Do all patients with varicose veins need treatment?

Varicose veins are a very common problem and range from the classical appearing “bunches of grapes” on the legs if severe right down to tiny thread or spider veins.
In general terms, varicose veins cause very little harm, but the symptoms they cause can be irksome for the sufferer. That being said, it unusual for varicose veins to interfere terribly with activities of daily life. Common symptoms are:

• Discomfort in the veins
• Leg discomfort especially at the end of a day on your feet
• Burning or itching
• Cosmetic embarrassment

More uncommon symptoms which might represent a stronger indication for treatment: Eczema, Bleeding, Thrombophlebitis or Ulcers. Fortunately these complications are uncommon. Although there has been a lot of publicity about DVT or thrombosis in the deep veins (especially while flying) and ulceration in association with varicose veins, there is very little evidence that mild to moderate varicose veins cause either of these. More importantly there is no evidence that varicose treatment will prevent either DVT or later ulceration. In truth, there is often no strong medical need to have varicose veins treated. People who seek treatment of their veins do so usually because the veins are uncomfortable (even painful) or because they are concerned about the vein’s appearance. Both of these are entirely valid reasons to seek care. Most public providers around the world no longer provide care for uncomplicated varicose veins, pain and some swelling are almost inevitable and thus do not constitute complications.

I think my patient has a ruptured or leaking AAA.

Signs of a ruptured aneurysm include: • Collapse • Low blood pressure (But may be normal or even high) • Cold and clammy • New onset back or abdominal pain (Most patient with this do not have a ruptured AAA – but a high index of suspicion is required in men over 55years). Settle the patient down. Examine his or her abdomen feeling for a pulsatile mass. If the patient walked into your practice feeling fine and still does so the risk is very low, an urgent referral for ultrasound and then CTScan if a AAA is found is a good next step. If the patient remains symptomatic with pain or collapse Call 000 first, then call your local vascular surgeon, whoever answers the telephone be sure to use the term “ruptured AAA”. It is very likely that there is a plan for this sort of eventuality. Most surgeons who can, will stop what they are doing to talk to you and help you make the next decision. Alternatively, be sure to communicate your concerns to the ambulance crew who will likely also know where the best place to go is. If you think the patient has a ruptured AAA, this is a life threatening emergency, urgent transfer to an environment where the patients can be cared for by a vascular surgeon is essenti

My patient has a carotid stenosis, what does that mean?

Patients with a carotid stenosis have higher risk of stroke than those without, that is without doubt, what is more relevant is; which patients will benefit from surgery? There are two main things we look at in determining if a patient will benefit from surgery: symptoms and stenosis severity. If a patient has had symptoms likely to be related to their carotid stenosis and their stenosis is greater than 50% they will benefit from surgery. The margin of benefit is related to the degree of stenosis and to the severity of symptoms. Those with higher grade stenoses benefit more than lesser stenoses and those with more severe symptoms (eg; stroke rather than TIA) also benefit more. It is important to know that by “symptoms” we mean events that may be attributable to embolization such as TIA, stroke or amaurosis fugax. These are localising events attributable to a small part of the brain that might be affected by a small clot or piece of atheromatous debris embolising into the brain. More diffuse or generalised symptoms such as dizziness, syncope, confusion, disorientation, collapse and so on are not likely to be related to micro-emboli and therefore not of interest.
To answer the question therefore it is important to know why the patient has presented and understand a little about how the carotid stenosis came to light. If your patient has had localising signs and has a stenosis greater than 50% they should be seen urgently for carotid surgery to be planned. All other categories can be treated more electively. In general, symptomatic patients with stenoses less than 50% are treated with antiplatelet agents and a statin and that is all. Occasionally, patients who have multiple events despite appropriate medication, might qualify for an endarterectomy if their plaque is very unstable of irregular looking.
Asymptomatic patients also rarely qualify for surgery. Although in the past it was accepted patients with a stenosis greater than 70% should have surgery, we now know that in a population of people who take statins and aspirin and stop smoking, there is so little added benefit that surgery is no longer recommended by the majority of vascular surgeons. In some cases, patients with high grade (>70%) stenoses may be considered for surgery. Features that may suggest that a patient may benefit from surgery are: young age, male gender, occlusion or high grade stenosis on the other side, symptoms in the past, impending cardiac surgery requiring pump cardiac bypass or very high level of patient anxiety. Given that surgery will only really be considered in the presence of localising symptoms, ongoing carotid surveillance popular in the past is no longer thought to be of much value. My experience is that it does more to promote patient anxiety than allay it.

Carotid stenosis; what to do about asymptomatic patients.

