The 25th Charing Cross International Symposium

Open audit is a waste of time
(9.00 – 9.30, Monday 14 April)
For: Janet Powell Against: Peter Harris
Janet Powell states in her typical robust style. “Open audit is a waste of time – well almost.” She will pose the question “what is open audit trying to achieve?” One would hope that it would improve patient care, assess practice against evidence, establish protocols and generate hypotheses to test. Powell has moved from the leadership of a prolific vascular biology group to be a medical director. She is now in a world where audit is demanded as the ‘order of the day’.

Peter Harris, who will oppose the motion, has no such constraints in the position he holds but finds audit helpful. He says, “For centuries open audit has been the foundation of quality assurance in professional practice… …it is a device that has stood the test of time.” The essence of the opposition argument is that open audit is of immense value and in no sense do they need to show that random controlled trials are all bad. The opposition will not pose the question “audit or random controlled trial?” but will say that audit, when performed, is useful. We are in for a lively debate.

Endovascular AAA repair should be carried out as a day case procedure
(10.00 – 10.30, Monday 14 April)
For: Jacques Bleyn (Antwerp Belgium)
Against: Brian Hopkinson (Nottingham UK)
Jacques Bleyn has done it. Jacques Bleyn can do it. Possibly Brian Hopkinson can do it. To be able to do it does not mean to say one should do it. It nevertheless shows what can be achieved being able to perform an elective aortic aneurysm procedure through a percutaneous system and send the patient home the same day. This is a staggering achievement but is it asking too much for at least one night in hospital after any aneurysm procedure?

Endovascular procedures belong in a sterile operating suite
(10.30 – 11.00, Monday 14 April)
For: Ted Diethrich Against: Anna-Maria Belli
Ted Diethrich main’s argument is that a radiological department does not provide the strict sterile facilities that are required. He has referred to reports of infection and sepsis and accepts that the incidence is low.

Anna-Maria Belli points to the increase of procedural use in the X-ray departments in the United Kingdom over recent years and acknowledges that the facilities are not sterile but says this does not matter. Her main argument is that the prime requirement is excellent imaging facilities. Normally these are available only in the X-ray department but in an environment such as at the Arizona Heart Hospital, excellent imaging facilities in a sterile environment are available.

Both these protagonists would accept that excellent imaging facilities in a sterile environment would be ideal but there is often a tussle between either having sterility or excellent imaging facilities. There is also a turf tussle between vascular surgery and vascular radiology but perhaps the greatest tussle ahead lies with the cardiologists.

Deep vein thrombosis risk during flying is exaggerated
(12.00 – 12.30, Monday April 14)
For: Michael Horrocks Against: André Nevelsteen
Michael Horrocks supports this motion and acknowledges that even though there are a large number of newspaper articles describing an apparently high incidence of deep vein thrombosis following flying, there are few prospective studies to establish the true incidence. He says that true deep vein thrombosis incidence is grossly over exaggerated. The opposition acknowledges that the evidence for flight-related venous thromboembolism is largely circumstantial but believes that the incidence is significant. They stress that this potentially fatal syndrome can be prevented by simple means. All would agree that at-risk flyers should be advised against hazards.

Medicine beats angioplasty and stent for renal artery stenosis
(14.00 – 14.30, Monday 14 April)
For: George Hamilton Against: Jon Moss
The protagonists refer mainly to atherosclerotic renal artery stenosis and George Hamilton argues that essential hypertension forms a major part of renal vascular hypertension and does not respond to renal revascularisation. He also argues that progression from renal artery stenosis to renal failure is not as common as previously described and in any case the patients mostly die of other vascular causes ahead of renal failure. He stresses the high procedural morbidity for renal stent angioplasty and says that available data show no significant benefit for stent angioplasty in preservation of renal function. Hamilton concludes that the best medical treatment is at least as effective in preservation of renal function without the risks of angioplasty and embolism.

John Moss refers to the important ASTRAL trial in which a thousand patients are being randomised in order to investigate the effect of stenting on renal function. He also comments on the STAR trial and states that meta-analysis has shown trends in favour of revascularisation over drugs alone. He draws attention to high technical success of patency rate following renal artery stenting. This will be an ideal debate to remind of and inform on the latest renal artery stenosis thinking.

