REFREC026

VASCULAR SURGERY REFERRAL RECOMMENDATIONS

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Vascular Surgery problems are categorised under the following headings:
Arterial
Extracranial head and neck disease.
Upper Limb.
Thoracic.
Abdomen.
Lower Limb.
Venous
Peripheral.
Central.
  • Lymphatic
Congenital.
Acquired. / A thorough history and examination is required to determine a specific diagnosis and its degree of urgency. Some appropriate investigation by the referrer will facilitate the referral process.
Risk Factors include:
  • Smoking.
  • Hyperlipidaemia.
  • Diabetes.
  • Hypertension
  • Family history of aneurysmal disease.
Previously diagnosed arterial disease, eg coronary artery surgery. / Specific treatments depend on specific problems identified, as noted below.
Extent of symptoms and functional impairment.
Extent of stenosis or occlusions
Presence of rest pain / These guidelines are provided (below) to give greater clarity in situations of the primary/secondary interface of care. Clear telephone/fax communication would enhance appropriate treatment.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Arterial
Extracranial:
  • Carotid Disease.
/ Standard history.
History of TIAs (localising, global and amaurosis fugax) or stroke.
Examination – evidence of:
  • Carotid bruit.
  • Peripheral pulses.
  • Neurological deficit.
  • Cardiovascular assessment.
Investigations: Routine FBC and routine lipids, glucose, creatinine, electrolytes. Consider carotid artery duplex scan as long as this does not delay referral. / Commence Aspirin.
Manage other risk factors / Refer the following as Category 2 for Vascular specialist assessment:
–Carotid bruit with recurrent symptoms, critical carotid stenosis (greater than 90% by ultrasound).
–Patient with Crescendo TIAs/strokes.
Refer as semi urgent – Category 3 patients with TIAs and stenosis > 70%
Refer as routine – Category 4, patients with isolated TIAs with stenosis less than 70%, asymptomatic carotid bruit with greater than 70% stenosis.
Where there is significant co-morbidity, discussion with the Vascular Service is appropriate prior to referral.
Upper Limb:
  • Vasospastic Disease.
  • Embolic/occlusive Disease.
Sympathetic? / Standard history.
Examination:
  • Blood pressure taken in both arms.
  • Degree of ischaemia.
  • Trophic changes.
  • Check for cardiac arrhythmia including AF.
  • Assess for connective tissue disorder.
Investigations: Routine FBC and routine lipids, glucose, creatinine, electrolytes. / Manage cardiac causes:
Advice in regard to precipitants, eg cold exposure, machinery.
Avoid smoking.
Consider trial of medications such as Nifedipine, nicotinic acid. / Acute ischaemia should be referred immediately for admission – Category 1.
Refer as routine referrals – Category 4, connective tissue disorders when significant pain and/or disability not responding to conservative measures.
Cases with trophic changes should be referred semi-urgently – Category 3.
Thoracic:
–Thoracic Outlet Syndrome. / Standard history.
Related to arterial and venous insufficiency in upper limb and neurological symptoms.
Investigations: Rule out all other pathologies. Consider x-ray of cervical spine, chest x-ray and thoracic outlet. / None. / Routine – Category 4. Referral unless neurological symptoms or prolonged arterial or venous insufficiency when patient should be referred urgently – Category 2.
–Hyperhidrosis. / History of profound sweating of hands and axillae unresponsive to conservative treatment.
Investigations: Thyroid function tests. / Routine – Category 4. Referral for consideration of surgery.
–Thoracic Aortic Aneurysm. / Usually presents from routine chest
x-ray.
Cardiovascular assessment.
Investigations: Routine FBC, glucose, creatinine, electrolytes. / Control risk factors.
CT scan if radiological report recommends. / Refer if large sacular aneurysm greater than 5 cm as semi-urgent – Category 3. Otherwise, refer as routine referral.
Abdomen:
–Aortic aneurysm. / Standard history and risk factors above particularly positive family history.
Abdominal examination: Most significant abdominal aortic aneurysms are palpable.
Investigations: Abdominal ultrasound. Full blood count, glucose, creatinine, electrolytes. / Managing risk factors. / Referral to Vascular Clinic, in male if greater than 3.5 cm and female if greater than 2.5 cm, as routine referrals – Category 4. Surveillance in consultation with General Practice.
Aneurysms 5 cm or greater or tender aneurysms should be referred as semi-urgent, Category 3, to the Vascular Service.
–Renal artery stenosis.
–Mesenteric angina
–Other aneurysms / Referred usually from other specialty services, eg General Medicine, Renal Medicine, Cardiology.
Lower Limb
–Rest pain, ischaemic ulceration, gangrene. / Standard history and risk factors above.
Peripheral pulses.
Investigations: Full blood count, glucose, creatinine, lipids, electrolytes. / Managing risk factors, particularly smoking. / Refer urgently – Category 2.
–Diabetic foot disease. / Standard history and risk factors above particularly genetic factors and collagen disorders.
Peripheral pulses.
Investigations: Full blood count, glucose, creatinine, lipids, electrolytes. / Managing diabetes.
General foot care/podiatry assessment. / Active foot sepsis – Category 2. Refer Category 3 if any worsening of ischaemic state or increasing pain.
–Claudication. / Standard history and risk factors above.
Peripheral pulses.
Investigations: Full blood count, glucose, creatinine, electrolytes. / Managing risk factors, especially smoking. / Severe claudication less than 50 metres – refer as semi-urgent
Claudication more than 50 metres – refer as routine – Category 4.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Venous

Peripheral
Deep venous insufficiency.
  • Post phletic limb.
  • Pain of deep venous valvular incompetence.
Varicose veins (long saphenous, short saphenous, perforators).
DVT
Central
Eg. Pulmonary embolus. / Standard history and examination, particular reference to any history of DVT and in relation to previous surgery, accident or parturition, genetic factors.
History of oestrogen therapy, family history, intercurrent disease (particularly malignancy). / Consider graduated stockings.
None. / Refer Category 3 / Category 4
Only refer if symptomatic.
Immediate referral – Category 1 for assessment and treatment.
Immediate referral – Category 1, to hospital for most central venous conditions.

Diagnosis / Symptomatology

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Evaluation

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Management Options

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Referral Guidelines

Lymphatic

Acquired
Post surgery/trauma lymphoedema lymphocoeles. / Standard history and examination.
Consider tropical infections. / Early attention to wounds. / Refer as routine – Category 4.
Congenital
Primary lymphoedema. / Standard history and examination. / Refer as routine – Category 4.

Last updated February 2006Page 1 of 6