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: fph.tr.vascularnurses@nhs.net• • 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