Professional Documents
Culture Documents
SVTNewsletter Winter2017
SVTNewsletter Winter2017
SVTNewsletter Winter2017
VA S C U L A R T E C H N O L O G Y O F
G R E AT B R I TA I N A N D I R E L A N D
In this issue
4. Bubbles 6. How did we achieve IQIPS Accreditation
8. Femoropopliteal bypass graft entrapment: A Case Study 15. Presidents Annual Report 2016
Welcome to the Winter 2017 edition DATES FOR THE DIARY 2017
SVT Revision Days, Coventry
of the SVT Newsletter 29th-30th March
New Year message from the New President. SVT Research Grant
Application Deadline
Welcome to the winter edition of be taken in June this year at Pearson 21st April
the newsletter. As is tradition, I Vue testing centres. The exam will
CX Symposium, Olympia
write to introduce myself as the be available for a one month window Conference Centre, London
incoming President and update you and there will be multiple locations 25th-28th April
on some of what will be happening available.
in the coming year. Venous Forum Annual Meeting,
The redesign of the website has been Royal Society of Medicine, London
a great development and we continue 10th July
The collaboration with Inteleos
(the umbrella organisation to the to make improvements to the CPD Vascular Societies ASM, Manchester
American Registry for Diagnostic logging system, register of members 22nd-24th November
Medical Sonography and the and online CPD questions.
Alliance for Physician Certification BMUS Ultrasound 2017,
& Advancement) continues and the Im sure you are all aware that the Cheltenham Racecourse
SVT research committee has recently 6th-8th December
first electronic AVS examinations will
President: Helen Dixon Vice President: Sara Causley Past President: Tracey Gall Membership Secretary: Sara Causley
Shadow Membership Secretary: Lynne McRae Conference Secretary: Dominic Foy Treasurer: Kamran Modaresi
Newsletter Editor: Gurdeep Jandu Web Site Manager/ Job Adverts: Lee Smith SVT Website: www.svtgbi.org.uk
1
The Society for Vascular Technology 25th Annual Scientific Meeting
invited applications for the SVT some additions and changes to the I would like to take this opportunity
research grants. The closing date format this year. The SVT continues to thank all the members of the
for applications is the 21st April and to maintain and strengthen links executive, education, professional
further details on the grants can be with other organisations the Vascular standards and research committee for
found on the website. Society, BMUS, VASBI, SCoR, NSHCS, all the hard work and time they put
AHCS, NAAASP, VERN, CASE and the in to the Society. As a Society we will
The 2016 ASM was a very successful Circulation Foundation. We are also continue to maintain high standards
event and we received positive involved with projects within the across our profession and I believe
feedback from the membership. Deaprtment of Health and Health we can also provide support and
Early discussions for the 2017 event Education England. education to all those who perform
have started and there may be elements of vascular ultrasound.
James Wong
2
The Society for Vascular Technology 25th Annual Scientific Meeting
Jodie Weston receives her prize for the best student proposal from Tracey
Gall. Paul Brannigan presented with honorary membership
Steven Rogers receiving the prize for best proffered paper and also the
Ann Donald Award from Tracey Gall.
3
Bubbles
4
Bubbles
This is a wide ranging and and popliteal veins. The pulsatility diminished flow velocities throughout
complicated review, the findings of is a function of increased right heart the entire peripheral arterial system.
which I have briefly summarised here. pressure which allows transmission In these cases the left ventricular
I would recommend reading the of right heart haemodynamics pressure is not sufficient to reach
original paper. to the lower limb veins because the high velocities we normally use
the increased pressure keeps the to diagnoses stenotic disease, and
In summary, the conclusions and vena cava and iliac veins dilated velocity ratio must be employed in
recommendations are as follows: throughout the cardiac cycle. The stenosis diagnosis, and is reported
elevated pressure also maintains vena by the authors as being a reliable
this systematic review has
cava dilation through the respiratory method.
