Surgery: Vascular surgery

🩺 Vascular surgery. Vascular disease is mostly atherosclerosis -so every patient needs cardiovascular risk reduction (stop smoking, statin, antiplatelet, BP and diabetes control) as well as any procedure. The emergencies are acute limb ischaemia, ruptured aortic aneurysm and compartment syndrome -all time-critical. The medical side of aortic and arterial disease is in the Aortic and Peripheral Arterial Disease chapter; DVT and PE are in the Haematology and Respiratory chapters.
Your four questions for every patient: Is the limb or life threatened right now? Where is the disease (arteries, veins, lymphatics) and how severe is it? Has cardiovascular risk been treated? Is a procedure needed -and is the patient fit enough to benefit from it?

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Vascular Assessment and ABPI

• History -pain on walking (distance, site, relief with rest), rest pain (worse at night, eased by hanging the leg down), ulcers, numbness, smoking, diabetes, heart disease, stroke or TIA.
• Examination:
  • Inspect -colour (pale, dusky, dependent rubor), hair loss, shiny skin, ulcers, gangrene, wasting, scars from previous surgery.
  • Feel -temperature, capillary refill (over 2 seconds is slow), pulses (radial, brachial, carotid, aortic, femoral, popliteal, dorsalis pedis, posterior tibial); listen for bruits.
  • Buerger's test -the leg goes pale when raised (Buerger's angle under about 20° suggests severe disease) and red when hung down (dependent rubor).
  • Check for an abdominal aortic aneurysm (expansile mass) and popliteal aneurysms (easily felt popliteal pulse).
• Ankle–brachial pressure index (ABPI) -ankle systolic pressure divided by the higher arm systolic pressure (using handheld Doppler):

  ABPI	Meaning
  Over 1.3	Calcified, incompressible arteries (diabetes, CKD) -falsely high; use toe pressures or waveforms
  0.9–1.3	Normal
  0.5–0.9	Peripheral arterial disease (claudication range)
  Under 0.5	Severe disease -chronic limb-threatening ischaemia likely; urgent referral

• Imaging -duplex ultrasound (first-line), CT angiography or MR angiography (to plan treatment), catheter angiography (usually with treatment).

Peripheral Arterial Disease and Claudication

• Intermittent claudication -cramping pain in the calf (femoral or popliteal disease), thigh or buttock (aorto-iliac disease) on walking, relieved by a few minutes' rest, at a similar distance each time.
• Leriche syndrome -aorto-iliac occlusion: buttock and thigh claudication, erectile dysfunction and absent femoral pulses.
• Differential diagnosis -spinal stenosis (neurogenic claudication -pain and numbness eased by bending forward or sitting, worse walking downhill, pulses normal), hip or knee arthritis, venous claudication, chronic compartment syndrome.
• Risk factors -smoking (strongest), diabetes, hypertension, high cholesterol, age, CKD, family history.
• Management of claudication (NICE CG147):
  • Stop smoking -most important.
  • Statin (atorvastatin 80 mg) and antiplatelet (clopidogrel 75 mg is first choice); in selected patients, low-dose rivaroxaban 2.5 mg twice daily with aspirin (COMPASS regimen).
  • Treat BP, diabetes, weight; foot care.
  • Supervised exercise programme -first-line (e.g. 2 hours a week for 3 months, walking to maximal pain).
  • Naftidrofuryl oxalate -if exercise doesn't help and the patient doesn't want revascularisation (review at 3–6 months).
  • Angioplasty or stenting -if exercise hasn't helped and imaging confirms suitable disease; bypass for longer or complex disease.
• Prognosis -the leg usually does well (few progress to amputation), but heart attacks and strokes are common -risk reduction saves lives.

Chronic Limb-threatening Ischaemia

• Chronic limb-threatening ischaemia (CLTI) -previously critical limb ischaemia -ischaemic rest pain for over 2 weeks, ulceration or gangrene, with objective evidence of poor blood flow (ABPI under about 0.4–0.5, ankle pressure under 50 mmHg, toe pressure under 30 mmHg).
• Rest pain -burning pain in the foot and toes, worse at night, relieved by hanging the leg out of bed or sleeping in a chair (gravity helps blood flow) -often with dependent leg swelling.
• Gangrene:
  • Dry gangrene -black, shrivelled, well demarcated, not infected; may auto-amputate.
  • Wet gangrene -infected, swollen, smelly, spreading; an emergency -antibiotics, debridement or amputation.
• WIfI classification -grades Wound, Ischaemia and foot Infection to estimate amputation risk.
• Management -urgent referral to vascular surgery (see the Vascular Society's PAD QIF -assessment within 5 days and revascularisation within 5 days for inpatients):
  • Revascularisation (angioplasty or bypass) to save the limb where possible.
  • Analgesia (often opioids), treat infection, wound care, best medical therapy.
  • Primary amputation if revascularisation isn't possible or won't help (extensive tissue loss, non-walker, very frail).

