Session 5: Vascular Surgery - A Day in the Life & Training Application (Part 2/2)



This on-demand teaching session will be an opportunity for medical professionals to gain practical and theoretical knowledge about vascular surgery. Participants will explore the variety of techniques used to treat various conditions such as limb ischemia, diabetic feet, abdominal aortic aneurysms, venous ulceration, renal access, and carotid endarterectomy. The session will also include case studies and pictures to demonstrate how to apply the acquired knowledge in practice. All of this presented by an experienced vascular practitioner.
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Welcome to the 5th FTSS surgical specialty teaching session. This is a collaborative initiative between the West Midlands Foundation Trainees Surgical Society(FTSS) and the Surgical Society of International Doctors(SSID).

This teaching series offers insider perspectives from trainees across diverse surgical specialities. An exclusive look into their weekly routines, shedding light on the pros and cons of their chosen specialities, the challenges they’ve faced and a succinct review of common cases they often encounter. Additionally, we also delve into details about the application process for their respective training programs.

In this session, we are excited to feature Ms Helena Smith MRCS, Vascular Surgery specialty trainee from the reputed West Midlands Deanery. Helena will give us an exclusive look into her journey through specialty training and the evolving landscape of women in surgical specialties!

Join us on the 23rd of August 2023!!!

Organisers: Dr Jefferson George, Dr Fraser Morgan, Ms Rebecca Lefroy, Mr Sriram Rajagopalan

Learning objectives

Learning Objectives: 1. Understand the principles of open surgical and endovascular techniques used for treating blockages in different arteries in the body. 2. Learn how to distinguish between embolism and thrombosis to effectively diagnose and treat acute limb ischemia. 3. Become familiar with the different procedures used to treat an abdominal aortic aneurysm. 4. Recognize the various conditions that can lead to acute limb ischemia and how to tailor the treatment accordingly. 5. Acquire knowledge of carotid endarterectomy procedures and the principles behind vascular access for peritoneal dialysis and hemodialysis.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

I know it's a bit of a faff, we'll just try it again. If not, we'll try and share screens and do little bits and Bobs, it's come on for me there. So if we can ask in a chat, if we can see that, can we see that everyone? Can, you, can you guys see the slides and on the speakers? Because the thing is, it's coming up for us. But I know it's probably not, it's maybe not been coming up for you guys. Ok. Let me just, um, crack on, I suppose. I think we can't figure out anything. We'll just, we'll just keep moving because I think the majority of it is, is what can nobody see any pictures? I've got to see him in the chat saying anything. No, I don't think you, we've got any still. Ah, shame, shame, shame, shame. I just rated mine. So again, that's me trying to do it again. Anything there zooming out apparently is working zoom out the browser. I don't know what that means. But um, I think we just crack on Helena and, and you can see the slides and have a go and if it works. It works. We'll keep having, having a play. Me and Jefferson behind the scenes and if it works then great. But if not, we'll, it's all about what the content of what you're saying, isn't it? Rather than the pictures, I suppose? So, we'll just know, well, just keep going, keep going and we'll uh we'll have a play. Is that right? Yeah. Sure. Uh So if you go to the next slide, so um like I was talking about with um techniques, we also do open surgical techniques. So, um this slide essentially showing an angiogram. I'm afraid I can't see that. Can you say Helena? Yes. Can everyone else you still haven't been? So, um this is an angiogram um like I said before, and it shows a blockage in the common femoral artery. So essentially what the picture shows is that there's been a cut down onto the femoral artery, which means the patient's on the operating table. And they've had a vertical groin incision, which goes down to the common femoral artery. Then there's been control of the artery with what we, they're called sloops. And they're essentially little elastic bands that you wrap around the artery to control it. So that when you open the artery up with a little knife that there's not free flow of blood coming out and that you can stop the blood so that you've got a clear field so that you can clear the plaque out. And we clear that plaque out with something called a Watson chain, which is a little um, silver spoon um, to get a, a plane between the plaque inside the artery. And then we scoop it out with, with this instrument. And then we use a bovine patch, which is a patch from a cow to sew back into the defect so that the artery doesn't narrow once we close it up and that hopefully means that the blood can travel down the leg where the blockage was previously. So, if you just go to the next slide, so vascular surgery is full of variety, essentially any artery in the body, within, within limits, you can form an anastomosis between. So this was a case study that sur surrounding the, the B MJ, which was a patient who had complete occlusion of their aorta beyond the renal arteries. And the surgeon had put in two prosthetic bypass grafts from the axillary artery to the femoral on art artery on each side. So it's pretty impressive. You can see these really long grafts traveling on the chest wall, on the abdominal wall, er to the femoral artery. So it just shows the sort of er, variety that you can have with vascular surgery. And there are many different options if you've got a blocked artery to reroute