highlighted important anomalies
cycle, diminishing its effect on
that challenge the hypothesis
venous flow. Increased right heart Aortic valve stenosis causes a damping
that asymptomatic carotid
pressure may be a result of several of the peripheral waveforms; carotid
disease (especially unilateral) is
pathologies including heart failure, waveforms may be persistently
an important cause of stroke after
cardiomyopathy, valve disease and turbulent or have increased systolic
carotid surgery
pulmonary disease; these are often rise times. Usually this particular
There is no compelling collectively termed congestive heart pathology will be known about
evidence supporting a role for failure. because a particular patient will be
prophylactic CEA/CAS in cardiac severely limited in their physical
surgery patients with unilateral Arterial activities due to the valvular disease.
asymptomatic disease Cardiac arrhythmia is generally the
Prophylactic CEA/CAS might still most difficult problem as it impacts Aortic valvular incompetence or aortic
be considered in patients with on accurate measurement of absolute insufficiency may affect both the
severe, bilateral asymptomatic velocities, with differences possibly systolic and diastolic flow phases
carotid disease, but such a being up to 50% between cardiac of waveforms and can cause a
strategy would only benefit 1-2% cycles. The authors recommend double peak due to regurgitation
of all cardiac surgery patients. application of representative back into the left ventricle. The
These recommendations may data and consistency. The first peak should be considered
be a useful starting point for any representative velocity is one that representative of peak systolic flow
discussion you have with your cardiac in the operators view represents the and used for velocity measurements.
surgeons. approximate velocity that would Aortic insufficiency can also affect
be measured in the absence of any diastolic flow, particularly in low
arrhythmia. Several methods are resistance systems resulting in low
Cardiac Effects on Peripheral proposed, averaging 2 successive or no diastolic flow. In carotids this
Vascular Doppler Waveforms peak systolic or end diastolic can wrongly be interpreted as flow
Bendick, P.J. Journal for Vascular measurements, or if the arrhythmia into a distal occlusion. Differentiation
Ultrasound (2014) 38(3): 156-62 is more random it may be possible to between aortic insufficiency and
find a sequence of at least 3 cardiac distal ICA occlusion can be made
This interesting paper describes cycles in a normal rhythm and by bilateral assessment, the cardiac
some of the most common effects measure the second or third cycle effect will be bilateral, whereas if
of cardiac pathology on peripheral (as recommended by Oates et al in this is a carotid effect it will often be
arterial and venous Doppler the paper Joint Recommendations unilateral. In addition, caution should
waveforms, and reminds us that for reporting carotid Ultrasound be applied to interpretation of end
the underlying assumption that Investigations in the UK). Another diastolic velocities (EDV) in the case of
cardiac function may be normal option for a random arrhythmia is to a significant ICA stenosis because the
when interpreting them is not always simply wait, the patient may go into effect of the aortic insufficiency may
justified. As patients with peripheral normal sinus rhythm. Use of velocity supress the ICA EDV.
arterial disease tend to be older, the ratios may also be employed, ensuring
likelihood of our group of patients consistency whereby measurements In summary, cardiac effects can
having heart disease is moderately are taken from waveforms with similar present in various ways, but follow 2
high, and an understanding of cardiac cycle lengths. Consistency general rules:
the peripheral effects of any is also applied by ensuring that Cardiac effects are systemic on
abnormalities is important. any velocity interpretations are the arterial side they will be seen
consistent with B-mode and in various sites, e.g. aorta, carotid
Venous colour information, and applied and femoral
A common example is readily seen in consistently for all measurements. Cardiac effects are bilateral if an
the venous Doppler waveforms of the abnormality is seen only in one
leg, where pulsatility, at the patients Other abnormalities include low carotid artery it is more likely to
heart rate, can be seen in the femoral cardiac ejection fraction resulting in be of carotid origin.
5
How did we achieve IQIPS Accreditation?
