This month we spoke to our Consultant General and Vascular Surgeon Mr Hamish Hamilton to find out the key tips and observations GPs need to know about vascular conditions.
Varicose veins
- Correlate the symptoms with the clinical venous presentation – typically venous symptoms are aching legs after standing or at the end of the day, venous
eczema, and skin pigmentation or lipodermatosclerosis. Numbness and sharp pains or focal tenderness without a superficial phlebitis are generally not
venous in nature.
- Always take a deep venous history, with questions on previous systemic anticoagulation use, previous fractures and any history of thrombophilia.
Surgery is less likely to be offered to a patient with a deep venous (post-phlebitic) history
- Take note of previous interventions, either open surgery, endovenous surgery or sclerotherapy. Recurrent varicose veins are harder to treat, and the interventions
used are guided by the previous surgical history and symptoms.
- Do not disregard skin changes in an asymptomatic venous patients as they are often an indicator of significant venous reflux, which is reversed flow going in the direction of the feet.
This equates to chronic venous hypertension and insufficiency in the limb and may be in the superficial venous system or in the deep veins or both. Refer patient with skin changes
to a specialist
Peripheral vascular disease
- A cold red leg is a dangerous leg, as this can indicate critical ischaemia. A hot red leg is likely to have an inflammatory cause such as cellulitis, phlebitis etc. Check the pulses and
ask about rest pain, which is pain often at night when the patient cannot have the leg horizontal in bed. They prefer the leg down as the flow is better with gravity as the flow is so poor.
- Claudication is less likely with a full set of palpable foot pulses. Any pain is probably not vascular in origin in this setting. This can be checked with an ABPI(ankle brachial pressure index) which is easily done in your surgery or by the bedside with a sphygmomanometer cuff and a hand held doppler.
- The treatment of a long distance claudicant is likely to be best medical therapy and exercise rather than angioplasty if the symptoms are not intrusive on lifestyle. Determine the
Relevance of symptoms on lifestyle and ability to meet daily needs.
- Mixed arterial and venous disease can result in ulcers. In this group compression for a venous looking ulcer is avoided especially if the ABPI is <0.8. Seek a specialist opinion.
Aneurysmal disease
- A large proportion of abdominal aortic aneurysms (AAA) over 5.5 cms are not palpable with a patient of large body habitus. All men over 65 years need an abdominal ultrasound although this is commonly offered as part of the National screening service. Be suspicious for this entity if no screening has been done.
- The threshold for AAA is 5.5 cm in this country based on trials in the past for open repair.
- EVAR (endovascular aortic aneurysm repair) has opened up the possibility of repair to a much frailer, older age group. The selection of patients for either intervention is based on the aortic diameter, aortic morphology and their cardiovascular fitness for general, regional or even local anaesthetic.
- Aortic rupture has a mortality of 25-50% based on the geographical stetting, transfer and expertise with available facilities. The screening programmes reduces this progressively.
- Small AAA ( 3.5 cm to 4.5 cm ) have serial monitoring, with decreased interval between abdominal ultrasounds as the size increases.
- Any patient with a pulsatile mass in the abdomen and abdominal or back pain should have an urgent specialist consultation.
Carotid Disease
- Peripheral vascular surgeons have a very specific role in carotid endarterectomy as the indications are precise. Usually with a decision in multispecialty meetings selected and only
symptomatic patients with high grade carotid stenoses are offered carotid endarterectomy within 2 weeks of the neurological event.
- The FAST algorithm Face, Arm, Speech and Telephone has mad public awareness of the possibilities of presentation. Amaurosis fugax is an ocular TIA, then other TIA’s can include short duration limb or facial weakness , dysarthria, with a stroke longer in duration and often with residual weakness or neurological signs. Urgent immediate referral is important.
- Best medical therapy (BMT) with a statin and antiplatelet agent is the first line of treatment whether or not adjunctive surgery is needed. The purpose of endarterectomy is to
reduce further embolic strokes from the carotid bifurcation, with the highest occurrence within 2 weeks of the primary event so the target to achieve surgery is within 2 weeks nationally in the U.K.
- BMT is used generally alone in asymptomatic patients.
- A bruit is the neck is not necessarily indicative of carotid disease and is not necessarily an indication for carotid duplex in an asymptomatic patient. The bruit correlates more with the presence of other atherosclerotic disease e.g in the heart.
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