A previously well, independent 20-year-old man presented with a 4-day history of progressive left lower limb pain with associated phlegmasia cerulea dolens. Duplex venous ultrasound examination and computed tomography venogram revealed extensive deep vein thrombus from the left popliteal vein to abnormal venous vasculature proximally. Notably, no infrarenal inferior vena cava was detected, with distal venous return channeled through lumbar and visceral collateral channels into the azygous system. Treatment included systemic anticoagulation, catheter-directed thrombolysis, and prolonged therapeutic anticoagulation. In the absence of other risk factors, anatomical abnormalities should be considered in young, well patients presenting with lower limb venous thrombosis.

Purpose Surgery is associated with a post-operative stress response, changes in cardiopulmonary reserve, and metabolic demand. Here recovery after abdominal aortic aneurysm repair is investigated using cardiopulmonary exercise testing and patient-reported questionnaires. Materials and methods Patients undergoing open (n = 21) or endovascular (n = 21) repair undertook cardiopulmonary exercise tests, activity, and health score questionnaires pre-operatively and, 8 and 16 weeks, post-operatively. Oxygen uptake and ventilatory parameters were measured, and routine blood tests were undertaken. Results Recovery was characterised by falls in anaerobic threshold, peak oxygen uptake, and oxygen pulse at 8 weeks which appeared to be associated with operative severity; the fall in peak oxygen uptake was greater following open vs. endovascular repair (3.5 vs. 1.6 ml(.)kg(-1.)min(-1)) and anaerobic threshold showed a similar tendency (3.1 vs. 1.7 ml(.)kg(-1.)min(-1)). In the smaller number of patients re-tested these changes resolved by 16 weeks. Reported health and activity did not change. Conclusions Aortic repair is associated with falls in the anaerobic threshold, peak oxygen uptake, and oxygen pulse of a magnitude that reflects operative severity and appears to resolve by 16 weeks. Thus, post-operatively patients may be at higher risk of further metabolic insult e.g. infection. This further characterises physiological recovery from aortic surgery and may assist in defining post-operative shielding time.

Purpose Over the past two decades, the proliferation of endovascular surgery has changed the approach to abdominal aortic aneurysm (AAA) repair. In Australia, close to two-thirds of surgical procedures are performed in the private healthcare system. We aimed to describe the trends in AAA repair in the Australian private sector throughout the early 21st century. Materials and Methods Medicare Benefits Schedule (MBS) statistics were accessed to determine the number of infrarenal open AAA repair (OAR) and endovascular AAA repair (EVAR) procedures performed between January 2000 and December 2019. Population data were extracted from the Australian Bureau of Statistics and used to calculate incidence per 100,000 population. Further analysis was performed according to age, gender, and state. Results During the study period, 13,193 (67.0%) EVARs and 6504 (33.0%) OARs were performed in the Australian private sector. OARs fell from 70.5% (n=567) of AAA repairs in 2000 to 15.7% (n=237) in 2019, while EVARs rose from 29.5% (n=151) to 84.3% (n=808). The frequency of EVAR surpassed OAR in 2004. The overall incidence of AAA repair varied minimally over the time period (range: 4.9-6.5 per 100,000 adults per year). AAA repair was more common in males than females (9.7 vs 1.7 per 100,000 population) and more common in older age groups. There was a 4-fold increase in EVAR among males older than 85 years (12.8-57.4 per 100,000 population), the largest rise of any group. The overall EVAR:OAR ratio increased from 0.4 to 5.4. There were considerable state-based discrepancies. Conclusion The landscape of AAA repair in Australian private sector has drastically changed with a clear preference toward EVAR. EVAR saw increased use across all genders, age groups and states, despite stable rates of AAA surgery. Further research is necessary to compare our findings to national trends in the Australian public sector.

