Arterial and Varicose Vein Surgery Mr Lasantha Wijesinghe Consultant Vascular and General Surgeon 4th December 2015

Vascular Update GP Refresher Day Friday 4th Dec Mr( Mrs) Chairman, ladies and gentleman. I would like to begin by explaining that the submitted abstract was found to contain errors caused by inaccuracies in the hospital coding system and computaer database. This presentation contains corrected data on a smaller number of patients which however, yields tha same result as that in the abstract. Mr Lasantha Wijesinghe Consultant Vascular Surgeon

Varicose Veins

Symptoms Itching

Symptoms Itching Aching

Symptoms Itching Throbbing or heaviness Aching

Symptoms Phlebitis

Symptoms Phlebitis Skin changes

Symptoms Phlebitis Skin changes Leg ulcer

Varicose Veins Is it worth treating them? Varicose veins lower quality of life; improved after surgery Journal of Vasc Surg 1999 Surgery improves quality of life JA Michaels 2006 Surgery and laser equally effective and safe K Rass 2012 (400 patients) Laser and radiofrequency equivalent at 3 years I Nordon 2012 (159 patients) Reduce chance of ulcer recurring

Varicose Veins Referrals CCG v NICE CCG: phlebitis, severe skin changes, bleeding, ulcer NOT for pain or cellulitis

Varicose Veins What treatment? Sclerotherapy (injection of foam) EVLT (laser) RF (radiofrequency) Surgery Others

EVLT endovenous laser Day case Local anaesthetic No groin wound Quick return to activity Long term results awaited Probably as good as surgery

Surgery Day case General anaesthetic Small groin wound Slower return to activity Long term results good Probably as good as EVLT

Results Before After

Vladek Sheybal

Aortic aneurysms National Screening National Screening Programme Men >65 Ultrasound Automatic referral from the programme or recall (>3cm) or discharge (<3cm) Unscreened AAAs: 5.5cm diameter is threshold for treatment Information leaflets from NAAASP or Vascular Society

Aortic aneurysms Management Control risk factors bp, smoking, wt loss No driving if over 65mm Don’t treat just because you can

Claudication Muscle pain/cramp Not at rest or in bed Brought on by exercise Relieved by rest Reproducible Buttock Thigh Calf

Claudication Not dangerous Risk factors Naftidrofuryl 100mg tds Smoking, diabetes, bp, obesity Naftidrofuryl 100mg tds Aspirin Statin Exercise classes

Claudication differential diagnosis Spinal claudication Orthopaedic Myopathy Combination Pulses ABPI

ABPIs Easy? >0.8 = fine Incompressible, don’t worry

Foot ulcers Ischaemic refer Diabetic, pulseless refer (foot clinic)

Leg ulcers Arterial (no venous problem) refer Venous Oedema ABPI > 0.8 compression Not healing despite compression refer ABPI <0.8 refer Oedema Arthritis (steroids/methotrexate) Heart failure Renal Failure

BMI Harbour Clinics Thursday afternoons 01202 702832 Christine.roper@nuffieldhealth.com

Case 1 42 yr old woman Primary varicose veins Itchy No visible skin changes

Case 2 78 yr old man Comes to discuss ingrowing toenail AF warfarin Poor cardiac function on echo Pitting oedema to knees You notice lipodermatosclerosis and mild varicose veins

Case 3 33 yr old ex IV drug user, cannabis and tobacco use Old left leg DVT Pain in left foot at night and in calf when walks Good femoral and popliteal pulses No foot pulses on left ABPI 0.7 Normal ABPI and pulses on right

Case 4 65 yr old man Fit, plays 2 rounds of golf a week Sudden onset of pain right calf and foot 3 days ago Some improvement but now only 9 holes Excellent pulses on left (prominent popliteal) Good right fem, no right pop pulse

Case 5 24 year old female nurse Fit and well Swelling left calf 3 weeks No trauma Non tender, no erythema Normal pulses No varicose veins Pitting oedema

Case 6 45 year old woman MS, wheelchair Blue discolouration in both feet Cool Pink when feet are elevated Good pulses