1. Thoracic Outlet Syndrome Commissioning and Organisation of Vascular Services David Gerrard

2. Thoracic Outlet Syndrome Cervical Rib Fibrous bands Idiopathic Iatrogenic Physiological – Exercise – Work related

3. Anatomy

4. Compression of neurovascular structures exiting the neck Varying pattern of symptoms Purely Neurological Purely Arterial – Embolic or thrombotic Purely Venous – Usually thrombotic Mixed

5. Diagnosis High Clinical Suspicion By Exclusion Examination – Cervical spine/shoulder MS exam – Inspection – Pulse – BP in each arms – Adson’s Test – Roos’ Test

6. Investigations Thoracic Outlet X-Ray Venous/Arterial Duplex Cervical MRI/CTA Venography Nerve Conduction Studies

7. Thoracic Outlet Syndrome

10. Treatment 3-6 months physiotherapy Adjust lifestyle Job Venoplasty Surgery

11. Surgical Approaches

12. Commissioning of Vascular Services Varicose Veins Hyperhidrosis Complex AAA repair

13. Commissioning of Vascular Services Varicose Veins – Based upon CEAP classification

14. CEAP classification Clinical classification Etiology classification Anatomic classification Pathophysiological

15. 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

16. CEAP classification Etiology classification – Ec: congenital – Ep: primary – Es: secondary – En: no venous cause identified

17. CEAP classification Anatomic classification – As: superficial veins – Ap: perforating veins – Ad: deep veins – An: no venous location identified

18. CEAP classification Pathophysiological – Pr: reflux – Po: obstruction – Pr,o: reflux and obstruction – Pn: no venous pathophysiology identifiable

19. Commissioning of Vascular Services Varicose Veins – Differing policies in Surrey, Hampshire & Berkshire

20. Commissioning of Vascular Services Varicose Veins – Surrey CEAP 3 Otherwise IFR required

21. Commissioning of Vascular Services Varicose Veins – N Hampshire CEAP 6 Otherwise IFR required

22. Commissioning of Vascular Services Varicose Veins – Berkshire Prior authorisation

23. Commissioning of Vascular Services Hyperhidrosis – Botox – Cervical Sympathectomy Common Policies – Not funded outside IFR

24. Commissioning of Vascular Services Complex AAA repair F-EVAR ‘Nellix’

25. Organisation of Vascular Services Pre-2012 – Network with ASPH S Central Review 2011 – Separate hubs – Separation agreement Screening Programme

26. 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

27. The Future FHFT – Basingstoke, +/- RSCH ASPH – +/- Epsom, +/- RSCH, +/- East Surrey One Vascular Centre

28. FHFT Clinics

29. FHFT Contact Details VASCULAR DEPARTMENT CONTACT DETAILS Contact details: Frimley Park Hospital main switchboard 01276 604604 Medical Secretaries for: Mr P W Leopold & Mr M Cleanthis:01276 604291 (Tracy Cullen) Mr D J Gerrard & Mr N Dastur:01276 604772 (Eileen Kean) Mr P F S Chong:01276 522141 (Sally Dolman) Miss S Sonnenberg:01256 313569 (Laura Dobson / Sally Dolman)

30. FHFT Contact Details Vascular Specialist Nurses Claire Martin Jean Nixon Tracey Craig Andrea Croucher Amy Dickenson (NHH) 07799 862858 Direct Dial 01276 526302 or Bleep 407 / 349 / 452 Email:fph.tr.vascularnurses@nhs.net Vascular Support Secretary01276 522555 (Joanne Briggs) Vascular Office Fax Number:01276 526516 Vascular Specialist Registrars Bleep 020 / 014 Senior House Officer Bleep 170 House Officer Bleep 019