Abstract Background An association between end-stage renal failure and exercise intolerance exists. Whether live kidney donation impacts on exercise tolerance is unknown. Here recovery post renal transplant and donation using cardiopulmonary exercise testing is investigated. Methods Renal donors (n = 28) and recipients (n = 24) undertook a cardiopulmonary exercise test, Duke activity score index and patient reported health score questionnaires pre-operatively and in the 7th and 14th week post-operatively. Anaerobic threshold, peak oxygen uptake and ventilatory equivalents were measured in relation to activity and reported health scores. Haemoglobin and renal function was recorded. Results Recipients showed impaired cardiopulmonary function compared to donors with lower anaerobic threshold (10.5 vs. 14.4 ml/kg/min) and peak oxygen uptake (18.5 vs 23.0 ml/kg/min). Post-operatively the anaerobic threshold of recipients improved and normalised by the 14th week, whereas that in donors fell by ∼20% by the 7th (mean 11.4 ml/kg/min), recovering by the 14th (mean 15.6 ml/kg/min). Reported health but not activity scores showed similar changes. Conclusions Recovery following renal transplantation and donation differ. Transplantation improves renal function resulting in an increase in anaerobic threshold and peak oxygen uptake which essentially normalise by the 14th week post-operatively. Donors suffer a 20% reduction in cardiopulmonary reserve post-operatively, which recovers by the 14th week, suggesting no associated chronic exercise intolerance. IMPLICATIONS FOR REHABILITATION Cardiopulmonary exercise testing is a real-time predictor of functional capacity and thus is used as a pre-operative tool to measure physiological fitness and predict outcomes. Renal failure is associated with exercise intolerance and transplantation is transformational in terms of quality of life, longevity and healthcare cost. Live – related renal donation is increasingly available but whether donation itself carries a long-term health burden has not been previously well established. This study suggests that renal donation is not associated with long-term cardiopulmonary compromise and patients who donate their kidneys recover their previous fitness within 14 weeks.

BACKGROUND:The aim of this study was to estimate separate risks of major lower limb amputation and death following revascularization for peripheral artery disease (PAD) using competing risks analysis.METHODS:Routinely collected data from Hospital Episode Statistics (HES) were used to identify patients who underwent endovascular or open lower limb revascularization for PAD in England from 2005 to 2015. The primary outcomes were major lower limb amputation and death within 5 years of revascularization. Cox proportional hazards and Fine-Gray competing risks regression were used to examine the competing risks of these outcomes.RESULTS:Some 164 845 patients underwent their first lower limb revascularization for PAD during the study interval. Most were men (64·6 per cent) and the median age was 71 (i.q.r. 62-78) years. Following endovascular revascularization, the 5-year cumulative incidence of amputation was 4·2 per cent in patients with intermittent claudication and 18·0 per cent in those with a record of tissue loss. The corresponding rates were 10·8 and 25·3 per cent respectively after open revascularization, and 8·1 and 25·0 per cent after combined procedures. The 5-year cumulative incidence of death varied from 24·5 to 39·8 per cent, depending on procedure type. Competing risks methods consistently produced lower estimates than standard methods.CONCLUSION:The 5-year risk of major amputation following lower limb revascularization for PAD appears lower than estimated previously. Patients undergoing revascularization for tissue loss and those who require an open procedure are at highest risk of limb loss.

Background: The availability and diversity of lower limb revascularization procedures have increased in England in the past decade. We investigated whether these developments in care have translated to improvements in patient pathways and outcomes. Methods: Individual-patient records from Hospital Episode Statistics were used to identify 103 934 patients who underwent endovascular (angioplasty) or surgical (endarterectomy, profundaplasty, or bypass) lower limb revascularization for infrainguinal peripheral artery disease in England between January 2006 and December 2015. Major lower limb amputations and deaths within 1 year after revascularization were ascertained from Hospital Episode Statistics and Office for National Statistics mortality records. Competing risks regression was used to estimate the cumulative incidence of major amputation and death, adjusted for patient age, sex, comorbidity score, indication for the intervention (intermittent claudication, severe limb ischemia without record of tissue loss, severe limb ischemia with a record of ulceration, severe limb ischemia with a record of gangrene/osteomyelitis), and comorbid diabetes mellitus. Results: The estimated 1-year risk of major amputation decreased from 5.7% (in 2006–2007) to 3.9% (in 2014–2015) following endovascular revascularization, and from 11.2% (2006–2007) to 6.6% (2014–2015) following surgical procedures. The risk of death after both types of revascularization also decreased. These trends were observed for all indication categories, with the largest reductions found in patients with severe limb ischemia with ulceration or gangrene. Overall, morbidity increased over the study period, and a larger proportion of patients was treated for the severe end of the peripheral artery disease spectrum using less invasive procedures. Conclusions: Our findings show that from 2006 to 2015, the overall survival increased and the risk of major lower limb amputation decreased following revascularization. These observations suggest that patient outcomes after lower limb revascularization have improved during a period of centralization and specialization of vascular services in the United Kingdom.

