Vascular (Guidelines)

Presentation

Definition

• ALI is defined as a sudden loss of perfusion in upper or lower limb for up to two weeks after the initiating event.
• The classical “six Ps” (pain, pallor, pulselessness, poikilothermia, paraesthesia and paralysis) are seen in most severe cases only. This implies irreversibility.
• ALI is a time critical vascular emergency. See Rutherford classification:

Treatment goals

• Limb salvage
• Palliation if patient in end-of-life situation

Primary Care input

• Immediate direct assessment by competent Practitioner
• Check vital signs
• Assess 6 Ps: pain – pulseless - pallor – perishing cold - paraesthesia – paralysis
• Give analgesics, consider oxygen and IV fluids
• Organise transport to hospital
• Consider palliative care in community for patients in end-of-life situation

Referral

Immediate phone call to Vascular Consultant on call

Secondary Care input

• Immediate assessment by Vascular Consultant
• Give analgesics, oxygen, IV fluids, IV heparin
• Arrange emergency intervention

Presentation

Definition

• CLTI occurs in the lower extremities due to atherosclerotic occlusive disease. The patients present with ischaemic rest pain, which is unremitting pain in the forefoot relieved by dependency, or with tissue loss, which can be ulceration, dry gangrene or wet gangrene.
• Note this condition used to be called critical limb ischaemia. The new term CLTI reflects that this is always a chronic condition developing over a period of more than two weeks.
• Early referral allows planned intervention.

Treatment goals

• Early diagnosis
• Relief of rest pain
• Wound healing
• Limb salvage if possible
• Rehabilitation

Primary Care input

• Ensure direct assessment by competent Practitioner at first presentation
• History and examination including pulses in both lower limbs
• ABPI are optional to help with decision making
• ECG, FBC, U+E's, HbA1C
• Assess social circumstances
• Prescribe adequate analgesics (rest pain may respond to opiates only)
• Prescribe an antiplatelet agent and statin for all patients with suspected CLTI
• Assess for soft tissue infection and treat appropriately (avoid treating wound colonisation)
• Provide active smoking cessation support as indicated
• Consider end of life care for selected patients

Referral process

• Refer to Vascular Surgery at the first presentation to Primary Care
• Outpatient referral via SCI Gateway marked Chronic limb-threatening ischaemia
• Emergency admission via phone call to Vascular Consultant if uncontrolled pain or advanced tissue loss

Secondary care

• Timely direct assessment by Vascular Consultant
• Consider emergency admission for patients presenting late
• Comprehensive history and vascular examination
• ECG, FBC, U+E's, LFTs, TSH, CRP, lipid profile, HbA1C as indicated
• Arrange vascular imaging
• Consider echocardiogram and pulmonary function tests
• Optimise pain control
• Optimise medical treatment
• Provide specialist smoking cessation support as indicated
• Discuss at MDT and plan definitive treatment
• Lead rehabilitation whilst in hospital

Further information for health care professionals: 

• UpToDate – Management of chronic limb-threatening ischemia
• BMJ Best Practice – Peripheral arterial disease
• NICE guidelines – Critical limb ischaemia
• ESVS guidelines – Management of chronic limb threatening ischaemia
• Vascular Society – Best Practice Clinical Care Pathway
• Circulation Foundation - Patient information leaflets
• BMJ Practice Pointer - Assessment of peripheral vascular disease in primary care

Presentation

Definition

• Foot ulcers in patients with diabetes in areas which encounter repetitive trauma and pressure sensation.
• Chose pathway to Acute Medicine/Diabetic Podiatry or Vascular Surgery if there is an ischaemic component

Identify patients with ischaemic/neuroischaemic ulcer:

• Absence of palpable pedal pulses for all new patient
• Deterioration of pulse status for patients known to Vascular Surgery
• Doppler assessment may augment examination, monophasic signals imply ischaemia
• Note that rest pain can by masked by neuropathy
• Infection is superimposed, this can anything from insidious to rampant

Treatment goals

• Early specialist input
• Wound healing
• Avoid amputations
• Improve quality of life
• Prevent further diabetic foot problems

Referral process

• Refer patients with ischaemic/neuroischaemic ulcer to Vascular Surgery using CLTI pathway
• Refer patients with neuropathic ulcer to Diabetic Podiatry or to Medical Receiving (out of hours)

Further information for health care professionals: 

• NHS Highland - Best Practice DFU and FU Pathway
• BMJ Best Practice – Diabetic foot complications
• Surgery Oxford – Diabetic foot disease
• StatPearls – Diabetic foot ulcer

