EP.WE.197Feasibility of a remotely supervised exercise programme

Aim To assess feasibility of a novel remotely-supervised exercise programme at a vascular hub during the COVID-19 lockdown. Methods Participants with arterial claudication (ABPI <0.90) who were able to walk 50m were enrolled into a 3-month programme by a vascular specialist nurse. The initial appointment addressed smoking cessation and best medical therapy. Baseline walking distance, ABPI and quality of life (QoL) were measured using the Intermittent Claudication Questionnaire. Following this, up to 8 WhatsApp video calls with a vascular specialist physiotherapist were undertaken to provide a tailored exercise programme. The Mapmywalk© App, or a pedometer, were used to monitor walking distances. Participants were instructed to record their daily longest walk and email results to their physiotherapist before each consultation. Results 12 participants were enrolled, of these 2 participants were unsuitable. Median age was 63 years and 2 (20%) were female. Baseline median ABPI was 0.7 (IQR 0.5-0.8), median baseline absolute walking distance was 75m (IQR 50-140) and median baseline QoL was 51/80 (IQR 15-79). 7 participants (70%) successfully completed the programme and were discharged. Their median daily longest walk was 2000m (IQR 200-4000) and QoL scores improved to 6/80 (IQR 2-20) (p = 0.02). Remaining 3 participants required revascularisation for disease progression. Reimbursement tariffs for the supervised exercise programme were £700 per patient, whereas for revascularisation were £2000 - £5000. Conclusion Remotely supervised exercise was feasible and improved walking distance and quality of life in 70% of participants. Approximately £3000 per patient was saved from a reduction in revascularisation procedures in our unit.

Utility of GPI+VIM dual-lead deep brain stimulation for Parkinson’s disease patients with significant residual tremor on medication

OBJECTIVE Randomized controlled trials have demonstrated that deep brain stimulation (DBS) of both the globus pallidus internus (GPI) and subthalamic nucleus (STN) for Parkinson’s disease (PD) is superior to the best medical therapy. Tremor is particularly responsive to DBS, with reports of 70%–80% improvement. However, a small number of patients do not obtain the expected response with both STN and GPI targets. Indeed, the authors’ patient population had a similar 81.2% tremor reduction with a 9.6% failure rate. In an analysis of these failures, they identified patients with preoperative on-medication tremor who subsequently received a GPI lead as a subpopulation at higher risk for inadequate tremor control. Thereafter, STN DBS was recommended for patients with on-medication tremor. However, for the patients with symptoms and comorbidities that favored GPI as the target, dual GPI and ventral intermediate nucleus of the thalamus (VIM) leads were proposed. This report details outcomes for those patients. METHODS This is a retrospective review of patients with PD who met the criteria for and underwent simultaneous GPI+VIM DBS surgery from 2015 to 2020 and had available follow-up data. The preoperative Unified Parkinson’s Disease Rating Scale scores were obtained with the study participants on and off their medication. Postoperatively, the GPI lead was kept on at baseline and scores were obtained with and without VIM stimulation. RESULTS Thirteen PD patients with significant residual preoperative tremor on medication underwent simultaneous GPI+VIM DBS surgery (11 unilateral, 2 bilateral). A mean 90.6% (SD 15.0%) reduction in tremor scores was achieved with dual GPI+VIM stimulation compared to a 21.8% (SD 71.9%) reduction with GPI stimulation alone and a 30.9% (SD 37.8%) reduction with medication. Although rigidity and bradykinesia reductions were accomplished with just GPI stimulation, 13 of the 15 hemispheres required VIM stimulation to achieve excellent tremor control. CONCLUSIONS GPI+VIM stimulation was required to adequately control tremor in all but 2 patients in this series, substantiating the authors’ hypothesis that, in their population, medication-resistant tremor does not completely respond to GPI stimulation. Dual stimulation of the GPI and VIM proved to be an effective option for the patients who had symptoms and comorbidities that favored GPI as a target and had medication-resistant tremor.

Endovascular Therapy for Stroke due to Basilar Artery Occlusion: A BASIC Challenge at BEST

Basilar artery occlusion stroke is known to have poor outcome with a high rate of morbidity and mortality despite best medical therapy. Since the original report of intra-arterial therapy for basilar artery occlusion in 1983, two recent randomized trials comparing endovascular therapy versus best medical management were completed on a large scale, BASICS (Basilar Artery International Cooperation Study) and the BEST trial (Basilar Artery Occlusion Endovascular Intervention Versus Standard Medical Treatment), both of which demonstrated equivocal benefit of the two modalities. In this commentary, we comment and highlight important lessons related to basilar occlusion stroke as learned from the BASICS and BEST randomized trials.