Background Availability and diversity of lower limb revascularisation procedures have increased in in the past decade, co-inciding with the reconfiguration of vascular services in the United Kingdom. The aim of our study was to investigate whether these developments in care have translated to improvements in patient outcomes. Methods We used data from Hospital Episode Statistics (HES) to identify patients who underwent endovascular or surgical (endarterectomy, profundaplasty or bypass) lower limb revascularisation for infrainguinal peripheral arterial disease (PAD) in England in 2006–2013. Major lower limb amputations and deaths were ascertained from HES and Office for National Statistics mortality register. Associations of revascularisation procedures with amputation and death outcomes were investigated using Fine-Grey competing risks regression, with adjustment for patient age, sex and comorbidity score. We examined the possible impact of patient selection by stratifying our analyses by indication for revascularisation (intermittent claudication only; severe limb ischaemia without tissue loss; severe limb ischaemia with ulceration; severe limb ischaemia with gangrene). Results Over the 8 year study period the overall number of endovascular revascularisations increased and the number of surgical procedures decreased: the evidence for this trend was the clearest among patients with the most severe underlying disease (severe limb ischaemia with ulceration or gangrene). The 1 year risk of major amputation reduced from 5.9% (in 2006–07) to 5.5% (in 2012–13) following endovascular evascularization and from 10.8% (2006–07) to 7.4% (2012–13) following surgical procedures (p<0.0001). The risk of death after both types of procedures also decreased, whilst the number of comorbidities and the proportions of patients with more severe underlying disease increased. Discussion Our findings suggest that patient outcomes following lower limb revascularisation have improved during a period of centralisation and specialisation of vascular services in the United Kingdom, despite higher morbidity and an increasing proportion of patients treated for the severe end of the PAD spectrum.

Native pastures account for approximately half the grazing area of the high-rainfall zone of southern Australia and the appropriate intensity of grazing management to improve pasture production and to sustain native species composition is still debated. This paper describes differences in pasture herbage mass, ground cover and composition for a native pasture managed under three distinct grazing-management intensities (1-, 4- and 20-paddock grazing systems). Grazing-management treatments were implemented for 4 years across a variable landscape and the interaction of grazing management and landscape position (high-, medium- and low-production zones) were examined. Increasing the intensity of grazing management (number of paddocks in the grazing system) resulted in higher standing, green and litter herbage mass and ground cover of pastures, with differences most pronounced in the high-production zone where selective grazing was regulated with grazing management. Landscape position largely influenced pasture composition, with higher pasture production and more productive species (e.g. Microlaena stipoides, Lolium rigidum and legumes) in the high-production zone. Small increases in the DM of native perennial grasses and lower levels of legumes and broad-leaf weeds developed in the 20-paddock system compared with grazing in 1- and 4-paddock systems. Net pasture growth was higher in the 20-paddock than 1-paddock treatment during spring in the last 2 years of the experiment, resulting in 21% (1.6 t DM/ha) more herbage mass accumulated over the year. While productivity and cover were higher under intensive rotational grazing, grazing management had little influence on pasture composition. A stable perennial pasture (>70% perennial grasses) stocking rates that were not degrading and the strong influence of landscape on pasture composition limited management influences. Practically, the results indicated that, at the same stocking rate, increasing the intensity of grazing management can increase the average pasture herbage mass, ground cover and pasture growth by more evenly distributing grazing.

It has been proposed that changes to grazing systems, from continuous to rotational grazing, alter the pasture mass and composition, which are reflected in changes to stored soil water. Additionally, in highly variable landscapes, determining whether the variation in soil water is due to the inherent landscape properties rather than the imposed grazing management has long been a contentious argument. To address this question, soil moisture was measured across a highly variable landscape under three differing grazing treatments (1-, 4- and 20-paddock systems). From the soil-water measurements, plant-available water and plant-available water capacity were determined. Different production zones (high, medium and low) were identified in the landscape by visually estimating green herbage mass in late spring. There were no observed differences in the measured plant-available water capacity across the grazing treatments; however, significant differences occurred in plant-available water capacity across the three production zones (high-production zone, 114 mm; medium-production zone, 102 mm; low-production zone, 88 mm) within the study period. There appears to be a trend between the plant-available water capacity and near-surface gravel content as measured in production zones. The high production zones held more plant-available water than did the low production zones, enabling more biomass and longer pasture growth during spring and autumn. The plant-available water in the low production zones significantly decreased with time. In all, 22 of the 50 soil-moisture monitoring locations displayed high temporal stability and were identified as being catchment-average soil water-content monitoring locations. A majority of these locations occurred in the medium production zone, demonstrating that representative soil moisture can be measured in these landscapes.