it. There's also a patient, a picture of a patient who's having a, a bypass operation, which is also a very common vascular operation where essentially there's a blockage in the artery in the leg. And you use either a vein which is harvested either from the same leg or a different leg. And then you plummet up at the top and beyond the level of the blockage so that the patient uh has blood flow restored. Next slide, please. And then of course, there are patients whose disease is too severe and they will be um if you have no options left, you can talk to these patients um about the possibility of an amputation. So we also um do all the amputations for the vascular patients as well. So that consists of below knee, above knee amputations through knee amputations. We also do lots of minor amputations and incision and drainage for people presenting with foot sepsis. Um So that's also a different type of skill that you get in vascular surgery. Uh Next slide, please. Yes. And then we get acute limb ischemia. That's also bread and butter vascular surgery. It's very important uh that you can diagnose it and recognize it. Uh We deal with it in the arms and the feet. There's a couple of pictures here of a guy with a very white hand and also a very white foot time is of the essence. So obviously, this is it falls into the emergency category. And um one of the early operations that you do in your vascular training is called an Embolectomy, which is essentially where you have a catheter that goes into the artery with a little balloon on the end and then you push it beyond the blockage and then you, you inflate the balloon and you trawl the clot out with this Embolectomy catheter. And it's called a Fogarty Catheter. And it was invented by, I think, a medical student in the US um when he was at med school. So it sets the bar pretty high in terms of um achievements, I guess. But we still use it today for all sorts of vessels. Uh Next slide, please. I think also you think of all the reasons why someone might present with acute limb ischemia and there's so many reasons and it just shows to you again, the level of complexity and the, the way you have to think about these patients. So we think about them in terms of embolism or thrombosis patients and you can have it from your heart. So it can be from a valve disease. It can be from an arrhythmia. It could be, for example, from a, a patient for a ovale, it could be from trauma. It could be yic if someone's had a, a line put in an artery instead of a vein, um it could be if they've had a heart attack and they've got a, a big clot in the heart which is flaking off into their, into their arms and their legs, they could have an aneurysm in of the thoracic aorta, which is letting off clot and so forth. So there's a huge amount to think about when you're seeing these patients and thinking about tailoring your treatment to that. And I think it's that challenge of thinking what operation you need to do and how you need to approach these patients with all the um techniques in your arsenal. That is why vascular surgery is so, so interesting and so varied because none of these presentations are ever the same. Uh Next slide, please. And then you get to um abdominal aortic aneurysm, which is I guess the glamorous um the big player in vascular surgery, what people probably think of um when they think of vascular surgery now that's, that's undergone a what I would call a revolution probably in the last 20 years because it's gone from having open surgery, which is your classic cut on the belly sewing, a grafting at the top, sewing a grafting at the bottom to the um endovascular techniques that I was mentioning at the start. So that's called endovascular repair of aneurysm. And that's essentially where you implant a stent graft into a patient under X ray guidance. So it's all done via the groins. It can also be done in other ways um but predominantly via the groins and it's a stent that you would need to follow up for life and potentially needs further interventions along the path. This is becoming a popular technique in vascular surgery and is growing um first and foremost, because a lot of our patients are very elderly and frail, like I mentioned. So they wouldn't necessarily be able to withstand having an open surgery which compromises their respiratory and their cardiac function. And also because there's been huge advances with industry partners who are developing new more effective devices that have longer longevity and that's proving to be very popular. Um in the field. Next slide, please. So I would say those are the main, main three limb ischemia, diabetic feet, chronic limbs, um and aneurysms, but there's a huge amount more. So, uh we've also got a lot of nice day case surgery. So that will be people having coming in to have their veins done who have varicose veins, venous ulceration, um recurrent veins. We also do vascular access, for example, um putting in um ports and uh vascular devices for patients having chemotherapy and other such treatments. We also do a lot of work with the renal team. So for patients undergoing either peritoneal dialysis, we will generally put in the peritoneal dialysis catheters that you can see in the middle and we will also create the fistula fistulas. So arteriovenous fistulas so that they're able to have uh hemodialysis. There's also potential to work in the transplant sector in renal transplant, particularly when I was in New Zealand, we did all the uh renal transplant as well. So um it's set up a little differently in the UK, sometimes renal access is its own specialty here. Um But definitely when I worked abroad, um vascular did all the um renal transplants as well. And also we get quite a bit of trauma. So patients who've got um severe fractures, supracondylar fractures, open fractures, and there's also pediatric vascular surgery, which is very niche, but there is a, there is a area for