There are two main things we look at in determining if a patient will benefit from surgery: symptoms and stenosis severity. In understanding this it is important to know that symptoms that vascular surgeons are particularly interested in are: • Stroke • Transient ischaemic attack: weakness of a hand or leg, facial drooping, slurred speech • Amaurosis Fugax: transient monocular blindness Patients who do not have localising signs are more likely to be thought of as asymptomatic. Global symptoms are due to more widespread events and are: dizziness, syncope, blackout, collapse, loss of cognitive function. These are unlikely to be related to a simple carotid embolis. In general terms these symptoms will not trigger a carotid intervention on their own. In addition, patients whose symptoms are more than 4 months old will also be regarded to be asymptomatic. The benefit for carotid endarterectomy is highest soon after the principle event, and as time passes the margin of benefit declines to almost nothing after some months. Some years ago, asymptomatic patients with a stenosis of 70% or more were thought to benefit from carotid surgery. In more recent times where ‘statin therapy and antiplatelet therapy are offered to all patients the benefit of this surgery has declined. This does not mean that patients with carotid stenosis do not have a higher risk of stroke, it just means that statistically this risk is not improved with surgery. This means that in general terms patients considered to be asymptomatic would not be offered surgery whatever grade of stenosis they present with. In some circumstances, a patient might be offered surgery despite this. Things that may make us consider surgery are: severe disease on the other side, male patients who are young and patients who are being worked up for cardiac surgery (not stenting). Asymptomatic patients who are found to have a carotid stenosis are known to have a higher risk of stroke than those without. It is important therefore that this group of patients is offered optimal medical therapy. This involves: • Antiplatelets therapy with aspirin or clopidogrel (not both). • 40mg of a preferred ‘statin (if tolerated), irrespective of cholesterol level, a target of under 4.5 is appropriate. • Optimal management of hypertension (ACE inhibitors are thought to be particularly beneficial) • Smoking cessation • Optimal diabetic control • Lifestyle modification: weight loss and exercise therapy

Which Carotid patients should have further investigation?

There are two main things we look at in determining if a patient will benefit from surgery: symptoms and stenosis severity. If a patient has had symptoms likely to be related to their carotid stenosis and their stenosis is greater than 50% they will benefit from surgery. In contrast, patients without carotid related symptoms are very unlikely to benefit from surgery whatever the grade of stenosis.
Good indications for a carotid duplex include patients presenting with the following: • Stroke • Transient ischaemic attack: weakness of a hand or leg, facial drooping, slurred speech • Amaurosis Fugax: transient monocular blindness In understanding this, it is important to remember that symptoms vascular surgeons are particularly interested in are those that might be associated with a small embolis of platelet or atheromatous material into the brain. They tend to be localised rather than global. Global symptoms are due to more widespread events and are: dizziness, syncope, blackout, collapse, loss of cognitive function. In general terms these symptoms will not trigger a carotid intervention on their own and probably such patients will benefit very little from carotid duplex. On the other hand, patients with a stenosis of 50% or more and localising symptoms should be referred urgently for review as the benefit for surgery is greatest in the early phase after the event. Up to 15% of patients with localising signs will have significant carotid stenosis, Carotid Surgery
This an operation that has changed little in the last 50 years or so. It involves a small cut on the appropriate side of the neck usually under local anaesthetic. After heparinisation, the artery is clamped and then cleared of plaque and atheromatous material. The artery is closed with a patch of prosthetic material. The surgery takes about 90 minutes and involves a two day stay in hospital unless there is a need for neurological rehabilitation.

My patient has an abdominal aortic aneurysm, what should I do?

The majority of Abdominal aortic aneurysms (AAA) are found on routine abdominal examination (physical, ultrasound, CT Scan) usually for an unrelated condition. In some cases the aneurysm will be large enough to cause imminent concern, however, the majority do not. The balance of risk in AAA surgery suggests that at approximately 55mm the risk of AAA surgery is overtaken by the risk of the AAA and surgery is offered. At less than this the risk of surgery outweighs the risk of conservative care. As such patients with AAA greater than 55mm should be referred for relatively urgent care. If there is new onset back or abdominal pain or the aneurysm is more than 6.5cm this referral should be extremely urgent, ideally you should speak with a vascular surgeon before the patient leaves your rooms. The majority of incidentally found AAA are less than 55mm and unless thought to be symptomatic can be treated with significantly less anxiety. The first thing to establish is the need for surveillance. In general, I recommend a new scan after 6 months, and then annually until the aneurysm reaches 50mm. At 50mm the AAA should be referred to a vascular surgeon for care. Alternatively, the patient may be referred to a vascular surgeon early and he or she will manage the surveillance. AAA is evidence of significant arterial disease and therefore it is important that this group of patients is offered optimal medical therapy. This involves: • Antiplatelets therapy with aspirin or clopidogrel (not both). • 40mg of a preferred ‘statin (if tolerated), irrespective of cholesterol level, a target of under 4.5 is appropriate. Even in a patient due for surgery there is evidence that as little as a few days of ‘statin therapy reduces perioperative risk. • Optimal management of hypertension (ACE inhibitors are thought to be particularly beneficial) • Smoking cessation • Optimal diabetic control • Lifestyle modification: weight loss and exercise therapy

Is EVAR Better than Open Repair for AAA?

