Thoracic Outlet Syndrome Commissioning 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

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 repair F-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 Medical Secretaries for: Mr P W Leopold & Mr M Cleanthis: (Tracy Cullen) Mr D J Gerrard & Mr N Dastur: (Eileen Kean) Mr P F S Chong: (Sally Dolman) Miss S Sonnenberg: (Laura Dobson / Sally Dolman)

FHFT Contact Details Vascular Specialist Nurses Claire Martin Jean Nixon Tracey Craig Andrea Croucher Amy Dickenson (NHH) Direct Dial or Bleep 407 / 349 / 452 Vascular Support Secretary (Joanne Briggs) Vascular Office Fax Number: Vascular Specialist Registrars Bleep 020 / 014 Senior House Officer Bleep 170 House Officer Bleep 019