it. Uh next slide, please. Um And then I was also going to brush on carotid endarterectomy. It's a bit of a shame if you can't see the pictures. Um but we have a lot of work from the stroke, physicians as well. So patients coming in with acute stroke, they will often go on to have a carotid duplex of their neck. And if we consider that the patient has had a stroke as a result of plaque rupture in the neck and the stenosis is meets the threshold, then we would consider them for this operation, which is essentially er the patient can be awake or asleep. You make an incision uh along the front of sternocleidal mastoid down to the artery, you gain control of the artery in the manner that I mentioned with the groin. So it's all these basic vascular principles that form kind of the bedrock of the specialty, exposing the artery, getting control. Um And then you're going to open up the artery if you just move to the next slide for me and I've got open up the artery, take the plaque out exactly the same way that I was talking about the groin earlier and then you would either close the artery directly or you would um close the artery with a patch. And essentially this is a prevention surgery to reduce the risk of the patient having future uh ti a or stroke. Now, next, uh s slide, please. And then this was just a picture of a patient showing the type of um repair that we would do at the end. It's quite neat. Cos you have the little patch and we use very, very fine er, monofilament sutures. So they take a bit of getting used to. Um, but the, it means that the repair is durable and that it has minimal trauma to the artery when we're closing it. And that's the patient with a classic scar from a carotid endarterectomy that we would see on our ward. Uh, next slide, please. So, um, I just wanted to talk about my training a little bit. So, um, because I got onto vascular surgery and what was essentially a pilot, which was a run through. Um, I've come in as a vascular registrar at ST three level, um, in the same cohort of people who did that interview for ST three. We have a, we have the same vascular surgery curriculum. So it's all the same benchmarks and there's a document that you can Google. It's from I SCP and it's called the Vascular surgery curriculum. And it's a very, very hefty document. I think it's about 8090 pages long and it essentially shows you all the types of procedures that you need to do as a vascular registrar in the UK to achieve competency to get your um CCT, which is your certificate of completion of training. And then you can apply for jobs as a consultant in the UK. Um So if you just go to the next slide, please. So I thought it was quite interesting to um look at what the er committee of training class as index procedures. So at my level, as an ST three, I, the, the expectation roundabout at my level is that I will be doing um amputations. So that was above knee, amputations below knee amputations. Um Also doing obviously digital amputations of the foot incision and drainage of a diabetic foot um starting to do veins as well. Um We use um radiofrequency ablation, which is basically a keyhole day case procedure to treat patients with varicose veins and venous ulcers. Um Also I'm doing groin cut down. So any groin dissection, we do that a lot in our surgery. So it's a pretty common um step in a procedure and also um opening abdomens for procedures such as an aorto bifemoral bypass or an open aneurysm repair, other procedures that they um have put as index procedures. So you should be able to make, make a fistula. Um and you should be able to do a carotid endarterectomy. An er, you should be able to treat veins, you should be able to do a femoral endarterectomy, which is the groin procedure and you should be able to do a bypass in the lower limb, an open aortic repair rupture, an elective, you should be able to do um, angioplasty and stenting in the leg and you should be able to do um deal with acute limb ischemia with a thromboembolectomy. So it's quite a range of procedures, but that's kind of the level at which they're setting it and there's different levels of competency that you have to achieve and demonstrate um on your online portfolio which you get from um core training level. So what's the next slide, please? So, um I had a question about work life balance as well. So, um it's a shame you can't see it really because it's my um work schedule that I have. So where I work at the moment we have um it's as a registrar, it's a pretty nice work life balance, I would say. So you're working on the ward. So you do the ward rounds, er, where I am, you would do the ward rounds. Um independently we normally have around in the region of 30 inpatients and outliers. You've also got an outpatient clinic where they're normally half day sessions. So you would be um normally reviewing patients independently discussing them with the consultant dictating a letter and then um ordering any investigations that are required. You also have, um, day case procedures. So that often takes place in what's called like a clinical day case suite. So the patient will come in for, for treatment of veins, for example, and go home the same day. So you would normally have three patients in the morning. For example, you also have your elective lists. Um, the elective lists where I currently work run from, um, 745 till seven at night. Um, that's not everywhere. This is a triple session list, but it's quite useful because you can get, uh, some of the larger operations in vascular surgery that take, er, many hours, you would need to stay, uh, late to finish them anyway. Um, and then we do on calls overnight. Um, and then we do weekend on calls as well, which are 48 hours. That's where you, um, are non-resident. Uh, but you have a phone. So if there's any vascular emergency, um, in the region, then you would get a call about it and have to respond appropriately. Um, so that's