139 Efficacy of Implementation of a Junior Doctors' Teaching Program on The Secondary Prevention of Peripheral Arterial Disease in Vascular Patients

Introduction According to NICE Guidelines, the Best medical therapy (BMT) for secondary prevention of peripheral arterial disease includes antiplatelet and statin therapy unless contraindicated. Junior Doctors are usually allocated the job of prescribing patients’ medications. Due to discrepancies in their exposure to vascular surgery in earlier training, we implemented an introductory teaching session for them regarding this BMT and audited the efficacy of this intervention. Method A retrospective review of admission and discharge medications of all vascular ward patients from August 12th to 30th September 2019 was done, and the data was analysed via Excel. Results Out of 127 patients (median age 70), 67% and 64% had antiplatelet and statin medications respectively,while on admission. 1 in each patient cohort was found discharged without either medication. The GP of the patient discharged without antiplatelets was contacted to ensure this was rectified. The other patient had refused statin therapy and thus a discharge note to their GP was conducted to reflect this. Conclusions A teaching session as part of a vascular departmental induction emphasising the evidence base for antiplatelet and statin therapy can contribute to improving prescription practices of junior doctors starting in the department.

Outcome after acute und subacute TEVAR in uncomplicated type B aortic dissection

Objective In the past years, a paradigm shift from best medical therapy to early thoracic endovascular aortic repair (TEVAR) has been observed in the treatment of uncomplicated type B aortic dissection (uTBAD). We aimed to analyze outcomes after TEVAR in the acute and subacute phase of uTBAD, focusing on aortic remodeling. Methods Retrospective analysis of consecutive patients who underwent TEVAR for acute or subacute uTBAD in two tertiary referral centers from 2008 – 2017. Two assessors per center reviewed computed tomography scans of each patient at presentation, at one year and at the last follow-up using post-processing software. Results Forty-nine patients were treated with TEVAR for uTBAD. The indication for TEVAR was the presence of multiple morphologic predictors of adverse aortic outcome. The most common predictors were a false lumen diameter of > = 22mm in 76% of patients, a primary entry tear of > = 10mm in 69% and a total aortic diameter of > = 40mm in 67%. There were no in-hospital deaths and no deaths at 1 year. The median follow-up was 40.6 months. Three-year cumulative survival was 94 % (46/49). Fourteen secondary interventions were performed in 10 patients (20 %) after a median of 4.2 months. TEVAR lead to remodeling of the descending thoracic aorta with a median reduction of the total aortic diameter of 4.5 mm within one year and stable diameters after three years. The median maximum false lumen diameter diminished from 26 mm to 15 mm in one year (at 3 years: 14.8 mm). Conclusion In this cohort of selected patients with uTBAD and multiple morphologic predictors of worse aortic outcome, elective acute or subacute TEVAR was associated with a low mortality and positive aortic remodeling in the mid-term follow-up.

A Randomized Clinical Trial on Acupuncture Versus Best Medical Therapy in Episodic Migraine Prophylaxis: The ACUMIGRAN Study

Introduction: A large corpus of evidence has reported encouraging results for acupuncture as a prophylaxis therapy for migraine. However, trials that investigated the efficacy of acupuncture in comparison with pharmacological treatment in episodic migraine showed conflicting results. The study aimed to evaluate if acupuncture is as effective as evidence-based pharmacological drugs in episodic migraine prophylaxis.Methods: This is a randomized controlled clinical study. Patients suffering from migraine without preventive treatment in the past 3 months were recruited. After the run-in period, episodic migraineurs were assigned randomly to two groups: the acupuncture group (A) was treated with 12 sessions of acupuncture, and the pharmacological group (B) was treated with the most appropriate medication for each patient. Headache frequency was compared at baseline and at the end of treatment. Both groups were evaluated 3 and 6 months after treatment.Results: A total of 148 patients (24 males and 124 females) were enrolled in the study. Out of these, 69 were randomized to A and 66 to B. At baseline, no significant differences were found between the two groups. Of the patients, 15.5% (21/135) interrupted the treatment, especially those randomized to B. After 4 months, migraine frequency decreased from 8.58 ± 3.21 to 6.43 ± 3.45 in A and from 8.29 ± 2.72 to 6.27 ± 4.01 in B. Headache frequency decreased significantly after treatment without differences between the two groups (time-effect: p < 0.001; group effect: p = 0.332; interaction time-group effects: p = 0.556). Approximately 34% of patients showed a reduction of headache days by at least 50% after the treatment. The improvements observed at the end of treatment persisted in 57.3% (59/103) after 3 months and 38.8% (40/103) after 6 months, especially in patients randomized to A.Conclusions: Our trial is the first one comparing acupuncture with the more appropriate pharmacological treatment for migraine prophylaxis. Data suggested that acupuncture could be adopted as migraine prophylaxis and seem to be slightly superior to pharmacological treatment in compliance and rate of adverse events.