Grazing-system experiments address complex interactions among animals, pastures, soils, climate and management. As part of the national EverGraze program, a grazing-system experiment was designed to determine how the intensity of grazing management, from continuous grazing (P01) to flexible 4- and 20-paddock rotational systems (P04 and P20), influences the profitability and sustainability of a Merino ewe, terminal sire, lamb production system grazed on heterogeneous native pastures. When implementing such an experiment, it is important to understand and characterise landscape variability, and include this in the design of the experiment. A second challenge for grazing-system research is to operate experimental systems with sufficient flexibility to adequately represent commercial production systems and maintain even utilisation across treatments. The present paper addresses the following two issues: (1) the process used to characterise the potential productivity of variable native pastures and the results of this characterisation; and (2) the development of flexible systems that adequately represent commercial production within an experiment. This was undertaken with input from a project-steering committee called the EverGraze Regional Group, comprising producers, extension staff and private consultants. Prior to the commencement, the site was mapped into three production zones, namely, high (HPZ), medium (MPZ) and low (LPZ), by visually estimating green herbage mass in late spring and marking boundaries between zones with a GPS. The production zones represented differences in soil properties (gravel, pH and available P) and pasture composition, and were used to balance potential production among plots within the same replication. Grazing-system options were evaluated using the sustainable grazing systems pasture model to help choose an appropriate starting stocking rate. The initial stocking rate chosen for the spring-lambing systems was 5.4 ewes/ha. The modelling predicted large variations in feed availability and quality over summer among years; flexible management criteria were therefore developed, including variable sale time for lambs, to utilise the greater feed supply in better seasons. Minimum-pasture benchmarks (>0.8 t DM/ha standing herbage mass and >80% ground cover) and variable green herbage-mass targets were designed to sustain high levels of livestock production and prevent pasture degradation. Criteria for adjusting ewe numbers were developed, but were constrained to pre-joining (March), scanning (July) and post-weaning (December), being consistent with commercial practices. The experiment incorporated flexible management rules as these were considered integral to the successful management of commercial grazing systems.

Objectives: Delayed discharges are a significant problem for the National Health Service. The objectives of this study were to determine the prevalence and impact of delayed discharge at a single specialist vascular surgery ward.Design: A cross-sectional observational study.Setting: A single specialist vascular unit in the UK during a 4-month study period (01/09/2014-31/12/2014).Participants: All patients admitted to the ward during the study period were included. Patients spending >= 1 night on the ward once declared medically fit for discharge (MFFD) were prospectively identified and data prospectively collected. All other patients were identified retrospectively with data collected retrospectively from electronic records.Outcome measures: Primary outcome was number of patients experiencing delayed discharge. Secondary outcome measures were length of stay, length of delay and cost of delay.Results: There were 268 admissions with a total length of stay (LoS) of 2776 days. 57 admissions (21.3%) experienced delayed discharges with a total 535 excess bed days (19.3% total LoS) once MFFD. Unplanned admission (relative risk 7.3 (95% CI 2.7 to 20.0; p<0.001)) and index amputation (relative risk 9.2 (95% CI 3.8 to 22.0; p<0.001)) were associated with increased risk of delayed discharge. There were significant differences in the length of delay by the reason for the delay (p=0.01). Delay due to the provision of social services and inpatient rehabilitation were associated with longer length of delay (post hoc analysis). Age was not independently associated with either increased risk of delayed discharge or length of delay. The total estimated cost of delayed discharges during the study period was 146 pound 055.Conclusions: A significant number of vascular patients experience delayed discharge. MFFD vascular patients occupy a high proportion of vascular beds at considerable financial cost. Unplanned admissions, amputees and those delayed due to social services contributed most to delays. Closer integration with community health and social care providers may reduce delays.

Shoot and root water content, shoot/root biomass ratio, and plant height were measured in Melilotus siculus (Fabaceae), Tecticornia pergranulata (Amaranthaceae: Chenopodiodeae), and Thinopyrum ponticum (Poaceae) to determine their growth performance in a glasshouse - pot trial using salinity levels of 0.0, 2.5, and 5.0 dS m(-1). The following indices, total-ion accumulation (TIA), bioaccumulation factor (BF), translocation factor (TF), and bioconcentration factor (BCF) of Na+ and Cl- were also measured enabling the evaluation of the remediation capacity of these plants. With increasing salinity in soil, total Na+ and Cl- accumulation increased in the tested plants in the following order: T. pergranulata > M. siculus > T. ponticum. T. pergranulata had the maximal phytoextraction capacity of Na+ and Cl-. The BF and BCF values of Na+ and Cl- were > 1 in the plants tested in different salinity treatments. The TF value of Cl- was > 1 for these tested plants, whereas the TF value of Na+ was > 1 in T. pergranulata and M. siculus and it <1 in T. ponticum. T. pergranulata and M. siculus performed the best, accumulating more of Na+ and Cl-, and therefore they appear to be the candidates-of-choice for phytoremediation of saline sites in central western New South Wales, Australia.

