1. A vascular surgery career: from student to specialist Mr. Patrick Coughlin Consultant Vascular Surgeon

2. Objectives  Why vascular surgery?  A personal path  Variety  Surgical advances  Co-morbidity – wont be out of work  How do I go about it?

3. How did I become a vascular surgeon?

4. Analysis Of Sensitivity, Specificity And Positive Predictive Value Of Cold Provocation Thermography In The Objective Diagnosis Of The Hand Arm Vibration Syndrome P.A.Coughlin, I.C. Chetter, P.J.Kent, R.C.Kester St. James ’ s University Hospital, Leeds U.K. Vascular Surgical Society, Hull 1998

5. Traditional Training Student – 5-6 years Pre-Registration House Officer – 1 year Basic Surgical Trainee – 3 years Higher Surgical Trainee – 5-6 years MRCS Exit exam => FRCS CCST Consultant Lecturer Research MD SSC Fellowships

6.  Medical School Leeds (1992)  MB ChB (1997)  MRCS Eng (2003)  MD Thesis (Leeds - 2004)  Treatment of poor circulation  FRCS Eng (2009)  Completion of Surgical Training (2010)  Consultant appt (2011)  Leeds  Hull  Perth, WA  London

7. Variety

8. Carotid disease Endarterectomy Stent Thoracic pathology Aneurysms Dissections AV Fistulas / RRT Vasospastic Disease AAA’s Open repair EVAR / Stent Lower limb PAD Endovascular Open Surgical Bypass AV Malformation Management of the diabetic foot Trauma Venous pathologies

10. Surgical Advances Abdominal Aortic Aneurysm

11. History - Aneurysms  Ebers Papyrus (2000 BC)  Traumatic aneurysms of peripheral arteries  Galen (131-203AD)  described an aneurysm as a localised pulsatile swelling that disappeared on pressure and wrote:  “if an aneurysm be wounded, the blood spouted out with so much violence that it can scarcely be arrested.”  Andreas Vesalius 16 th Century Anatomist  First description of AAA

12.  John Hunter  Popliteal aneurysm ligation in a beer delivery man (1785)  Astley Cooper  (Pupil of John Hunter’s) described ligation of AAA  Intraluminal wires (1880 – 1930)  Rea 1948  Reactive cellophane around neck and anterolateral surfaces of AAA to induce fibrotic reaction and limit expansion  Albert Einstein treated for symptomatic aneurysm. Survived 6 years before rupture (Nissen). History – Aneurysms (Treatment)

13.  Dubost (1951)  First successful abdominal aortic repair  Voorhees (1953)  Substituted Vinyon-N cloth for unreliable homograft  DeBakey  King Edward VIII  Endoaneurysmorrhaphy and intraluminal Dacron graft History – Aneurysms (Treatment)

14. Management of AAA  Open repair  Laparotomy & aortic clamp  Mortality 3-8%  Significant complication list  Prolonged recovery  Herniae & adhesions  No long term follow up needed

15. Wilhelm Konrad Roentgen discovers x-rays in 1895

16. Management of AAA  Endovascular repair  Minimally invasive  Can be LA procedure  Mortality 1-2%  Short recovery  Reduced complication rate

17. Management of AAA  How does EVAR work?

18. Management of AAA  How does EVAR work?

19. Evolving technology  Stents applicability limited by sealing zone  Currently 75% of AAA can be treated with EVAR

20. Evolving technology  Stents applicability limited by sealing zone  Currently 75% of AAA can be treated with EVAR

21. Evolving technology  To increase the landing zone fenestrations can be created

22. Evolving technology  Very extensive AAAs can be treated with longer branched grafts

24. Thoracic aneurysms  Open surgical repair causes significant morbidity and mortality  Needs thoracoabdominal incision  Visceral ischaemia  Spinal cord ischaemia  Significant blood loss  Prolonged ITU stay

25. Thoracic aneurysms

29. Co-morbidity

30. Comorbidity - trends

31. Student to Specialist Vascular Surgery – A New Specialty

32. A New Specialty  New curriculum  New training programme  Open surgery  Endovascular / Interventional Radiology  New exam  Deliver a new type of consultant

33. Student to Specialist Vascular Surgery – A New Competitive Specialty

36. Parodi performs first human AAA stent graft repair in 1991 ? 2007

37. Present (1960 - 2005)  Endoaneurysmorrhaphy with intraluminal graft placement  Endovascular repair  Laporoscopic-assisted AAA repair  AAA thrombosis by Iliac resection & axillobifemoral bypass

38. Intraluminal Wires Thrombosis currents and intraluminal wires Ann Thorac Surg 1999;67:1959-62 1884 Moore 1879 Corradi 1921 Power 1938 Blakemore

39. Cellophane  Rea (1948)  Reactive cellophane around neck and anterolateral surfaces of AAA to induce fibrotic reaction and limit expansion  Albert Einstein treated for symptomatic aneurysm. Survived 6 years before rupture (Nissen).

40. Interposition grafts Carrel 1912 Goyanes 1906 DuBost 1951

41. Artificial graft material  Voorhees et al subsituted Vinyon-N cloth for unreliable homograft (1953)