April 2011: Surgery On The Leg And Foot In Patients With Peripheral Vascular Disease

Vascular surgeons are frequently asked about this topic. The patient may come along before surgery when the surgeon has detected or suspected peripheral vascular disease. About once a year, patients have presented after having had foot or ankle surgery with non healing wounds. The questions here are how should one proceed, what are the useful signs and tests.

Patients with peripheral vascular disease are easily suspected. They will have a history of hypertension, high cholesterol, ischaemic heart disease, carotid artery disease, previous vascular angioplasty and generally be over 50 years of age. Many will be diabetic and if they are diabetic, the patients may be younger. Virtually all will be smokers or ex-smokers or diabetics.

Examination of the Lower Limb

It will typically be warm, but the pulses will be hard to feel. This indicates chronic ischaemia. In this circumstance, the amount of blood supply reaching the foot is sufficient to stop spontaneous ulceration or skin breakdown after minor trauma, but will not be sufficient to heal a surgical wound in most cases.

The golden rule is, if there are no pulses, then there will be no lower limb surgery.

Having detected or suspected a peripheral vascular patient, then one should send the patient to a vascular surgeon for investigation, management and an opinion. This will very likely result in a consultation, possibly an ultrasound, almost certainly an arteriogram, hopefully an angioplasty, a final opinion stating whether proposed lower limb surgery is reasonably safe or feasible. If it is knee joint replacement surgery that is being considered, there may be a comment regarding whether a thigh tourniquet is appropriate in the presence of calcific superficial femoral artery disease or superficial femoral artery or popliteal artery stents. There should also be a comment whether the patient should be on Aspirin or Clopidogrel and when these could be ceased in relation to surgery. There is a general feeling amongst Vascular Surgeons that Clopidogrel is helpful if the patient has had tibial angioplasty and stenting and probably should continue for 4-8 weeks before being stopped.

If the surgeon wishes, he can arrange a duplex ultrasound and possibly some ankle brachial pressure indices. Indices below .08 are abnormal but may be completely normal in diabetics. In my practice, I have some preferred ultrasound practises and it is probably easier for the patient to see me first.

We are all clinicians with various commitments but requests for vascular assessment before orthopaedic surgery are easily accommodated. If there is an urgent matter, i.e. a non healing wound after orthopaedic surgery, then prompt assessment is readily available by calling the surgeon.

This problem can announce itself in other ways, i.e. podiatrists who have trimmed corns or calices on the foot and this results in slow healing wounds, patient with severe lumbar disease who are told the pain in their legs is spinal in nature, when in fact they have concurrent aorto-iliac or lower limb occlusive arterial disease. Some patients with rheumatoid disease etc. may have vasculitis. A specific group are younger patients with peripheral vascular disease where a non-vascular clinician’s index of suspicion would be low, e.g. the young smoking man with Buerger’s disease or the young patient with undiagnosed mild diabetes or pre-diabetes.

Surgery on pulseless feet continues to occur. It is easily avoidable by asking a few brief questions and by a clinical examination of the lower limbs. The sequelae of non healing lower limb wounds with peripheral vascular disease can mean months in hospital, a threat to the limb and a threat to the life of the patient and possible permanent disability. Importantly these days, it could be difficult to defend surgery on a pulseless foot because the detection of a peripheral vascular disease would almost certainly be viewed as within the competence of all doctors, podiatrists, nurses, orthotists, physiotherapists.

GREG SELF
Vascular Surgeon
© 2010

 

 

March 2011: Are Varicose Veins Genetic?

“Varicose Vein Frequent Flyers”

Are varicose veins genetic? This is a good question. There is no doubt that there is an inbuilt constitutional tendency and that is worsened by standing, age, pregnancy obesity and probably bad luck. Two parents with varicose veins gives one a very high chance of having varicose veins. In many families a large number of the members have varicose veins. It is likely one single genetic defect is not responsible.

This means patients with varicose veins should realise that they have received mum or dad’s varicose vein tendency as well as their long legs and good looks! Management therefore may involve surgery, injections, laser treatment etc., but should include a management plan. Isolated treatments without consideration of the next few years or of the patients expectations of treatment will lead to dissatisfaction and ultimately treatment failure.

We see many patients who come from patients who have been treated i.e. brothers or sisters, husbands or wives, sons, daughters etc.. We often see younger daughters of women with varicose vein disease and in that case we are very happy to offer them advice even if they don’t need treatment.

Patients should identify their previous family or friend connections with our practice. We usually then apply a “frequent flyer” discount that involves various options such as discounted consultations, discounted support stockings. There are options even to discount operative procedures. We aim to provide a useful discount. Costs remain higher than some purely surgical clinics and lower than many purely cosmetic clinics. “Welcome to Southern Vascular!!”