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REFREC026 VASCULAR SURGERY REFERRAL RECOMMENDATIONS Diagnosis / Symptomatology 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. Last updated February 2006 Evaluation Management Options Referral Guidelines 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. Specific treatments depend on specific problems identified, as noted below. 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. Risk Factors include: Extent of stenosis or occlusions Smoking. Hyperlipidaemia. Diabetes. Hypertension Extent of symptoms and functional impairment. Presence of rest pain Family history of aneurysmal disease. Previously diagnosed arterial disease, eg coronary artery surgery. Page 1 of 6 REFREC026 Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Arterial Extracranial: Standard history. History of TIAs (localising, global and amaurosis fugax) or stroke. Carotid Disease. Commence Aspirin. Manage other risk factors Examination – evidence of: Carotid bruit. Peripheral pulses. Neurological deficit. Cardiovascular assessment. Refer as routine – Category 4, patients with isolated TIAs with stenosis less than 70%, asymptomatic carotid bruit with greater than 70% stenosis. Investigations: Routine FBC and routine lipids, glucose, creatinine, electrolytes. Consider carotid artery duplex scan as long as this does not delay 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. Last updated February 2006 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% Manage cardiac causes: Advice in regard to precipitants, eg cold exposure, machinery. Avoid smoking. Consider trial of medications such as Nifedipine, nicotinic acid. Where there is significant co-morbidity, discussion with the Vascular Service is appropriate prior to referral. 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. Page 2 of 6 REFREC026 Thoracic: – Thoracic Outlet Syndrome. – Hyperhidrosis. – Thoracic Aortic Aneurysm. 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 for consideration of surgery. History of profound sweating of hands and axillae unresponsive to conservative treatment. Investigations: Thyroid function tests. Usually presents from routine chest x-ray. Routine – Category 4. Referral unless neurological symptoms or prolonged arterial or venous insufficiency when patient should be referred urgently – Category 2. 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. Cardiovascular assessment. Investigations: Routine FBC, glucose, creatinine, electrolytes. Abdomen: – Aortic aneurysm. Standard history and risk factors above particularly positive family history. 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. Abdominal examination: Most significant abdominal aortic aneurysms are palpable. Investigations: Abdominal ultrasound. Full blood count, glucose, creatinine, electrolytes. Last updated February 2006 Aneurysms 5 cm or greater or tender aneurysms should be referred as semiurgent, Category 3, to the Vascular Service. Page 3 of 6 REFREC026 – 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. Managing risk factors, particularly smoking. Refer urgently – Category 2. Managing diabetes. General foot care/podiatry assessment. Active foot sepsis – Category 2. Refer Category 3 if any worsening of ischaemic state or increasing pain. Managing risk factors, especially smoking. Severe claudication less than 50 metres – refer as semi-urgent Peripheral pulses. Investigations: Full blood count, glucose, creatinine, lipids, electrolytes. – 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. – Claudication. Standard history and risk factors above. Peripheral pulses. Investigations: Full blood count, glucose, creatinine, electrolytes. Last updated February 2006 Claudication more than 50 metres – refer as routine – Category 4. Page 4 of 6 REFREC026 Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Consider graduated stockings. Refer Category 3 / Category 4 Venous Peripheral Deep venous insufficiency. Post phletic limb. Pain of deep venous valvular incompetence. Standard history and examination, particular reference to any history of DVT and in relation to previous surgery, accident or parturition, genetic factors. Varicose veins (long saphenous, short saphenous, perforators). DVT Central Eg. Pulmonary embolus. Last updated February 2006 Only refer if symptomatic. History of oestrogen therapy, family history, intercurrent disease (particularly malignancy). None. Immediate referral – Category 1 for assessment and treatment. Immediate referral – Category 1, to hospital for most central venous conditions. Page 5 of 6 REFREC026 Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Lymphatic Acquired Post surgery/trauma lymphoedema lymphocoeles. Congenital Primary lymphoedema. Last updated February 2006 Standard history and examination. Early attention to wounds. Refer as routine – Category 4. Consider tropical infections. Standard history and examination. Refer as routine – Category 4. Page 6 of 6