kind of how the work life balance pans out. It's a good variety. You do get a lot of, um, time in different areas. So I don't find that you ever get bored, there's always things to do. There's a lot of throughput in vascular surgery and, um, it's a growing population of patients, um, especially, even though smoking is on the decline, there is a huge rise in patients who are developing diabetes. So that is a area that's going to explode probably in the next few years. Um, and also, um, renal access is also an area which is undergoing a lot of development at the moment. So they are quite good areas to um have interest in research in at the moment, I would think. Uh, next slide, please. Um, so vascular surgery, the pros and cons, I mean, I'm a bit biased because obviously I'm a trainee. Um I've spoken about the different settings that you have in vascular surgery. It's really nice to work with different people. You work in all areas of the body. Like I've said, there's different patterns of disease. Everybody's unique in vascular surgery because their vessels disease in different ways and to a different degree. So it's, it, you have to put your thinking cap on a lot of the time to think about what exactly you're gonna offer this patient. And also because they're so frail, what they can actually um tolerate, which is another matter. So y you have to balance things very carefully, which is part of the art of um making decisions for these people, which is so interesting. Um You've got a lot of techniques at your fingertips. So open endovascular or even mixing the two and having what's called a hybrid procedure. Um There's a lot of technology that's coming out, um especially with industry. Um They go to lots of conferences. You can find out all about different techniques and strategies and um technology that they're adapting to help you cure your patients. Uh We work with all the different specialties, like I've said. So the renal team stroke, team, spinal team urologists, cardio everybo everybody. So you, you're always gonna have friends in different departments. Um, when you do vascular surgery, I would say, um and also it's life and limb scenarios, There's lots of pressure, there's lots of em emergencies. So, if that's not necessarily for you, you might want to think again about doing vascular surgery. Um I've also put a little asterisk at the bottom of what I was going to say, er, about vascular. I can't be completely biased. Um So I have said potential things that might put you off are the patients are frail. So if you don't necessarily like that popu like treating that population, it's going to be difficult for you. Also, the patients have a fairly poor prognosis in many cases. Um The, and I think the five year survival for after an amputation is, you know, 30% something like that. So you're not necessarily gonna be seeing these patients forever. Um And also there's less private potential if that's something that um you are interested in. Uh, next slide, please. So this is also a slide. So, um I did have quite a rapid turnaround in what I wanted to do and I thought maybe vascular surgery isn't something that I would want to do because you do have preconceived ideas about who is a vascular surgeon. You know. Um, I think we all know what we probably think about when you think of a vascular surgeon, probably an older male, um, alpha type. But there are lots of women in vascular surgery. Um, when I was af one half of the faculty was um, female. Um, there are a lot of vascular surgical trainees who are women, uh especially in the, in the West Midlands. And I wouldn't let be a woman put you off from applying because if it's something that you're interested in, then you should definitely pursue it. And next slide please. And then I just wanted to talk a bit about surgical opportunities. So, um I think if you are interested in surgery, obviously, you're going to be thinking about sitting in the MRC S parts A and B for that. I use the EE MRC s which was a great resource. Um I went on courses so I did the at LSI, did the basic surgical skills. I did crisp. I also for those of you interested in trauma, I did a course in London that was called Talons, which is um run by the Pan London Trauma Network. It used to be face to face, but I've looked it up recently and it's now online, but that was absolutely fantastic. So, um a lot of those surgeons work at the Royal London and they put the course together and they also run a trauma masters. So if you are interested in that, um it's definitely worth having a look at and I think it is free. Um Also you will have heard of the log book, which is an online resource that you can use if you're going to any operations in any capacity, even if you're there assisting, I would still sign up to it and still put in all the information because it's nice to see that trajectory from when you've first been interested to actually getting an interview and then onto the training program. Um I've put some conferences here that are um vascular conferences, which I've been to, which I would wholeheartedly recommend you need to look for the conferences when the submission window is for um oral presentations, post presentations so that you can plan ahead a lot in advance. Um There's a society called British Site of Endovascular Surgery, which has a conference in Bristol in June. There's Charon Cross, which is a major vascular conference that's based in London. And there's also the European Society of Vascular Surgery, um which is in Belfast next month. Uh There's a UK Vascular Society, there's the American Vascular Society which is in June, there's also the venous Forum for the Royal Society of Medicine and also Regional Surgical Society. So in the West Midlands, there's a Vascular society, it's called vari. It's um essentially trying to um gain collaboration between different units in the West Midlands uh to run Multicenter studies