Below you will find information on the diagnosis and treatment of some key conditions treated by the Vascular Surgery Team.
ABDOMINAL AORTIC ANEURYSM (AAA)
CAROTID ARTERY ATHEROMA AND STROKE PREVENTION
PERIPHERAL ARTERIAL DISEASE
VENOUS AND LYMPHATIC DISEASE
AAA are generally asymptomatic and are generally diagnosed on physical examination or on scans (usually ultrasound or CT) done for some other reason. Occasionally they cause symptoms e.g. abdominal or back pain – these are generally ominous symptoms of impending rupture and require immediate referral to hospital. Other symptoms e.g. distal embolisation can occur but are less common.
Generally AAA are treated once they are 5 cm in females or 5.5cm in males. However the decision to treat can be complex and depends on the patient’s co-morbidity and the type of treatment they will require. Occasionally in patients with major co-morbidity a decision will be made not to treat an AAA, although this is becoming less common now. There is no effective medical treatment for AAA.
Rupture of AAA has a mortality of 60-80%. This is why it is vital to treat in the asymptomatic stage
There are 2 main types of surgical treatment:
- Open repair
- Endovascular repair (EVAR)
Open Repair
Open repair involves a midline laparotomy with cross-clamping of the aorta. A Dacron graft is used to replace the aneurysm (Image 1). It is a significant operation and carries a mortality of 5-7%. It is, however, a very effective operation and is very durable. It requires minimal follow-up and the risk of re-intervention is low. It is a well tried and tested operation.
EVAR
The morbidity and mortality associated with open repair have prompted the development of a minimally invasive approach – EndoVascular Aneurysm Repair (EVAR). EVAR involves small incisions in both groins (as opposed to midline laparotomy). A stent graft (image 2) is placed into the aorta in a constrained form and deployed (image 3). This excludes the aneurysm from the circulation (Image 4). Cross-clamping of the aorta (and the attendant ischaemia-reperfusion injury) is not necessary. The mortality of EVAR in major randomised trials was approximately 1.5%. Not all patients are suitable for EVAR – roughly 60% will be. A lot depends on the detailed anatomy of the aneurysm. Complex planning, with dedicated thin slice CT scans and reconstructions is necessary. Each stent-graft is individually tailored / sized for individual patients. Follow-up is more assiduous than with open repair (usually yearly CT scans) and re-interventions are more likely (although becoming less common and generally only minor procedures).
The EVAR programme in UHW commenced in July 2011 and generally involves a 2-3 day stay in hospital without the need for HDU or ICU stay.
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Carotid athero-embolisation is one of the major mechanisms of ischaemic stroke
It has long been recognised that for symptomatic patients (with an appropriate TIA) and critical carotid stenosis, carotid endarterectomy is beneficial in terms of stroke prevention.
For asymptomatic patients with carotid stenosis the decision is less clear – there may be a benefit to endarterectomy but with recent improvements in medical therapy this is less clear.
Carotid stenting has been an area of interest to professionals involved in the area of stroke prevention for many years. It is an attractive option as it is less invasive than endarterectomy. There have been many trials in this area and consistently it has not been consistently shown to be as safe as endarterectomy in terms of peri-operative stroke risk. For the time being ‘the jury is out’ on carotid stenting and its use is generally restricted to certain specific indications e.g. recurrent stenosis after previous surgery.
We would recommend that any patient with carotid stenosis should be evaluated by a vascular surgeon to decide the best course of treatment (surgery, best medical therapy or stenting).
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Peripheral arterial disease is one of the commoner conditions we deal with. It manifests in 2 main forms:
- Intermittent Claudication
- Critical Limb Ischaemia (Ischaemic Rest Pain and / or arterial ulceration)
Intermittent claudication is the pain that a patient gets, in a major muscle group, on walking, secondary to vascular insufficiency. It is an important marker of vascular disease. Its presence should alert one to the possibility of vascular disease elsewhere e.g. coronaries, carotids. It is fairly benign and most people will not progress to critical limb ischaemia (CLI), especially if they stop smoking. The decision whether to treat intermittent claudication usually revolves around the extent of the effect it has on the patient’s lifestyle. Most if not all patients should have vascular referral at some point to decide treatment strategies.
Critical Limb Ischaemia is the presence of ischaemic rest pain and / or arterial ulceration. It is a very serious condition and signals a threat to the affected limb. It is generally associated with an ABI (ankle-brachial index) of less than 0.5, but it can be normal or artificially elevated, especially in diabetics. It mandates urgent vascular referral and urgent vascular intervention. We will see patients with CLI urgently in clinic or sooner if required.
Treatment Options for PAD
Secondary prevention is vitally important and is beyond the scope of this site.
Direct treatments include endovascular treatments (angioplasty + stenting) or open surgical treatments (e.g. endarterectomy or bypass). The treatment approach is individually tailored to the patient and depends on their co-morbidities as well as the type of lesion they have.
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Varicose veins are dilated, tortuous, incompetent veins and are generally hereditary. They can cause a variety of symptoms. They can also be asymptomatic. The symptoms include heaviness or tension in the legs. There is often a feeling of swelling, aching, restless legs, cramps and itching. Symptoms such as these are often worse after a long day of standing. Symptoms are often worse in hot weather or after exercise and many women find symptoms are worse during their periods. During pregnancy many women notice that their varicose veins become more prominent and more symptomatic. In many patients these problems will settle after the birth of the baby. Unfortunately, symptoms from varicose veins are rather non-specific and it is difficult to correlate the severity of symptoms with the severity of the venous disease. Despite this it is also clear that symptoms do mainly resolve after varicose vein treatment. The appearance of the veins is also a cause for distress in some patients.
Complications of varicose veins include thrombophlebitis, bleeding, chronic venous insufficiency and ulceration (although most patients with varicose veins never get an ulcer).
There are a variety of treatments for varicose veins. Treatment is usually recommended for patients with complications of varicose veins. For others it is generally felt that treatment improves quality of life, especially if symptomatic. Treatment is not absolutely essential in simple varicose veins and would generally not be recommended in patients with significant co-morbidity.
Treatment options include surgery and endovenous ablation of the long saphenous vein. Conventional surgery remains the gold-standard therapy. This is usually carried out as a day-case in all but exceptional cases.
Endovenous ablation therapies have come to the fore in the last 5 years and appear effective. They involve the placement of a probe (laser or radio-frequency) into the long saphenous vein from below and destruction of the vein by thermal energy. They involve additional consumables and are generally therefore more expensive unless used in an outpatient setting.
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