With an understanding of these principles, it is still above and no matter how long you have been scanning
possible to acquire the quantitative velocity information to carotids, will probably encourage you to scrutinise and
make peripheral vascular diagnoses. interpret your waveforms with new confidence.
The paper contains many photographic examples of
typical Doppler waveforms in the scenarios described
6
How did we achieve IQIPS Accreditation?
this seems to be the consensus view. whole process is so daunting anyway a shared approach, which we found
I personally think that the usefulness that I thought a % complete score worked very well.
of the SAIT to departments post would be rather off-putting, so I took
accreditation needs reviewing..and the view that gradually working my How did you find the time?
saving on the fees would help cash- way through it and having more yes Once our staffing levels improved we
strapped budgets. than no answers was the way to allocated all scanning staff 20% of time
maintain morale. It took about 2years to away from scanning duties to reduce
complete the SAIT from when we first risk of musculo--skeletal injury and this
How long did it take? registered. was fundamental to creating time for
For our department it was a long IQIPS. We still have IQIPS protected
journey. We started in soon after the Having scored enough yeses, we time and use this to develop various
scheme was launched in 2012 and had applied for accreditation in Sept 2015. aspects of the service and for research.
completed the SAIT by September 2015, Because the Audiology department
we then received our accreditation in our Trust were accredited the We divided up the departmental
(October 2016). previous year, we took the decision, responsibilities and have staff who are
encouraged by UKAS, to become an responsible for:
Dont let this put you off as there were extension to their scope. This had
good reasons for it taking us so long. advantages and disadvantages. The Patient information
In 2012 we were a very under-staffed advantages were that all the generic Manual Handling
department with 3 part-time AVS Trust documents and policies that they PACS/CRIS
(1.4wte in total) and 2 STP students had uploaded to the UKAS evidence Clinical protocols
to train. For the majority of 2013, one web-based tool were accessible to us QA (see the article Penny Gill &
of our AVS was unavailable due to ill and we didnt need to replicate them. Catherine Rogan wrote for the
health. At that time we completed This also reduced our UKAS fees. The last Newsletter)
around 6500 scans each year including disadvantage was that we had to piggy- Etc etc etc the list fills an A4
the DVT service, so were a very busy back onto their accreditation cycle sheet
department. We managed this by which meant that we couldnt actually
having 3 wte support staff who do have our first accreditation visit until
This has been beneficial in terms of
all of our bookings and look after the summer 2016 which seemed like a long
giving staff increased responsibility
patients so that the scanning staff can delay. This actually proved to be a very
and hence job satisfaction and has
be really efficient. We didnt do much good decision as it gave us 6 months
apart from scanning for a couple of to submit all of our evidence to UKAS (I
given the STP students, in particular,
years and were very fortunate that our dont think we could have managed it the opportunity to fulfil some of
STP students were excellent and able to any quicker). their STP competencies. This sort
spend some of their time contributing of responsibility is also excellent
to our service from fairly early on. We We finished uploading all the portfolio evidence for anyone seeking
check all of our trainees images and information to UKAS by the end of Academy of Healthcare Science
reports until they are AVS, and fondly March 2016, and had the assessment Equivalence. Responsibilities have
remember those days of scanning in visit to our department at the end been allocated according to staff skills
one room and having trainees in the June. The visit was quite an experience and particular strengths and this has
2 other rooms to supervise only and we all found it totally exhausting, resulted in service improvements
achievable by having such a good team. although the 3 assessors were very that otherwise wouldnt have been
In 2013 we were lucky enough to have approachable and carried out their thought of.
a qualified Vascular Scientist apply for inspection without interfering with
one of our job adverts (after 8 years our usual workload. We were given Do we need to have PACS?
of advertising!) and the team was detailed feedback at the end of the Lack of access to PACS is often
expanded, this was a turning point and day and informed of several findings, thought of as a barrier to gaining
enabled us to concentrate more on which are essentially minor things to IQIPS accreditation but isnt actually a
IQIPS. attend to before accreditation can be requirement.