Objective: Diabetic foot disease (DFD) imposes a major burden on the National Health Service. The positive impact of the multidisciplinary foot team (MDFT) approach in the management of DFD is well established. However, the workload created at individual vascular surgical units is not known. The objective of this study was to assess the workload created from patients with active DFD at a major arterial centre (MAC). Methods A 6 weeks prospective study was carried out. All patients attending the weekday diabetic podiatry clinic and fortnightly MDFT clinic were included. All patients admitted under the vascular surgical team with active DFD were included. Results 92 patients were reviewed through our elective pathway. The majority of patients (n= 60, 65%) were managed within the podiatry clinic. 32 patients (35%) were managed at the MDFT clinic. 5 patients required immediate vascular review, and only 1 patient was admitted directly under the vascular team. During the study period, there were 35 vascular admissions due to active DFD, mostly as emergency admissions (n= 27, 77%). The majority of patients (n= 18, 67%) admitted as an emergency had never been seen through the elective DFD service at the MAC. DFD admissions equate to 33% of emergency admissions and 8% of elective admissions during the study period. Conclusions Despite a well-organised elective DFD pathway, individuals frequently present with new or worsening DFD that requires emergency surgical input. Improving outcomes will require pathway re-design to place more patients identified with at risk feet on the elective pathway.

We measured proline and glycine betaine levels and photosynthetic performance (net-photosynthetic rate (Pn), stomatal conductance (gs), maximum quantum yield of PSII (Fv/Fm) and non-photochemical quenching (NPQ)) in relation to Na+ and Cl- accumulation in Melilotus siculus (Turra) B.D.Jacks. (Fabaceae), Tecticornia pergranulata (J.M.Black) K.A.Sheph. & Paul G.Wilson (Amaranthaceae: Salicornioideae) and Thinopyrum ponticum (Podp.) Z.-W.Liu & R.-C.Wang (Poaceae) grown under saline conditions in the greenhouse. These plants were selected in this study because of their known salt-tolerance capacity and value as forage plants. Moreover, the pasture legume M. siculus is considered to have particular potential for saline land remediation because of its salinity and waterlogging tolerance. Maximum Na+ and Cl- accumulation occurred in Te. pergranulata shoots. Minimum was in Th. ponticum shoots. Maximum Na+ accumulation occurred in the roots of Te. pergranulata, whereas that of Cl- occurred in the roots of Th. ponticum. Accumulation of both Na+ and Cl- was the least in M. siculus roots. Te. pergranulata metabolized high levels of glycine betaine (110µmolg-1 DW). M. siculus metabolized high levels of proline (6µmolg-1 DW). Th. ponticum accumulated intermediate levels of these organic osmolytes. No significant change occurred in Fv/Fm values. Pn value increased and NPQ value decreased in Te. pergranulata with increasing salinity and the reverse occurred in both M. siculus and Th. ponticum. A negative significant correlation occurred between Pn and glycine betaine in M. siculus and Th. ponticum. A positive significant correlation occurred between NPQ and glycine betaine in M. siculus. No correlation occurred between proline and Pn, proline and NPQ in the tested three plants. Te. pergranulata could maintain cell-osmotic balance by synthesising high levels of organic osmolytes especially glycine betaine and concurrently showing the most efficient photosynthetic performance. Compared with the levels of osmolytes in Te. pergranulata, the levels of osmolytes that occur in M. siculus and Th. ponticum were insufficient to maintain cell-osmotic balance and also that M. siculus and Th. ponticum showed a lower level of photosynthetic performance. We conclude that glycine betaine is potentially the vital organic osmolyte for Te. pergranulata and Th. ponticum enabling salinity stress tolerance. However, in M. siculus, proline appears to be the potential organic osmolyte in salinity stress tolerance. In terms of the potential of these species for stabilising saline soils in central-western New South Wales, Te. pergranulata would be the candidate of choice; however, for greater pasture value Th. ponticum would be the next.

