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• W1885283983 abstract "Edsell and Fletcher [1], commenting on the editorial by Wong and Irwin [2], have highlighted some of features of the changing landscape of vascular anaesthesia, including the recent increasing frequency of endovascular aorta repair (EVAR), the increasing relative complexity of open repair and the requirement for new skill acquisition by vascular anaesthetists such as near-patient testing, invasive cardiovascular monitoring and echocardiography. The Vascular Anaesthesia Society of Great Britain and Ireland (VASGBI) has considered the changing world of vascular anaesthesia carefully. We do not disagree with some of their comments; however, we do not believe that cardiac and vascular surgery are best served by the amalgamation of cardiac and vascular anaesthetists. In particular, we believe that vascular patients are a specialised group just as cardiac patients are. Whilst some of the pathophysiology overlaps, we believe that the evolution of vascular surgery in the UK merits the evolution of a distinct anaesthetic sub-specialty. We have the following specific observations to make: The centralisation of vascular services, a Department of Health-driven reconfiguration of major vascular surgery from peripheral (‘spoke’) hospitals to a large central ‘hub’ hospital, will mean that many more patients undergoing aortic surgery are operated on in hub hospitals than are currently. Despite what the authors say about the Darzi report [3], some centres already designated as vascular centres do not, and probably never will, provide cardiac services. Equally, in some centres there are already ‘cardiovascular’ anaesthetists anaesthetising both cardiac and vascular patients. The final balance of EVAR vs open repair is not yet finalised. Despite EVAR rates of 90% or more in London, other units have been slower to adapt to EVAR, as the mid- to long-term results of the EVAR trials have become apparent. Another new variable is the impact of the aortic screening programme, which should mean that younger patients presenting for aortic surgery may be more suited to open rather than endovascular repair because of long-term follow-up problems related to EVAR surgery. We agree with Edsell and Fletcher that peri-operative transoesophageal echocardiography (TOE) may be a useful adjunct to other invasive cardiovascular monitoring and a valuable skill for (cardio)vascular anaesthetists to acquire. Some vascular anaesthetists already possess these skills. We believe that anaesthetists in general are still behind the times regarding cardiac output monitoring, and TOE is not the only way of monitoring the vascular patient – for example, in patients undergoing vascular surgery awake. Vascular anaesthetists do a great deal more than just anaesthetise vascular patients, including pre-operative assessment, implemention of optimisation strategies, engagement in multidisciplinary team meetings and provision of data to the National Vascular Registry as and when it is up and running. Are cardiac anaesthetists really going to take all this on? Vascular anaesthesia itself involves a lot more than anaesthetising patients for aortic surgery. Carotid and distal revascularisation surgery are also important components requiring their own specific skill set. The implication of Edsell and Fletcher’s letter is that surgery on the ascending aorta has the same consequences, problems and solutions as surgery on the abdominal aorta, which it clearly does not. There are big differences in the pathophysiology, the anaesthetic techniques and monitoring used, the results, implications and management of cross-clamping and the complications of surgery between these two procedures. Vascular anaesthesia is one of the few – perhaps the only – anaesthetic subspecialty for which improved mortality has been demonstrated. A recent publication from the Norfolk & Norwich hospital [4] showed improved outcome in all major vascular surgery with the presence of a designated ‘vascular’ rather than ‘general’ anaesthetist. We believe this is a stimulus for us to expand and rationalise vascular anaesthesia rather than be taken over by another subspecialty. The VASGBI has been, and continues to be, involved in negotiations with the Royal College of Anaesthetists regarding the format, intensity and duration of vascular anaesthetic training. We hope that this will result in a more structured training programme for vascular anaesthetists, which should, of course, include training in invasive cardiovascular monitoring, point-of-care testing and perhaps TOE. In summary, we believe that rather than cardiac anaesthetists’ taking over vascular anaesthesia, the current and future plans for the organisation of vascular surgery in the UK require that vascular anaesthesias become a more defined subspecialty working with vascular surgeons to improve outcomes in this challenging group of patients." @default.
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• W1885283983 date "2012-10-03" @default.
• W1885283983 modified "2023-09-26" @default.
• W1885283983 title "EVAR fever - response from the Vascular Anaesthesia Society of Great Britain and Ireland" @default.
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• W1885283983 doi "https://doi.org/10.1111/anae.12014" @default.
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