBT excision. Procedural risks associated with tumour excision were considerable, especially with Shamblin III tumours where 4% suffered a peri-operative stroke and 17% suffered a CNI.

European Journal of Vascular and Endovascular Surgery, 2018

Using combined data from randomised controlled trials and observational studies, eversion carotid... more Using combined data from randomised controlled trials and observational studies, eversion carotid endarterectomy (eCEA) was superior to conventional CEA (cCEA) regarding peri-operative outcomes (death, stroke, death/stroke) and late (>50%) restenosis. However, when eCEA outcomes were compared with outcomes after patched CEA, there were no significant differences. This updated meta-analysis suggests that early and late outcomes following cCEA are similar to eCEA, provided the arteriotomy is patched. Introduction: A 2011 meta-analysis comparing eversion (eCEA) with conventional (cCEA) carotid endarterectomy in 16,251 patients concluded that eCEA was associated with lower rates of peri-operative stroke and late occlusion compared with cCEA. However, randomised controlled trials (RCTs) showed no difference in outcomes. Since then, the literature contains outcome data on 49,500 patients undergoing eCEA or cCEA. An updated metaanalysis was performed to establish whether eCEA confers significant benefit over cCEA. Methods: This was a systematic review of PubMed/Medline, Embase, and Cochrane databases for RCTs and observational studies (OSs) comparing eCEA with cCEA. A sensitivity analysis was also performed using data from OSs with a Newcastle-Ottawa score >5. Results: There were 25 eligible studies (5 RCTs, 20 OSs) involving 49,500 CEAs (16,249 eCEAs; 33,251 cCEAs). RCT data: Compared with cCEA, eCEA did not confer significant reductions in 30 day stroke, death, death/stroke, death/stroke/MI, or neck haematoma. However, eCEA was associated with reduced late restenosis (OR 0.40; p ¼ .001). OS data: eCEA was associated with significant reductions in 30 day death (OR 0.46; p < .0001), stroke (OR 0.58; p < .0001), death/stroke (OR 0.52; p < .0001), death/stroke/MI (OR 0.50; p < .0001), and late restenosis (OR 0.49; p ¼ .032) compared with cCEA. RCT and OS data combined: eCEA was associated with significant reductions in 30 day death (OR 0.55; p < .0001), stroke (OR 0.63; p ¼ .004), death/stroke (OR 0.58; p < .0001), and late restenosis (OR 0.45; p ¼ .004) compared with cCEA. eCEA vs. patched cCEA (RCT and OS data): There were no differences between the two procedures except for neck haematoma, where eCEA was better than patched cCEA. Conclusions: Using combined RCT and OS data, eCEA was superior to cCEA regarding peri-operative outcomes (stroke, death, death/stroke) and late restenosis, but was similar to patched CEA in both early and late outcomes. This updated meta-analysis suggests that early and late outcomes following cCEA are similar to eCEA, provided the arteriotomy is patched.

Anaesthesia Cases, 2017

A 77-year-old male presented with an abdominal aortic aneurysm (AAA). He underwent preoperative c... more A 77-year-old male presented with an abdominal aortic aneurysm (AAA). He underwent preoperative cardiopulmonary exercise testing (CPET) to help assess his suitability and fitness for complex major vascular surgery. His aneurysm subsequently ruptured in the post-test period and he underwent emergency open repair. CPET is a useful tool in the repertoire of anaesthetic pre-assessment and helps inform decisionmaking in high-risk surgical patients. However any single test has its limitations and it should not be used in isolation as a reason to deny a patient surgery. Patients with a diagnosed AAA should not forgo CPET for fear of rupture but should be closely monitored for signs of rapid uncontrolled hypertension-an indication to terminate the test early.

ANZ journal of surgery, Jan 12, 2016

Clinical risk scores (CRS) within the context of neoadjuvant chemotherapy for colorectal liver me... more Clinical risk scores (CRS) within the context of neoadjuvant chemotherapy for colorectal liver metastases (CRLM) has not been validated. The predictive value of clinical risk scoring in patients administered neoadjuvant chemotherapy prior to liver surgery for CRLM is evaluated. A prospective database over a 15-year period (April 1999 to March 2014) was analysed. We identified two groups: A, neoadjuvant chemotherapy prior to CRLM surgery; and B, no neoadjuvant chemotherapy. Overall median survival in groups A and B were 36 (2-137) months and 33 (2-137) months. In group A, nodal status, size, number of metastases and carcinoembryonic antigen levels were not found to be independent predictors of overall survival (OS). However, patients with a shorter disease-free interval of less than 12 months had an increased OS (P = 0.0001). Multivariate analysis of high- and low-risk scores compared against survival in group B (P < 0.05) confirms the applicability of the scoring system in tradit...

Annals of surgery, Jan 12, 2014

Chest computed tomographic (CT) scans frequently detect indeterminate pulmonary nodules (IPNs) in... more Chest computed tomographic (CT) scans frequently detect indeterminate pulmonary nodules (IPNs) in patients with colorectal cancer. The discovery of such nodules creates a clinical dilemma. This study was performed to identify clinical characteristics of IPNs and develop a predictive model to predict the risk of progression to pulmonary metastases in patients with colorectal cancer. We analyzed data from a prospectively collected database involving 1195 patients with colorectal carcinoma who underwent curative surgery between January 2008 and June 2010. A predictive model was constructed on the basis of the probability risk score and validated in 115 patients collected from a separate treatment period. Of the 1195 patients who underwent a baseline staging chest computed tomography, 326 (27.2%) had IPNs. During a median follow-up of 26.7 months (interquartile range: 18.0-37.2), 74 (28.1%) showed pulmonary metastases. Five variables maintained prognostic significance after multivariate...