This study aimed to measure the effects of elevated levels of Na+ and Cl- on ion concentration, growth, and photosynthetic performance of Melilotus siculus, Tecticornia pergranulata, and Thinopyrum ponticum in pot trials under controlled glasshouse conditions. Experiments were conducted using Na+ and Cl dominant saline soil treated with constituted saline solutions (0, 2.0 and 4.0 dS m(-1) Na+ or Cl-). Maximum Na+ and Cl- concentration was in T. pergranulata shoots; maximum Na+ concentration was in T. pergranulata roots, whereas maximum Cl- in T. ponticum roots. Maximum quantum yield of PSII [Fv/Fm] values did not change significantly. Net-photosynthetic rate [An] and stomatal conductance [g(s)] values increased and non-photochemical quenching [NPQ] value decreased significantly in T. pergranulata with increasing Na+ dominant treatments and the reverse occurred in Cl- dominant treatments. Pn, g(s), and NPQ values did not significantly change in T. ponticum with increasing Na+ and Cl- dominant treatments. The shoot and root biomasses of T. pergranulata were the maximum at 4.0 dS m(-1) Na+ dominant treatment. In T. ponticum, the maximum shoot and root fresh masses and shoot dry mass occurred in the control treatment and the maximum root dry mass occurred in the 2.0 dS m(-1) Cl- dominant treatment. In T. pergranulata, strong positive correlations occurred between Na+ concentration in shoots and salt tolerance (shoot mass over control) and moderately positive correlation occurred between Cl- concentration in shoots and salt tolerance. However, strong negative correlations were observed between Na+ and Cl- concentration in shoots and salt tolerance in T. ponticum as well as between Cl- concentration in shoots and salt tolerance in M. siculus. Our glasshouse experiments indicate that 4.0 dS m(-1) Cl- solutions in the soil was more intensely damaging than that of Na+. The greatest concentration of both Na+ and Cl- was in T. pergranulata under the tested circumstances indicating it to be the candidate of choice for restoring saline soils, followed in capacity by M. siculus and T. ponticum. (C) 2016 Elsevier GmbH. All rights reserved.

Background Despite advances in perioperative care, elective abdominal aorta aneurysm (AAA) repair carries significant morbidity and mortality. Remote ischaemic preconditioning (RIC) is a physiological phenomenon whereby a brief episode of ischaemia-reperfusion protects against a subsequent longer ischaemic insult. Trials in cardiovascular surgery have shown that RIC can protect patients’ organs during surgery. The aim of this study was to investigate whether RIC could be successfully introduced in elective AAA repair and to obtain the information needed to design a multi-centre RCT. Methods Consecutive patients presenting for elective AAA repair, using an endovascular (EVAR) or open procedure, in a single large city hospital in the UK were assessed for trial eligibility. Patients who consented to participate were randomized to receive RIC (three cycles of 5 min ischaemia followed by 5 min reperfusion in the upper arm immediately before surgery) or a sham procedure. Patients were followed up for 6 months. We assessed eligibility and consent rates, the logistics of RIC implementation, randomization, blinding, data capture, patient and staff opinion, and variability and frequency of clinical outcome measures. Results Between January 2010 and December 2012, 98 patients were referred for AAA repair, 93 were screened, 85 (91 %) were eligible, 70 were approached for participation and 69 consented to participate; 34 were randomized to RIC and 35 to the sham procedure. There was a greater than expected variation in the complexity of EVAR that impacted the outcomes. Acute kidney injury occurred in 28 (AKIN 1: 23 %; AKIN 2: 15 % and AKIN 3: 3 %) and 7 (10 %) had a perioperative myocardial infarction. Blinding was successful, and interviews with participants and staff indicated that the procedure was acceptable. There were no adverse events secondary to the intervention in the 6 months following the intervention. Conclusions This study provided essential information for the planning and design of a multi-centre RCT to assess effectiveness of RIC for improving clinical outcomes in elective AAA repair. Patient consent was high, and the RIC intervention was carried out with minimal disruption to clinical care. The allocation scheme for a definite trial should take into account both the surgical procedure and its complexity to avoid confounding the effect of the RIC, as was observed in this study. Trial registration Current Controlled Trials ISRCTN19332276 (date of registration: 16 March 2012). The trial protocol is available from the corresponding author.