which have more power than for example, case studies or single center studies. Um They do a meeting twice a year, so they do a, a spring meeting and they do an autumn meeting as well. Um So if you're interested in that, um I can give you the details as well. Um I also did a taste a week in vascular surgery. I'd recommend that if you're interested, it is helpful to get on the ground and um see if you're still interested when you sort of take, follow a registrar and see what they're doing. Um Also membership. So there's a great society um in the UK, it's called the Rouleaux Club, which is a trainee vascular Society. You can join as a medical student and you can even run for leadership positions as a medical student. Uh within the society. They have a newsletter, uh which is every month. So you can get updated um information about opportunities, et cetera for applying for training. They run an essay competition that, that counts as a national prize. Um They also have a series called Humans of Vascular Surgery, which is short youtube videos, basically interviewing trainees about their um experiences and motivations in vascular surgery, which is also interesting to get another perspective. And um there's also other surgical societies. So the vascular society, you can join as an affiliate member to get updates about information to do with vascular surgery. And there's also asset which is um Multidisciplinary Surgical Society which I'd recommend joining as well for, for more information. Um Next slide, please. And that's it. Thank you. Um I think I've talked very fast and at length, he was a great, I liked it quite inspirational. Yeah, sorry about all the technical difficulties, did a very good job carrying on. I think hopefully we managed to retain most people for all that. So thank you guys for sticking around for that as well. And it was very good talk. I think if there's any slides that you think people would like to see with pictures that we could probably go back through. Now, you've got those slides, you think maybe they should do that very briefly. I mean, there are things that we, we were talking about in terms of the uh endovascular repairs. I think you were mentioning. I we'll probably show those pictures next start and I can just go, I can, I obviously I'm not, we're not gonna go through it again. I can just walk through very, very OK. So that's all the theaters you're talking about as well. Yeah, so that's the theater that I was talking about. So that one looks particularly expensive and brilliant. Um But it does look quite like that. Um So that's where we do all the radiation work. So you have to have lead protection all of. So forth. That's a stent that I was talking about. That's, that would be nice behind the knee where you can have a lot of conform. Um That's the angiogram I mentioned. So when we do angioplasty, that's quite a nice result on the right hand side where they've um plati the vessel and then that graphic in the bottom, right is um quite futuristic where it's showing, it's showing advice called rotor X, which is basically a mini drill inside the artery to drill all the calcium out. And that's one of the looks pretty brutal treatments that we can do. Um just go to the next one. Um So this is another angiogram. That's the common femoral artery you can see on the left, it's splitting into the superficial femoral and the profunda arteries in the same patient, they've opened them up. So what you're seeing there is a groin incision. Um the common splitting into the profunda and the SFA like you can see on the, on the first picture. Um And then those elasticated er bands are potentially called sloops that we use to control the artery. So that's why you can see the artery nice and bare on the inside rather than gushing blood at high velocity. Um And then obviously the self retainers, that's a lovely view. They've already endarterectomized the artery. And then that little um thing on the, on the swab is just the plaque that's come out. So that's what you would expect to see and that just goes in, in the rubbish at the end of the operation. Uh next slide. So this is the um picture that II mentioned from the B MJ. Er if you look at that patient, you can see uh there's the aorta up to the up to the kidneys and then the the aorta doesn't go down, it sort of stops. And then is that a axillar graft? Yeah. So the patient's had axillobifemoral grafts. Oh, so you'd be able to, if you saw that patient, you'd be able to see the graft uh under the skin and you'd be able to feel it and you'll be able to feel it all under the chest wall, abdominal wall going down to the er arteries. So, were you able to feel a pulse in that graf and in the, the, the wall? Uh Well, you would in that one because it's got contrast flowing through. So that indicates it's patent. Um Sometimes the problem with grafts is they can be tricky. So they don't always last forever, they can thrombo. So potentially that, that is something that could happen with a graft that you can send the patient for the graft could potentially block. And you might need to come back in this particular situation. Is that a harvested graft? It's quite big and patent or would you, is that, that definitely wouldn't be a harvested graft because the for, for, for very long grafts like like an axilla feb, you have to use a prosthetic graft. Sure. Um, I think impressive or for, um, well, the preference is vein because vein can't get infected. Uh, it's part of your body. Um, and it's got a reduced risk of thrombosis and blocking off. But for something like this you'd never find a vein. That, that, that's that long. So he's had to make do. Oh, that's incredible. And then this person is standard for someone having a bypass. So you can see the is going to below the knee. So that's the, you can see their knee's got the light shining on it and then where the self retainer is, is below the knee. So that's