granted, with a 3 month deadline to
My approach to the SAIT was to go evidence that we had done this. What are the benefits of IQIPS
through it systematically from the Our accreditation was finally granted in accreditation?
beginning to the end putting into October 2016, so, it was a 4 year journey Our service has improved
place the requirements (writing policies altogether.
substantially over the last 3-4 years,
where we only had the information in
we have increased understanding
our heads/starting patient satisfaction
and control of our processes and
surveys/reviewing our protocols etc) Did one person do all of the work?
as I ticked things off on the SAIT. The I took responsibility for the majority of
now have an established culture of
other approach would be to spend a the web-based submissions and writing continuous improvement. We have
few hours going through the whole policies, but there were plenty of other flourished as individuals in various
SAIT ticking either yes or no, tasks for members of the team to help ways as we have had to tackle new
resulting in a % complete figure. The with. The total workload was very much challenges. This has increased our
7
Femoropopliteal bypass graft entrapment: A Case Study
confidence in our abilities and enabled us to discover new includes a staff calendar/rota for all staff to view. Use
talents. the generic area to develop a repository for all of your
We also have a service which routinely scores over 98% evidence and store it as you go through the SAIT.
in our patient satisfaction surveys so we know that our Think audit - how can we prove that we do what our
patients are benefitting. Our QA programme has helped us policies require? This neednt be complicated you
ensure that our machines are performing well and given just need to regularly check processes.
us reassurance that our images, reports and diagnoses are Divide the work up, but have 1 organised person who
consistent between different Vascular Scientists. is responsible for storing and uploading the evidence.
We have been able to inform our managers and Trust Consider IQIPS time for all staff.
Board that we have gained this CQC approved badge of Start the process and dont be daunted it is achievable.
quality which helps to increase our departmental profile
within the Trust. I am very happy to provide further advice and
encouragement.
What are your top tips?
Ask your ICT department for a departmental Generic Alison Charig
area where you can store all of your documents, Alison.charig@porthosp.nhs.uk
policies and a Vascular Outlook mailbox which Tel 02392 286456
PRIZE
E
ARTICL
Femoropopliteal bypass graft entrapment: A Case Study
Michelle Cooper, Clinical Vascular Scientist, Peterborough City Hospital
Presentation
A 65 year old man attended for a
routine duplex surveillance scan of
his right femoropopliteal bypass
graft. The surgery was undertaken
as an emergency procedure for a
critically ischaemic limb that was
of questionable salvageability. The
patient was 11 weeks post procedure
and had recovered well from his
surgery with the ulcer on his heel a
quarter of the size it was during his
admission. The patient had ceased
smoking five weeks prior to his
surgery. His consultant review four
weeks post operation was positive
and a strong dorsalis pedis pulse was
palpable.
8
Femoropopliteal bypass graft entrapment: A Case Study
position with his knee slightly flexed, this section was no in graft stenosis or compete occlusion with the knee in
longer compressed and the waveform become a lower extension and can lead to graft failure due to thrombosis.
resistance profile. The anterior tibial and posterior tibial Stenotic lesions can also develop within the artery due to
arteries were patent and assessed 1. with the patients persistent long term trauma to the vessel wall during knee
knee flexed to approximately 30, and 2. with his knee movements (Sanni et al., 2005).
fully extended. The flow velocity decreased significantly
in both vessels with the patient in position 2 (image A) in Features at presentation vary from asymptomatic, such
comparison to position 1 (image B), with the waveform as in this case, to claudication or severe ischaemia (Abbas
becoming damped. The peroneal artery was occluded. et al., 2004, Abbas et al. 2006). Symptoms can arise
during the immediate postoperative period or months
Due to the abnormal findings, ankle brachial pressure or years after bypass surgery (Carpenter et al., 1993) and
index (ABPI) measurements were performed in order can be sudden, frequently occurring during exercise and
to further assess the effect of knee extension on limb resolving with a change of position (Abbas et al., 2004). It
perfusion. The posterior tibial artery could not be is important that asymptomatic patients are identified to
accessed due to the location of the patients ulcer so ABPIs allow for surgical intervention to release the entrapment
were calculated using only the dorsalis pedis. The ABPI to prevent graft failure.