Most nations with developed healthcare systems have a strong interest in audit, both for financial and clinical quality control. Whereas financial control has been a key political requirement for managing healthcare, the use of clinical outcome data has, until recently, taken more of a back seat. Clinical audit has a long history of describing outcomes and challenging established attitudes or practice.1Bridson E.Y. Iatrogenic epidemics of puerperal fever in the 18th and 19th centuries.Br J Biomed Sci. 1996; 53: 134-139PubMed Google Scholar Responses to published audits vary. Some clinicians voice criticism of bias as a result of selective reporting, either from a few units, or because of incomplete datasets.2Wyatt J. Acquisition and use of clinical data for audit and research.J Eval Clin Pract. 1995; 1: 15-27Crossref PubMed Scopus (29) Google Scholar Attitudes have gradually changed with improved understanding of the role of audit as a tool to examine and refine standards of practice.3Fowkes F.G. Medical audit cycle. A review of methods and research in clinical practice.Med Educ. 1982; 16: 228-238Crossref PubMed Scopus (35) Google Scholar This has been accompanied by a growth in clinical audit across all branches of medicine. The turn of the century marked a shift towards more widespread clinical audit, with development of political interest in using quality to justify or contain costs. The advent of organisations such as the National Institute for Clinical Excellence (NICE) in the UK saw a growth in the use of research and audit to set standards both for outcomes and processes of care. A good example of this in vascular surgery is the NICE clinical guideline 68, which sets out clear standards for assessment, referral, and treatment of patients with TIA and minor stroke.4Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). https://www.nice.org.uk/guidance/CG68.Google Scholar These standards are incorporated into national audits in Europe and reporting now encompasses both outcomes and performance indicators such as timeliness of surgery and cranial nerve injury.5http://www.vascularsociety.org.uk/wp-content/uploads/2014/04/UK-Carotid-Endarterectomy-Audit-Round-5-Report.pdf.Google Scholar Such reporting has driven improvement in quality of services by focussing clinicians on key components of high-quality pathways of care. Vascunet was formed in 1997 as a collaboration of national registries in Europe, New Zealand, and the state of Victoria in Australia, with its first report produced in 2007.6The first Vascular Surgery Database report 2007. www.esvs.org/committees/vascunet.Google Scholar, 7Björck M. Gibbons C.P. Jensen L.P. Laustsen J. Lees T. Moreno-Carilles R. et al.Vascular registries join to create a common international dataset on AAA surgery.Eur J Vasc Endovasc Surg. 2007; 34: 257-259Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Since then, the Vascunet group have published comparative data on carotid surgery,8Menyhei G. Björck M. Beiles B. Halbakken E. Jensen L.P. Lees T. et al.Outcome following carotid endarterectomy: lessons learned from a large international vascular registry.Eur J Vasc Endovasc Surg. 2011; 41: 735-740Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 9Vikatmaa P. Mitchell D. Jensen L.P. Beiles B. Björck M. Halbakken E. et al.Variation in clinical practice in carotid surgery in nine countries 2005–2010. Lessons from VASCUNET and recommendations for the future of national clinical audit.Eur J Vasc Endovasc Surg. 2012; 44: 11-17Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar abdominal aortic aneurysm,10Mani K. Lees T. Beiles B. Jensen L.P. Venermo M. Simo G. et al.Treatment of abdominal aortic aneurysm in nine countries 2005–2009: a Vascunet report.Eur J Vasc Endovasc Surg. 2011; 42: 598-607Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar lower limb bypass,11Björck M. Beiles B. Menyhei G. Thomson I. Wigger P. Venermo M. et al.Editor's choice: contemporary treatment of popliteal artery aneurysm in eight countries – a report from the VASCUNET collaboration of registries.Eur J Vasc Endovasc Surg. 2014; 47: 164-171Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar and popliteal artery aneurysm.12Lees T. Troeng T. Thomson I.A. Menyhei G. Simo G. Beiles B. et al.International variations in infrainguinal bypass surgery – a VASCUNET report.Eur J Vasc Endovasc Surg. 2012; 44: 185-192Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar One of the key features of these publications has been to describe the variation in clinical practice across neighbouring countries, notable examples being rates of surgery for asymptomatic stenosis and rates of lower limb bypass for intermittent claudication. Variation in outcomes is also reported at a national level. The value of such reporting was demonstrated by the 2008 Vascunet report. This demonstrated outlying mortality rates after elective repair of abdominal aortic aneurysm surgery in the UK.13Second Vascunet database report 2008. http://www.esvs.org/journal/vascunet.Google Scholar This was a stimulus to a quality improvement initiative14Abdominal aortic aneurysm, improving outcomes for patients. http://www.health.org.uk/areas-of-work/programmes/closing-the-gap-through-clinical-communities/related-projects/abdominal-aortic-aneurysm-improving-outcomes-for-patients/.Google Scholar that sought to standardise practice and improve outcomes. The transparent publication of standards led to their widespread adoption both by clinicians and service commissioners within the UK. Recent publications have demonstrated a marked improvement in UK outcomes.15Outcomes after elective repair of infra-renal abdominal aortic aneurysm. http://www.vsqip.org.uk/wp/wp-content/uploads/2013/12/Outcomes-after-Elective-Repair-of-Infra-renal-Abdominal-Aortic-Aneurysm.pdf.Google Scholar This cycle of audit, analysis, standard setting, and re-audit demonstrates the improvement in quality that can follow acknowledgement of poor outcomes. This experience mirrors those in other clinical specialities such as cardiothoracic surgery. Comparative audits suffer from a number of shortcomings, such as incomplete datasets with potential for bias and misleading interpretation. Most national registries rely on voluntary data contributions from practising clinicians who have varying levels of enthusiasm for audit. It is widely