accessing the, either the popliteal or the trifurcation arteries um to plug the graft in at the bottom. And then at the top, you can just see that there's a clip there with some of those elasticated sloops, which is where they've obviously gone in at the groin and exposed the artery there. And then the graft will be tunneled in either under the skin or uh anatomically where the artery normally travels depending on the preference of the surgeon. Uh These are amputations. Um This is called a Ballard incision, which you can see in the bottom, right, which is um in diabetic foot surfaces to essentially re release all the, all the compartments of the er the plantar compartments of the foot for drainage. Um That's what a bologna amputation looks like. So you do what's called a long posterior flap and then you will bring the um posterior flap up and then you will have almost a seam of sutures. Like the bottom picture where the patient's had the baloney amputation. And does that help in terms of further prosthesis then, or what's the, what's the purpose of the, the flap posteriorly? So essentially, you need something to cover up the bones. Otherwise, it would just be like you can see there. Um There's different ways to do a bologna amputation, but I would say long posterior flap is probably the commonest in the UK. What about the re Stokes amputation? How often do you do that? Um Not usually not, not, not commonly. The commonest is either um below knee or above knee. In some cases, people will have gritty Stokes. But um it is a competency for um the is ep portfolio. What, what is gritty Stokes or us? Um Potential people who don't understand. So it's essentially through me. OK. Yeah. So if you just go on to the next slide, uh so there's some ischemic feet. That was the fogarty catheter, I'm talking about um which goes down into the artery, you inflate the tiny balloon on the end, it's got saline in it. And then you use that to pull back and basically the embolus comes out um like a squiggly worm essentially. And you bring it all out until you've done some sort of three clean swipes and hopefully the foot looks a bit pink and nice at the end. Yeah. Um, so that's the graft. That's a tube graft. Um, on the top left, it's made of Dacron. It's nice and soft. You cut it to size and then you close the aortic sac over the top. You can use different types of grafts so you can use like a trouser graft. Um, or you can use a straight graft depending on the anatomy. Um, the bottom left is a ct scan of an abdominal aortic aneurysm. You can see it's um, so standing at the feet looking up, there's the aortic aneurysm where it's very bright white is the blood flowing through and then it's lined by thrombus around the outside, which is chronic and normal. Um, and then on the right is um showing what an, er, looks like. So the um white structure in the middle is essentially the, the, er, it's made of two bits. Um, and you put them in via both groins. So you put it in percutaneously with a needle under ultrasound guidance and then you can close the artery as well without having to cut down, but you have to, you can cut down in some situations if the artery is very diseased or it starts falling apart or that kind of thing. Um, but the, the er, is keyhole and it's used quite frequently. It's very common. Yeah, I remember one of the vascular consultants telling me that it's, it's not merely a graft, it's, it's called a stent graft. It is a stent graft because a stent is just er, without fabric, whereas the graft has the fabric over the top. So we do call it a stent graft and, and uh there's something that I recently got to know that uh nowadays we use something called the perclose device for ears, which means the patient doesn't even have an open groin access. There's barely a 0.5 centimeter incision in the groin and they've had their aorta repaired. Yeah. So you can even do an er under local anesthetic. So if the patient's very comorbid or they're a rupture, then you don't even have to give them a spinal or a G A, you can do it under local anesthetic at the groin and they're awake. So it really is uh I guess, minimally invasive in that sense, but it is still an aortic repair. So there are still things that can go wrong in a major way. So I won't go into that now. But fascinating. Um That's the dialysis machine. Um There's a kidney transplant there, there's a peritoneal dialysis catheter that we put in uh for the renal team. And that's creating a fistula in the top right hand corner, we can create them at the wrist, the arm, you can put a fistula anywhere really. But the wrist and the, the antecubital fossa are the commonest ones. And that's someone who's had a fistula previously. You can see the scar. Um, so this is, I just like this picture cos it's a good demonstration of all the anatomy around that area because lots of people love this operation in vascular. Um, because of the anatomy, it is very, it is a very stunning operation. Uh And then the next slide. So again, there you can see the steps of the open surgery for carotid. So there's the carotid bifurcation, er, with the floop round it again for control. Um They're taking the plaque out. Um the next slide and then they're just extending the arteriotomy, I think in that picture. A and then you can see the patch. That's quite a nice demonstration of the bovine patch. And then you use the proline monofilament to essentially put er anastomose the patch. It's called patch plasty. If you just closed it primarily it would narrow, which would be an issue in that area. And then there's the score. Yeah. So that's the curriculum. There's my rota that I mentioned a bit about is probably nicer than a lot of sho rotors. So um I don't have anything more to say about that really. And then these are the women who um were consultants where I was an F one and they're very inspirational, very uh amazing surgeons. Brilliant, hopefully. Um