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Mr Junaid Sultan

Vascular Research Fellow

Mr Junaid Sultan, our Vascular Research Fellow is currently undertaking research in the area of venous disease. It involves the development of the engineered compression stocking, which is a novel technology and also the introduction of compression in the management of ankle fractures. Details of some of his projects are below.

Development of Engineered Compression Stocking (ECS):

We propose collaboration between Vascular Studies in Manchester, the Clinical Trials Unit and Health Economics in Glasgow and Advanced Therapeutic Materials Ltd (ATM) to develop Engineered Compression Stockings (ECS) for the treatment of venous disease and lymphoedema.

Over 5 million people in the UK have venous disease, 1.5 million chronic venous insufficiency (CVI) and 1 million lymphoedema. The NHS cost of treating leg ulcers alone is £600 million/year, a small fraction of that for venous and lymphatic disease. Elastic compression has an important role in the prevention of deep vein thrombosis (DVT, an important cause of CVI) and in the treatment of varicose veins (VVs), CVI, lymphoedema and leg ulcers. The compression required for each indication remains uncertain as current treatments do not deliver accurate pressures.

Leg compression is applied currently using multi-layer bandages or circular knit compression stockings (CS). These are difficult to put on and uncomfortable, leading to poor compliance. CS are available only in five sizes, which fail to fit 20% of patients. The pressures exerted (Laplace’s law) by CS vary markedly from those intended, being excessive over bony highpoints, inadequate in the concavities with occasional negative pressure gradients.

We plan to develop and commercialise ECS, discovered in a unique collaboration between Vascular Studies and Textiles in Manchester. The leg profile is captured as a 3D image and transmitted to a computerised flat-bed knitting machine to produce precisely fitting ECS delivering pressures prescribed by the doctor. This uniquely allows research on the optimal pressures needed for DVT prophylaxis and treatment of VVs, CVI, lymphoedema and leg ulcers.

The ECS intellectual property was licensed to ATM Ltd by Manchester University. ATM will refine 3D scanner/knitting machine interfaces to produce ECS delivering a range of pressure profiles. The vascular studies team will evaluate the pressure delivered and clinical efficacy using objective criteria for each clinical indication. ECS delivering optimal pressure profiles will then be manufactured for pilot clinical studies designed by the Clinical Trials Unit in Glasgow to inform the design of future definitive randomised clinical trials (RCTs). We plan a range of ECSs that will profoundly affect quality of life for millions of people in the UK, reduce NHS costs and with massive export potential.

Scan to knit technology

Scan to knit technology

Role of Compression in the management of ankle fracture:

This research is to find out whether engineered compression stockings (ECS) stabilise and prevent swelling in ankle fractures resulting in improved healing and more rapid recovery. Over 70,000 people in the UK suffer ankle fractures; expensive for our NHS and costly to the UK economy through time off work.

ECS were developed by a collaboration between Vascular Studies and the Department of Textiles at the University of Manchester: A 3-dimensional video profile of the leg sent over the internet programmes computerised knitting machines to produce a bespoke seamless ECS that applies pressures prescribed by the doctor. ATM Ltd, a small UK company supply ECS for this study. Our services user group tested ECS and advised on elastic range and applicators to fit ECS over painful ankles. ECS may also prevent DVT, which frequently complicate ankle injuries, and enhance wound and fracture healing. To see if ECS improve recovery, 90 patients with ankle fractures will be allocated to either i) ECS + inflatable boot or ii) inflatable boot alone. ECS will be applied immediately following fracture even when surgery is required. We will measure recovery using ankle function and quality of life scores at 4, 8, 12 weeks and 6 months. DVT will be detected by ultrasound.

Our results will establish the role of ECS in treating ankle fractures. If ECS improve healing with earlier recovery, the benefits for patients, the economy and our NHS are clear. The cost of treating ankle fractures would be reduced, especially if control of swelling allows earlier surgery and complications such as DVT are prevented. The benefit to the economy by reducing time off work would be even greater. Patients, nurses and physiotherapists helped in the design of this study.

Engineered Compression Stocking     +     Inflatable Boot     vs     Inflatable Boot

Should incompetent pelvic veins be occluded in the treatment of varicose veins? A randomized controlled trial

Varicose veins (VVs) are tortuous dilated veins that disfigure the legs and cause aching on standing, itching, swelling, venous eczema and phlebitis. They are the most frequent cause of leg ulcers which are painful and smelly sores that afflict over 450,000 of our elderly population in the UK causing social isolation and costing the NHS £600 million/yr. The treatment of VVs costs the NHS over £117m/yr with 30% of this spent on potentially avoidable recurrent VVs.

VVs are caused by blood refluxing down the superficial veins due to the failure of vein valves higher in the leg or pelvis. Some women with VV have dilated veins at the top of the inner thigh near the vagina caused by incompetence in a pelvic vein; usually a vein from the ovary or draining the pelvis. This can be confirmed by a trans-vaginal ultrasound. When there are incompetent pelvic veins, standard VV treatments almost inevitably lead to recurrence within 1-2 years. We now propose to test whether treating incompetent pelvic veins via embolisation of incompetent pelvic veins with coils will prevent recurrent VVs in these women. Standard treatment is still required to treat the VVs in the legs.

Pelvic vein incompetence is also an important cause of cyclical pelvic symptoms in women, such as heaviness, aching or bloating during menstrual periods, sometimes associated with heavy or swollen legs. Our study is also designed to see whether treating incompetent pelvic veins reduces pelvic or leg symptoms and improves quality of life. If this low risk coil occlusion procedure is effective, the benefit to the patient is obvious by reducing unpleasant symptoms and preventing recurrent VVs. The benefit for the NHS is to improve the efficacy of VV surgery, reducing the risk of leg ulcers and the cost of treating recurrent VVs . We estimate that NHS savings may exceed £24 million/yr. If not effective, the coil occlusion procedure being used increasingly across Europe and the UK could be abandoned.

Ten vascular clinics in a large city have agreed to help find patients with vulval varices. Ethical approval has been requested from the North West Research Ethics Committee. R&D approval will be obtained for all sites within a month of obtaining this ethical approval.

Vulval varices filling from pelvic vein incompetence

Manchester Venous Ulcer Predicting Scoring System:

To establish risk factors associated with venous ulceration and develop Manchester Venous ulcer Predicting Scoring system (MVPS). To identify those factors that are independent and to identify potential confounding factors. Identification of populations at particular risk of venous ulceration will allow future research into the influence of prophylactic strategies.

Risk factors, which are associated with venous ulceration in this study, will be used to derive a Manchester Venous Ulcer Predicting Scoring System (MVPS). This scoring system aims to predict patients who could be at risk of developing venous ulcers in a reliable, easily understandable and systematic way.

A case-control study to compare the prevalence of risk factors between patients with venous ulceration and those in age and sex matched controls. A total of 200 matched case-control pairs will be sufficient to detect differences of 15% or more in the prevalence of important risk factors.