acknowledged that incomplete audit data is a source of bias and may give misleading messages. This has allowed some to ignore the messages from comparative audit, and may be the explanation behind some countries not wishing to participate in data analysis and publication. The recognition of this issue leads to the linking of Swedvasc (and the Helsinki datasets in Finland) data to national administrative datasets to improve accuracy. Similarly in the UK, data for carotid and aortic aneurysm procedures are now compared with national administrative datasets to demonstrate the quality of data. A secondary benefit has been an improvement in data quality, presumably as a result of peer pressure. Vascunet has recently taken this further with external validation of data subsets in Hungary 16Bergqvist D. Bjorck M. Lees T. Menyhei G. Validation of the VASCUNET registry-pilot study.Vasa. 2014; 43: 141-144Crossref PubMed Scopus (25) Google Scholar and Sweden (ongoing project). This pilot demonstrated that national datasets can be validated by expatriate experts, providing an independent and even more robust measure of data quality. It is planned to extend this throughout the Vascunet registries group, if funding can be found. Clinical audit data is one important source of information, about routine clinical practice, that can be used to highlight inconsistencies in clinical outcomes. The use of data, however incomplete, as an agent for change and as a guide for standard setting is established. We believe that the use of national audit data should be extended to drive quality improvement across geographical boundaries. There are significant challenges to achieving this, but Vascunet believes that the time is right to embrace this. With increasing financial constraints on healthcare, clinicians need to be seen to lead on issues of quality of care. Part of this requires an open approach to measuring the standards of care, with the aim of improvement, rather than criticism. We believe that we have the support of patients in this aim and that transparent publication of data serves to both inform and educate in the debate about allocation of limited resources. There is debate about what and how much data should be collected. Most enthusiasts approach clinical audit wishing to obtain a large amount of data to enable a detailed analysis of behaviour. The problem with this approach is that it inevitably relies on busy clinicians collecting the data, often after delivery of care. Unsurprisingly, the levels of enthusiasm for this vary hugely, with some seeing it as an intrusion on their relationship with the patient. The end result is incomplete and unreliable datasets and limited reporting. An alternative is to collect small amounts of data about critical steps in the patient pathway of care. Such “key performance indicators” (KPI) can be linked to nationally collected administrative data to provide a moderately detailed account of the process of care. An example of this is seeking both outcome data (stroke and death) following carotid endarterectomy and collecting data on symptom to treatment time, to provide a more balanced picture of the quality of care. The resultant “less is more” approach allows for small datasets to provide important information to clinicians. A number of factors determine how effective clinical audit is at changing clinician behaviours and patient outcomes. There is now a growing science around audit and feedback.17Ivers N. Jamtvedt G. Flottorp S. Young J.M. Odgaard-Jensen J. French S.D. et al.Audit and feedback: effects on professional practice and healthcare outcomes.Cochrane Database Syst Rev. 2012 Jun 13; 6: CD000259https://doi.org/10.1002/14651858.CD000259.pub3Crossref PubMed Scopus (906) Google Scholar, 18Ivers N.M. Sales A. Colquhoun H. Michie S. Foy R. Francis J.J. et al.No more ‘business as usual’ with audit and feedback interventions: towards an agenda for a reinvigorated intervention.Implement Sci. 2014; 9: 14Crossref PubMed Scopus (216) Google Scholar This states some factors that seem self-evident. For example there is evidence that audit and feedback can be made more effective by setting explicit goals and having a clear and realistic action plan, based on evidence about best practice. There needs to be clarity about the changes required and a commitment to multiple feedback cycles, with availability of peer group data for comparison. Repeated feedback delivered in both written and verbal format by people perceived to be part of the clinical team (i.e. part of the professional group) is much more effective in bringing about change than delivery by outside agencies (e.g. departments of health, commissioners of care). We believe that Vascunet can fill this role as it is made up of representatives from all participating audits. Open reporting of data in a manner designed to support and encourage change, can be used to drive quality improvement by focussing on a small number of measures associated with a quality service. This has now been happening in many countries for some years. This approach has been used successfully for some years in Sweden, the UK and parts of the USA to demonstrate the quality of service and drive up standards by placing this in the public domain. The focus has been on care delivery within each country. We believe that the next step is for outcomes data analysis and quality improvement in vascular surgery to cross national boundaries, by common reporting of KPI for core vascular procedures. This is why Vascunet has begun validating national registries and has formed links with the North American Society of Vascular Surgery Quality Initiative (SVS-QI). What is now required is clinical support to agree that it is in both our and our patients' best interests to support a broadening of clinical audit to provide quality feedback across Europe. This will involve defining agreed datasets and seeking financial support to set up a data centre for analysis and reporting. Data collection should remain a local activity, owned by units and national societies, each committed to collaboration within the Vascunet group. We believe that the time is ripe to use the European registry experience to develop quality improvement initiatives throughout the European society nations and share our experiences openly to the benefit of our patients and clinical practices.