Thank you for all that. That was really, really good. I needed that second explanation of all the picture, even though I saw them twice, I think they definitely, definitely very useful to me as someone who's very vascular shy, I think generally. So I think that was great. Thank you. You've got to have pictures in vascular surgery, muscular surgery without pictures. If you're very uh if you enjoy that kind of visual element, there's certainly a lot to feast your eyes on in vascular, for sure. Brilliant. Thank you. Um We've got a couple of questions going. I think I want to start with one question. Um How do you manage with the smell of people's feet? A very interesting question. I don't know. II guess it's never really bothered me. I thought it would be much worse to be a colorectal surgeon. But there you go. True. Yeah. True. Um, I think you're either bothered by it or you're not. I think if you are bothered by it you can probably get over it. Sure. Sure. Sure. Um, so we've got a couple of questions in the chat. Um Is there any benefit to core training, over, run through training? How do they differ? So, I suppose it's the, the, the pathway that you've done versus the traditional pathway. Well, the thing is because I essentially the pathway that I was on, I believe it is now actually defunct because it was a pilot done by health education England, which has since been withdrawn. I don't, I don't know the ins and outs of why it was withdrawn. Um, but essentially, II imagine it was becoming too complex to be running multiple different streams for the same training. Ultimately. Um, is it still not available in Wales and Scotland or is it just England? It, I think the thing is, I've never looked at jobs in Scotland or Wales, but it's not, I don't believe I may be wrong but I don't believe it's available in the UK and in England anymore. Did you think it kind of changed your skilled you differently to people who joined via, um, CST into ST three? I mean, do you, do you feel like you've got more experience going in because you had those previous vascular themed rotations in your equivalent ST one and two or do you think it's sort of much so much? Mm. Um, I think it definitely, um, cemented the idea that I am wanting to do vascular surgery perhaps in the minds of those who are training you. And I found that to be quite beneficial because they know that you're in, in it for the, for the long haul, essentially, you've made that commitment earlier on than perhaps other people might have done. Um, but in actually, in terms of the core training that I received, I don't feel like it was any different to my peers if that's of any use and the jobs that I did, I did a lot of general surgery. I did all general surgery on calls. Um, and I did thoracic, which was very useful actually for vascular surgery, um, being able to operate in the chest. And also, um I did an upper gi job as well, which was very useful because their patients are so sick. It has parallels with vascular surgery in many ways and it was good to get that broad spread because you're gonna have patients under your care in vascular surgery who've had all these operations because the person having a lung resection when they're in their may, maybe their fifties is in that same cohort of patients who might come to you in 1015 years with peripheral arterial disease. So it's good to know these uh conditions as well, I think. Yeah. Yeah, I remember when I once scrubbed in for a AAA repair and open repair, uh, the patient had loads of adhesions all over his bow and the vascular surgeon spent at least half of the surgery dividing these adhesions and, and then got to actually repairing the aorta. Yeah, I think there's, there's a lot of overlap between vascular surgery and general surgery and uh considering the fact that you've had that experience, I think it uh it helps uh, a vascular surgeon. Yeah, definitely. I would agree. Um, a question about um the competition, II suppose it's different now, obviously with the, the training pathways as they are. But how, how do you, how did you think it was different? I suppose at the time when you did it, in terms of competition ratios. So people were getting into, I suppose where you were in ST one with your run through and how, how is it now in terms of ST three vascular, um, applications? Um, I'm not, I don't know what the ratios are but, um, I did look at them a couple of months ago, II believe. And it didn't look too, it didn't look dissimilar to, I think general surgery. Um, there are some specialties which I think are always going to be potentially more competitive, you know, your neurosurgery, cardiothoracic, potentially plastics. Um I don't think it's in that kind of realm in terms of competition ratios, it's competitive to get in, but I think it is achievable. Um And I think for some reason, vascular surgery, um because it's not necessarily well known what we do. People don't necessarily get that exposure in medical school and as a foundation job perhaps, you know, that's why people aren't going for it because they don't actually know what it involves. And so I think there is potentially an exposure problem which you can use to your advantage if you are interested. So at what point did you think? And, and that's why we are doing these sessions so that everyone knows about every specialty a, at what point I suppose in, I suppose in your sort of f two F three kind of um, time frame. Were you thinking about this um, er application to, to specialist training. And I suppose people looking at these talks will have to, you know, start thinking about their portfolios and things to add and things to go to and audits to do. And how, how did that sort of process come about for you? Um, so at the end of my f so my, just to put it into context, my vascular surgery job was my last job of F one. And bearing in mind you applied for core training at the start of F