decreased from 0.83 when performed with the patient
supine in position 1 to 0.40 with the patient supine in Duplex assessment is widely used in the surveillance
position 2. of bypass grafts and is a useful diagnostic tool in the
early identification of graft entrapment. It has the
Patient Management advantage over other imaging modalities of providing
The patient was admitted to the regional vascular centre functional haemodynamic information which can aid
and a repeat duplex confirmed the findings of extrinsic in the diagnosis, particularly when used as part of a
compression of the graft on knee extension. The patient dynamic scan with knee extension and flexion. ABPIs
also had a CTA; this was performed with the patients can further assist in the diagnosis of graft entrapment
leg straight which meant the graft was compressed and by demonstrating the reduction in pressures with
appeared occluded. knee extension. CTA and angiography can be useful in
confirming the diagnosis although careful interpretation
Surgery was performed to relieve the compression of is required as the imaging may be deceptive if performed
the graft on knee extension in order to prevent graft during knee extension as the absence of flow may suggest
failure. Initially several fibrous bands were released which graft occlusion (Abbas et al. 2006). MRA can also be of use
appeared to be the cause of the compression. However, in demonstrating graft entrapment and has the advantage
an on-table angiogram revealed that this had not resolved of also showing the detailed relationship of the graft to
the graft entrapment (image C). The medial head of the surrounding structures which can aid in planning surgical
gastrocnemius muscle was then divided which released intervention (Carpenter et al., 1993).
the entrapment and was confirmed by a further on-table
angiogram (image D). The patient was
reviewed by the vascular consultant
seven days later and was found to
have a warm foot with excellent
pedal Doppler signals on both knee
extension and flexion.
Discussion
Popliteal artery entrapment syndrome
is an uncommon but potential
cause of ischaemia. It occurs due to
extrinsic compression of the popliteal
artery due to either an anomalous
course of the artery or an abnormal
arrangement of fibrous or muscle
bands. A similar condition can arise
following femoropopliteal bypass
graft surgery where entrapment of
the graft can occur when the graft is
tunnelled superficially to the medial
head of the gastrocnemius muscle
Image A: Right anterior tibial artery with the patient positioned with their knee fully extended
(Carpenter et al., 1993). This can result (position2).
9
Femoropopliteal bypass graft entrapment: A Case Study
Image B: Right anterior tibial artery with the patient positioned with his knee flexed to approximately 30 (position 1)
References
Abbas, M., Clayton, M., Ponosh, S.,
Theophilus, M., Angel, D., Tripathi,
R., Prendergast, F. and Sieunarine,
K. (2004). Sonographic diagnosis
in iatrogenic entrapment of a
femoralpopliteal bypass graft.
American Institute of Ultrasound in
Medicine, 23, 859-863.
10
Notices
All sonographers whose name is listed on the Public Voluntary Register of Sonographers will be required
to renew their registration in March 2017 for the registration period leading through to the end of February
2019.
If your name is already listed on the voluntary register this will be very straight forward and is similar to
HCPC renewal processes. There will be no charge if you are an SCoR ordinary or associated professional
member, Society for Vascular Technology (SVT) PII member or are statutorily registered with the HCPC or
NMC.
Full details of how to renew will be sent by e-mail to the address we on file, so please update if necessary
via www.sor.org. If you have any problems with updating records then please contact Christian Ellwood in
our membership department ChristianE@sor.org
As previously notified those voluntary registrants who are not also statutorily registered will be subject to
audit of their continuing professional development (CPD). Those randomly selected to present their CPD
portfolios for audit will be separately notified.
The Research/Innovation award is for small-scale studies such as pilot or feasibility studies, with the hope
that larger grants will be applied for at a later date. There is a total of 9,000 per year, with a maximum of
4,000 per award.