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Arterial stents are not required for femoropopliteal angioplasty
(16.30 – 17.00, Monday 14 April)
For: Dierk Vorwerk Against: Jim Reekers
Two distinguished radiologists will lock horns and wrangle vehemently about stenting or not stenting the superficial femoral artery. They each make a strong case, one for need of stent and the other for angioplasty alone, and both slate the Transatlantic Inter-Societies Consensus! So here you have it.

The two radiologists have the floor and both kill off vascular surgery and put it behind them and argue the toss about whether there should be angioplasty with or without stent. Dr Vorwerk places great importance upon the morphology of the lesion and clearly relates strictly to the precise morphology. He and his senior colleagues in CIRSE clearly want to have a category of femoral artery lesion agreed so that audit in the future can give more accurate results by combining the data. Dr Reekers largely rests his argument upon the absence of present data to argue the toss one way or the other. In essence he is saying that as we are uncertain about whether arterial stents are required for femeropopliteal bypass, they may be, so you cannot say that they are not required.

Time will tell and, as Reekers says, we will await the first randomised controlled trial results to tell us. A surgeon would like both of these treatment modalities compared with an alternative. It is likely that if very mild lesions are chosen, the alternative will be best medical and supervised exercise, smoking cessation advice, control of diabetes etc., against all of that plus angioplasty with or without stents. This is exactly what the proposed MIMIC trial seeks to test and there will also be useful data on the different modalities of exercise in the so-called EXACT trial.

Thrombolysis is irrelevant in the treatment of acute arterial graft occlusion
(17.00 – 17.30, Monday 14 April)
For: Alun Davies Against: Ken Ouriel
It never ceases to amaze the listener that data can be used to make an argument in two totally different directions and here we see this approach in its full glory!

Take the Stile Study; the proposers show the broken down data and stress the superiority of surgery over lytic therapy in terms of composite clinical outcome (adverse outcome), and also the significant superiority of surgery in terms of ongoing and recurrent ischaemia. This latter factor is given as 50% for surgery and 73% for lytic therapy, a significant difference with a p value of 0.01. Then the opposition states about the same study ‘overall there were similar rates of mortality (4% thrombolytic, 5% surgery) and amputation (5% thrombolysis, 6% surgery) in the two groups’. What are we to believe?

Ouriel comments, “From the start, one must realise that thrombolytic therapy must be followed by definitive therapy to address the underlying lesion that causes the occlusion. Clearly he is not saying that surgery and angioplasty play no role, but poses the motion that thrombolysis is irrelevant in the treatment of acute arterial graft occlusion.” He also draws attention to the different thrombolytic agents used over the years and it is clear that the price of thrombolytic agents such as urokinase vary considerably in different parts of the world, being apparently much cheaper in the US than in parts of Europe. These issues are relevant. Ouriel placed great store in making certain that the catheter is placed right inside the clot. He implies very careful supervision of lytic therapy and clearly finds limited lytic therapy helpful as an adjunct. It is possible that it matters in which centre lytic therapy is performed and under whose control. If it is performed by an unenthusiastic radiological group for example, then complications can easily occur. By the same token if a patient with thrombolysis is sent to a surgical ward and receives poor supervision during this lytic phase, this also invites complications. The implication is that thrombolysis, if used, should be targeted, low dose and injected right into the clot. This is to be followed by surgery or angioplasty for correction. Certainly this is not available at every vascular centre and clinical trials meta-analyses can only report what is in the literature at the present time and the proposers have done just that.

The Great Endovascular Debate – Drug-eluting stents will revolutionise stent outcome
(17.30 – 18.30)
For: Barry Katzen (Miami USA) Against: John Rose (Newcastle UK)
Drug-eluting stents are the rage for 2003. Drug-eluting stents will change the current paradigm for vascular intervention according to Barry Katzen. Re-stenosis has dogged these stents. He assesses that the results of the SIROCCO Trial as well as an increasing body of evidence in animals and the coronary circulation provide abundant reason to be optimistic that drug eluting stents will have great impact on peripheral intervention. John Rose draws attention to the pitfalls of extrapolating data from the coronary literature to the peripheral vessels. He stresses that coronary trials of drug eluting stents are short term. There could be loss of benefit at 12 months. He also believes that the data are insufficient to support the use of drug eluting stents in the peripheral vessels. Tom Fogarty doubts the value of drug eluting stent above the popliteal artery in the peripheral circulationis and is also due to comment.

This subject is in its infancy. There is a wide spectrum of opinion. No-one knows for sure. Just wait for evangelism on the day.

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