At the moment in Australia the vast majority of vascular surgeons would suggest that where feasible an Endovascular repair (EVAR) should be performed in preference to open repair. There is no doubt that the immediate perioperative mortality and morbidity is lower in patients undergoing EVAR compared to Open surgical repair (OSR), this is a very powerful driver for patients and surgeons.
There have been some long term outcome studies which have recently challenged the assumption that EVAR is in fact better than OSR. They show that the survival benefit enjoyed at the time of repair by EVAR patients is usually lost within 5 years and that ongoing issues with EVAR cause problems for many years. The promise of cost savings with EVAR is also not borne out in research. The National Institute of Clinical Excellence, which is a branch of the NHS tasked with examining cost effectiveness of care has recently issued draft guidance which suggests that, in fit patients, OSR should be the first option for patients with AAA. Superficial analysis of the data certainly supports this view. I think that there are several points which make the situation a little more complex than initially apparent.
• The most important in my mind is that anatomical suitability for EVAR is not a simple “Go -No go” issue. Frequently patients anatomy is partially suitable, what this means is that it is possible that we can identify a subgroup of suitable who are more suitable than others and might therefore be expected to have fewer long term complications from their EVAR. The corollary to this of course is that we can also predict that there are some patients who, while technically suitable, are more likely to run into trouble in the long term. The enthusiasm for EVAR in the vascular community has resulted in a tendency to adopt an EVAR, if at all possible, approach, and I feel that this is the source of some of the longer term problems. • The availability of a lower intensity treatment has I believe resulted in a significant lowering of the physiological threshold for AAA repair. To some extent this is valid because many patients not fit for OSR may still be expected to live for many years, certainly long enough to die from their significant AAA. This is increasingly true as we get better at looking after the elderly. • For some patients the burden of surveillance is much heavier than others. This can be linked to geographical remoteness, anxiety or the desire to travel. These patients may well consider that the risk of an OSR is justifiable to avoid surveillance. • In the modern age there is often a lot of conflicting information from the internet, social media, apparently well informed outspoken relatives and so on that patients have to juggle and that often interferes with a sensible doctor patient dialogue.
• Fear of treatment (in all forms) is an increasing burden for our society and many patients are prepared to accept relatively minor short term benefit over greater longer term safety. Many patients find the real threat of mortality associated with an OSR unacceptable. The truth is, though, in experienced hands the risk of mortality is very low So….what is the best thing to do? What I do is to try and analyse all the competing priorities and try and advise the patient on an acceptable way forward. The first thing to do is establish that the anatomy is either suitable or not suitable for EVAR and if suitable just how suitable exactly. I then establish the patient’s willingness to accept major surgery and their likely tolerance of surveillance. I then try and anticipate their attitude to risk, recognising that there are differing elements to risk in this situation, the risk of immediate mortality and morbidity and then the risk of reintervention. Younger fitter patients will be steered towards OSR as will those with challenging anatomy, elderly, less fit patients will be advised to have an EVAR if suitable. One of the most important considerations is that the surgeon must be truly confident with both types of repair in order to advise the patient appropriately. It is a growing concern in the vascular community that many surgeons are not confident to undertake complex open repair.

My patient has a stenosis in a tibial vessel is this important?

This is quite a common finding in my experience, our frequently elderly group of patients tends to get this. The usual scenario is that during workup for some sort of leg pain or swelling an arterial duplex reveals that there is some element of atherosclerosis in the tibial arteries. Understandably terms like occlusion and stenosis are very concerning for the patient and GP. There are a couple of important things to know in this area. • In general, a single vessel to the ankle is sufficient to avoid significant risk to the foot. • Angioplasty of the tibial vessels has a very short term patency, probably less than three months and is therefore unlikely to be a solution for a long term problem like leg pain or claudication. • Arterial deficiency in isolation is unlikely to cause swelling of the leg. My approach to this problem is as follows. I start with a careful examination. If there is a strong popliteal pulse it is unlikely that there will be significant ischaemia in the foot (this is a good guide but not certain). The colour and warmth of the foot is also important. A warm foot is unlikely to be ischaemic. If there are ulcers or gangrene on the foot then a distal angioplasty may improve the circulation for long enough to augment or even deliver healing. In these cases I arrange an angioplasty but warn the patient that the net benefit might not be that great. If the ulcer is on the ankle or higher rather than the foot, the contribution of distal disease is less certain, but a tibial angioplasty may improve the circulation somewhat and make compression therapy an option where it previously was not. The truth is that many patients without foot pulses but a palpable popliteal pulse will still heal a lower leg or even foot ulcer with good wound care. In short, most patients with isolated tibial arterial disease do not require intervention. In the event that there is a non-healing ulcer I will try and improve the circulation by offering them a distal angioplasty. Importantly, angioplasty of distal arteries is very unlikely to play a role in swelling, walking distance or weakness, and the long term patency of these angioplasties is quite limited.

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