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

2. 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

3. Varicose Veins

4. Symptoms
Itching

5. Symptoms
Itching
Aching

6. Symptoms
Itching
Throbbing or heaviness
Aching

7. Symptoms
Phlebitis

8. Symptoms
Phlebitis
Skin changes

9. Symptoms
Phlebitis
Skin changes
Leg ulcer

10. 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

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

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

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

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

15. Results
Before
After

16. Vladek Sheybal

18. 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

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

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

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

22. Claudication differential diagnosis
Spinal claudication
Orthopaedic
Myopathy
Combination
Pulses
ABPI

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

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

25. 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

26. BMI Harbour Clinics Thursday afternoons 01202 702832

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

28. 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

29. 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

30. 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

31. 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

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