UK NVR annual report highlights “extremely high” case ascertainment rates despite pandemic pressures

The UK National Vascular Registry (NVR) recently published its 2022 annual report—the 10th since the registry was launched in 2013—highlighting important outcome data for vascular procedures performed in the period between 2019 and 2021.

The report, which was prepared by the NVR team at the Clinical Effectiveness Unit at the Royal College of Surgeons of England alongside the Vascular Society of Great Britain and Ireland (VSGBI) and the British Society of Interventional Radiology (BSIR), contains comparative information on five major interventions for vascular disease: repair of aortic aneurysms; lower limb bypass; lower limb angioplasty/stenting; major lower limb amputation; and carotid endarterectomy.

Jon Boyle (Cambridge University Hospitals NHS Trust, Cambridge, UK), the 2021–2022 president of the VSGBI, notes in the foreword to the report that it highlights outcome data from a period during which vascular practice “came under unprecedented pressure from the COVID-19 pandemic”. Despite this, he reports that case ascertainment rates in the NVR remain “extremely high,” which is of “great credit” to the vascular community.

The report looks closely at lower-limb interventions for peripheral arterial disease (PAD), with Boyle noting a particular focus on the five-day target for revascularisation for emergency admissions with chronic limb-threatening ischaemia (CLTI). He relays that, overall, 55% of these patients underwent lower-limb bypass or angioplasty within five days of admission and stresses that the ‘five-day revascularisation target’ has been adopted into clinical practice in many centres.

In addition to the outcome data, the report also includes the findings of an organisational survey of all vascular arterial units that was undertaken in the summer of 2022. “Of particular interest is the wide variation in support for data entry into the NVR in many trusts and limited access to barcode scanning,” for FEVAR of about 1.91. Outlining the results of a subgroup analysis, he said that FEVAR “does appear to be equivalent to open repair for shortnecked aneurysms at three years,” again noting “significantly higher” reintervention rates for both EVAR (HR, 2.18) and FEVAR (HR, 2.67).

Considering the wider context of the trial results, Vallabhaneni addressed the question of overtreatment of aortic aneurysms. “Effective clinical decisionmaking in aneurysm repair calls for personalised decision-making,” he stressed. While Vallabhaneni stated that the facets of the “clinical practice ecosystem” in which practitioners are making aneurysm repair decisions— namely evidence, governance structures, and professional attitudes and aspirations—are “all important in their own way,” they provide “in combination, very little scope to provide personalised decision-making in aneurysm practice”.

The presenter posited that “perhaps we are doing too many aneurysm repairs,” adding that there is “relatively good quality evidence to suggest that many a patient who survives the operation may not gain the overall survival benefit we hope for”.

Selection of the appropriate patients and techniques is crucial here, Vallabhaneni reiterated, specifying that clinic-ready tools are needed that would allow practitioners to make personalised decisions regarding aneurysm repair.

Boyle writes. Despite this, he communicates the fact that 60% of aortic devices are being captured for a non-mandatory field, which “reflects the fact that clinicians recognise the importance of collecting this data to drive improvements in the management of aortic aneurysms”.

Speaking to Vascular News, chair of the VSGBI Audit & Quality Improvement Committee and clinical lead for the NVR, Arun Pherwani (University Hospitals of North Midlands NHS Trust, Stoke on Trent, UK) comments on the key takeaway messages from the 2022 report: “We have focused on three particular areas; lower limb interventions for PAD and the ‘five day target for CLTI’, a ‘state of the nation’ report on type B aortic dissection (TBAD) with six-year data and units that treat TBAD in the UK depicted in an interactive map, and the results from the ‘organisational survey’ where all 69 vascular units in the country have participated.” He adds:

“I am confident the VSGBI Quality Improvement Programme for PAD (PAD QIF) helped by the NHS England Commissioning for Quality and Innovation (CQUIN) incentivised payment scheme, will deliver long-term benefits to the care of patients with CLTI.”

Pherwani also highlighted the UK Government’s December 2022 update on the implementation of the recommendations from the 2020 Baroness Cumberlege Independent Medicines and Medical Devices Safety Review. Medical devices safety and information are to be recorded under the new NHS Outcomes and Registries programme and the NVR has been identified as an exemplar registry. Pherwani remarks: “Our work with aortic devices and aortic reintervention data has reinforced our reputation as a ‘world leading vascular registry’.”