Presentation

Definition

• This is a common manifestation of generalised atherosclerotic disease
• IC typically refers to lower extremity muscle pain that occurs during exercise
• The pain tends to be in the same muscle group (buttock, thigh or calf), is reproducibly induced by a certain walking distance and relieved with rest
• The onset is usually gradual. Occasionally, acute limb ischaemia can present with claudication symptoms without rest pain

Treatment goals

• Avoid progression of generalised arterial disease and cardiovascular mortality
• Improve quality of life
• Vascular intervention for selected patients (e.g. interfering with employment)

Primary care input

• Direct assessment by competent Practitioner
• History and examination including pulses in both lower limbs
• ABPI are optional to help with decision making
• ECG, FBC, U+E's, HbA1C
• Assess social circumstances and employment status
• Prescribe an antiplatelet agent and statin for all patients with claudication
• Ensure blood pressure control
• Provide active smoking cessation support as indicated
• Encourage exercise, support weight reduction where appropriate

Referral

• Outpatient referral letter via SCI Gateway
• Clinical dialogue if the intention is to manage patient in Primary Care
• Phone call to Vascular Consultant on call if suspicion of acute limb ischaemia

Secondary care input

• Direct assessment by Vascular Nurse Specialist or Vascular Consultant
• Comprehensive history and vascular examination
• ECG, FBC, U+E's, LFTs, TSH, CRP, lipid profile, HbA1C as indicated
• Optimise medical treatment
• Detailed discussion of risk factor modification
• Provide specialist smoking cessation support as indicated
• Offer participation in supervised exercise programme
• Provide information leaflet to all patients
• Consider angiogram if risk factors controlled and symptoms impacting on quality of life
• Discuss at MDT and plan definitive treatment as indicated

Further information for health care professionals:

• BMJ Best Practice – Peripheral arterial disease
• NICE guidelines – Intermittent claudication
• ESVS guidelines – Diagnosis and treatment of peripheral arterial diseases
• Vascular Society – Best Practice Clinical Care Pathway
• StatPearls – Intermittent claudication

Patient information:

• Circulation Foundation - Patient information leaflets
• NHSH Vascular exercise programme - Home Exercise For Claudication

Presentation

Definition

• CVI typically refers to lower extremity oedema, skin trophic changes, and discomfort secondary to venous hypertension. 
• If CVI is left untreated it is usually progressive and leads to venous ulcers. This is by far the commonest cause for leg ulcers.

Treatment goals

• Healing of leg ulcer
• Manage venous skin changes
• Prevention of new ulcers
• Improve quality of life

Primary Care input

• Direct, holistic assessment by competent Practitioner
• Leg ulcer management by appropriately trained Community/Practice Nurse
• Measurement of ankle brachial pressure index
• Initiate compression bandaging or provide elastic stockings
• Upload photo to Medical Image Manager where appropriate
• Consider prescribing Pentoxifylline

Referral process

• Outpatient referral letter via SCI Gateway
• Consider CLTI pathway if patient unable to tolerate compression
• Consider phone call to duty Vascular Consultant if there is advanced tissue loss or bleeding
• Consider Clinical Dialogue if patient managed in community
• Follow Scottish Protocol for Access to Varicose Vein Surgery

Secondary care

• Direct assessment by Vascular Nurse Specialist or Vascular Consultant
• Venous Duplex scan in clinic
• Application of recommended dressing and compression bandage
• Referral to Orthotics for long-term elastic support
• Assess suitability for endovenous or open intervention
• Information leaflet given to all patients
• Referral to Sonographer for enhanced venous Duplex scan as indicated

Further information for health care professionals: 

• BMJ Best Practice - Chronic venous insufficiency
• NICE guidelines - Venous leg ulcers
• ESVS guidelines - Management of chronic venous disease of the lower limbs
• NHS Highland - Local protocol on management of venous ulceration
• NHS Scotland - Protocol for access to varicose vein surgery
• Circulation Foundation - Patient information leaflets
• StatPearls - Venous Insufficiency

Presentation

Other conditions that may require vascular input

• Ulcers of unknown aetiology
• Lymphoedema
• Pressure sores
• Pretibial haematoma
• Severe soft tissue infection
• Complications of IV drug abuse

Treatment goal

• Identify dominant factor
• Pain control
• Treat sepsis
• Wound healing
• Improve quality of life

Referral pathway

• Use Clinical Dialogue with Vascular Surgery if ischaemia a dominant factor
• Consider emergency referral to Medical Receiving for patients with severe sepsis
• Consider advice from other specialities:
  • Tissue Viability
  • Lymphoedema Service
  • Dermatology
  • Rheumatology
• Upload images to Medical Imaging Manager

Further information for health care professionals:

• NHS Highland - Tissue Viability Referral Criteria
• Oxford Surgery - Chronic ulceration of the leg
• Oxford Surgery - Lymphoedema
• BMJ Best Practice - Systemic vasculitis