The Travel/Education grant is for things like travel to another lab to learn a new modality, educational
courses, or conference expenses to present results. There is total of 1,000 available, with a maximum of
250 per award.
For both of these awards we will operate a top down funding approach, so the best applications will get
the full amount and so on. The application forms and guidance are available in the research area of the
website. Please email Richard Simpson with any questions and to submit the application forms.
Email: richard.simpson@nuh.nhs.uk
11
Online CPD
Online CPD
The CPD questions which usually feature in the newsletter will now be available for members on the SVT website.
When members first visit the site they will need to complete the registration form *Please note this is separate from your SVT
website login so everyone will need to complete this registration step*
Results for the assessments are available immediately and CPD certificates are emailed straight to the address provided on
registration.
Trainee Competition
A. When measuring an ABPI, it is important to use the correct sized cuff for the limb being
assessed. Will the blood pressure be falsely increased or decreased when using a cuff in which
the air bladder does not cover at least 80% of the circumference of the limb?
B. A patient has an ABPI of 0.70 in the Right Lower Limb and an associated symptom of
intermittent claudication. What is the cause for the decreased lower limb blood pressure; what
is happening to the pressure energy?
C. Explain 3 contraindications to performing an ABPI and list 3 alternative investigations which
could be performed to assess for lower limb arterial disease.
The winner will receive a 25 book token and have their answers printed in the Spring newsletter
Closing date: 10th May 2017
12
Crossword
3 4
7 8
10 11
12
13
14
Across
3. This function comes in read and write mode
4. Can be adjusted to improve the lateral resolution
of an image
6. This type of flow can be seen in arteries when an Down
infection is present
1. Increasing this will improve the resolution of the image
9. If this function is set too high, low velocity blood
flow may be missed 2. An image display where the brightness of each point in the
image varies in relation to the intensity of the detected signal
10. This is the ratio of output signal strength to the
input of signal strength 5. The process by which small voltages are increased to large
ones
12. A higher frequency will give better -----
resolution 7. Increasing the PRF will reduce this
13. If the frequency increases, this decreases 8. A measure of the system to distinguish between closely
spaced objects
14. A reduction in the intensity and amplitude of a
sound wave as it passes through a medium 11. The breaking up of the frequency components of a wave
13
Presidents Annual Report 2016
14
Research Committee Report 2016
this September. The Modernising preparing for third year administration soon due to size and
Scientific Careers pathway has reaccreditation. Portsmouth have continuing growth of the
also extended to offer a vascular been successful in achieving the membership. I would like to say thank
healthcare science assistant and Accreditation this year and there are you to the Vascular Society for the
associate program (HSAA) and the still 7 further labs registered for the support they have given the SVT over
HSST is now live. Although there process. the years.
is no vascular PTP, discussion are
progressing with the ASP You may have noticed a change of Writing this report has been a
(advanced scientific practice) modules correspondence address on the footer challenge, trying to ensure that I have
which will be available to anyone of the SVT website. The included everyone who has been and
wanting to access specific Vascular Society vacated their offices continues to be involved with the
modules for continuing professional at the Royal College of Surgeons Society and ensure high standards
development. earlier this year and have of vascular ultrasound are continued
outsourced their administration to be met through education,
The IQIPS accreditation program to Fitwise. The British Medical accreditation and collaboration with
is still ongoing with Jo Walker and Ultrasound Society have kindly other Societies with the same aims. I
Alison Charig acting as vascular offered us a mail receipt services feel privileged to have been a part of
assessors. IVS Ltd have been through their Milton Keynes offices it and wish Helen the very best for her
successful in securing reaccreditation although the SVT may have to look year as President.
for a second year and are now to securing their own employed
15
Professional Standards Committee Report 2016
16
Education Committee Report 2016
17
Committee Members 2016
Trainee Network
Laura Haworth
laura.haworth@nhs.net
Non-portfolio
Sophie McDermott