two, which was I think about four months later, that was never going to work for me. And also I felt like that was a big leap to go from someone who's going to do hematology or neurology to then putting together a portfolio and applying for vascular surgery in the space of, you know, four months. It's just not achievable. I wanted to know a bit more about it. I suppose I wanted to travel as well. I've done my elective in New Zealand. Um, it's a beautiful country. Once you commit to training, you know, training is a, is a massive commitment, especially if you're going for, run through. That's eight years. It's much easier to do things that you want to do on your bucket list, et cetera and get into training. Once you've done that, once you've scratched that itch, you know, than to do an out of program or something like that. Cos it, it's just a perfect time F three. And I thought, I thought that it gave me a real nice transition and some a, a place to sort of breathe and travel between my foundation and, and where I am at now. So, um portfolio wise as well, I would say pick something that, you know, can be used in multiple areas. Um So, you know, if you're going to do the audit, make sure that it's presented regionally as a practice present it nationally, make sure it's publishable. So you can do, you know, fulfill all the boxes with one thing. Um There's no point doing multiple things that tick one box each, you might as well do something that hits all of those criteria and also make sure that you're doing for the interview. Um What you need to, you know, fulfill, do the minimum to get the maximum. If you see what I mean, do what you've got to do in all the domains rather than absolutely excel in one area where it's unnecessary, you just have to do well and be good across the board. I would say. So, is that all you trying to tick all the boxes, I suppose? Isn't it being aware of it? There's no kind of, I would say do something as well, get link up with somebody who's got a real track record. So maybe some a consultant who has that time in their, in their um in their work plan to do research because they, they will have the time to mentor you in whatever you're doing. If you pick, if you, you know, do research or something with somebody who doesn't have that time in their job plan, it's going to be very difficult for you to uh gain the mentorship that you need to publish or to go to an international conference. So just um think carefully about the sort of person who, you know, you can sort of, you want to help them with their research, but also they're there to help you and teach you. Um, I think that's the best advice that I would give. So essentially pick one project that you can present, publish and uh tick all boxes with one project and actually even travel somewhere like for the project that I did, I went to Washington to present at the SBS at the end of my 12. And that was just like the best thing ever. Um, you know, it was just absolutely amazing and, um, you know, you want to go into career feeling that enthusiasm. You've got an, a project and you got a, you know, all the rest of it and it, it just means that you feel amazing when you start your training. Yeah. Yeah, absolutely. Um, I, I've got one question about uh, vascular surgery as a specialty. Um, now all the other specialties like general surgery and orthopedics, they all have subspecialties like general surgery. There's colorectal, um, gi, cancer work and so on. Uh, what's vascular surgery like? Do they have subspecialties? Do consultants specialize? Yeah, absolutely. Um, I mean, modern vascular you're going to be getting, um, just broadly, I would say aortic team, then you would have limb salvage, which is all the patients that have, talk pretty much all the patients I've talked about. You'd have diabetic foot specialist, you'd have renal access and dialysis. Um, that's what I would say. And then you might have somebody who perhaps does limb salvage from an endovascular skew if you see what I mean? So there's a thoracic outlet is also another vascular that it's just, there's like other specialties. It's kind of limitless. You have deep venous, superficial venous specialists, it goes on and on. There's all sorts of different areas to suit the person I would say. Oh, that, that, that's a lot of subspecialties. Which one do you want to do? Uh, I think it's a long way off but limb salvage or renal access, it's kind of the, er, I always think AORTAS are the most glamorous one but the thing is aortas have kind of had the spotlight for the last 20 years. So I think it's time the spotlight moved on to something else. Brilliant. Um, any more questions at all? From the chat? I think we, we've gone on for quite a long time, which I, yeah, I appreciate. There's some technical difficulties but you know, a great job of going through some stuff. Thank you for carrying on listening. Despite the slide issues, I do appreciate that incredible talk. Thank you e listening to your journey. All the different things that you do on a daily basis, firsthand experience. Really? Right. So if people can scan that feedback form, uh scan the QR code for a feedback form and there's also a feedback form that will release um uh via email. Um So you do that and get a certificate and we will stay in touch for some, for some more talks coming up in the future. The other talks we've done previously are on um medal so you can access those recordings. It might be a little bit of us fluffing around but you know, there is some very good content in there as well from people such as Helena, very inspiring speakers. Um So they'll be in touch. So again, thank you to Helena for all that. It was, it was a brilliant talk. So thank you for you guys for hanging around with us. So hopefully we'll see you next time. All right, thanks Helena and thank you everybody for attending. See you in a couple of weeks. Brilliant cheers. Bye.