Revascularisation -Angioplasty and Bypass

Procedure	Best for	Points and risks
Angioplasty (± stent) -endovascular	Short narrowings or blockages, iliac disease, frail patients	Local anaesthetic, quick recovery; groin haematoma, false aneurysm, dissection, contrast nephropathy; restenosis
Femoro-popliteal or distal bypass	Long blockages in fit patients with a good vein	Own vein (great saphenous) lasts better than synthetic grafts; graft surveillance with duplex
Aorto-bifemoral bypass	Extensive aorto-iliac disease	Major surgery; good long-term patency
Femoral endarterectomy	Common femoral artery disease	Often combined with angioplasty (hybrid)
Extra-anatomic bypass (axillo-femoral, femoro-femoral crossover)	Unfit for aortic surgery or infected aortic grafts	Lower patency

• After revascularisation -antiplatelets (dual for a period after stenting), statin, smoking cessation, graft surveillance; watch for graft occlusion (sudden return of symptoms -urgent review).
• Graft infection -fever, wound discharge, false aneurysm, bleeding; serious (especially synthetic grafts); prolonged antibiotics and often graft removal.
• Before angiography -check kidney function, metformin (follow local contrast policy), anticoagulants, contrast allergy.

Acute Limb Ischaemia

• A sudden loss of blood supply threatening the limb -a surgical emergency (muscle and nerve damage become permanent after about 6 hours).
• The 6 Ps -pain (often first, out of proportion), pallor, pulselessness, perishingly cold, paraesthesia and paralysis (the last two are late and mean the limb is at serious risk).
• Causes:
  • Embolus -sudden onset, often from the heart (atrial fibrillation, recent MI, endocarditis) or an aneurysm; no history of claudication; normal pulses in the other leg.
  • Thrombosis in situ -on existing atherosclerosis; history of claudication; reduced pulses in the other leg; a collateral supply may make it less severe.
  • Others -graft or stent occlusion, popliteal aneurysm thrombosis, trauma, dissection, iatrogenic.
• Severity (Rutherford):
  • I -viable -no sensory loss or weakness.
  • IIa -marginally threatened -minimal sensory loss (toes).
  • IIb -immediately threatened -sensory loss beyond the toes, rest pain, mild to moderate weakness -needs urgent revascularisation.
  • III -irreversible -fixed mottling, profound paralysis, rigid muscles -amputation (or palliation).
• Management:
  • IV heparin (unfractionated, bolus then infusion) straight away to stop clot spreading; analgesia; oxygen; fluids.
  • Urgent vascular review; CT angiography if it won't delay treatment.
  • Embolus -embolectomy (Fogarty balloon catheter).
  • Thrombosis -angioplasty, bypass, or catheter-directed thrombolysis (for less threatened limbs).
  • Find the source -ECG (AF), echo; long-term anticoagulation after embolism.
• After revascularisation -watch for compartment syndrome and reperfusion injury.

Compartment Syndrome and Reperfusion

• Acute compartment syndrome -raised pressure in a closed muscle compartment cuts off blood flow:
  • Causes -fractures (tibia, forearm), crush injury, reperfusion after limb ischaemia, tight casts or dressings, burns, prolonged immobility (drug overdose, long surgery), IV drug injection.
  • Pain out of proportion to the injury, pain on passive stretching of the muscles (earliest sign), a tense swollen compartment, paraesthesia; pulses are usually present until late.
  • Diagnosis is clinical; compartment pressure measurement if unclear (a delta pressure -diastolic BP minus compartment pressure -under 30 mmHg suggests compartment syndrome).
  • Management -remove all dressings and casts down to skin, keep the limb at heart level (not raised), oxygen, analgesia, fluids; urgent fasciotomy (all four compartments in the lower leg).
  • Complications if missed -muscle necrosis, Volkmann's contracture, nerve damage, amputation, kidney failure.
• Reperfusion injury -when blood returns to dead or dying muscle:
  • High potassium, metabolic acidosis (arrhythmias, cardiac arrest).
  • Rhabdomyolysis -myoglobin causes AKI; very high CK, dark urine.
  • Treat with IV fluids (aim for good urine output), correct potassium and acidosis, monitor ECG and U&E closely.

Abdominal Aortic Aneurysm

• Abdominal aortic aneurysm (AAA) -an infrarenal aorta of 3 cm or more in diameter.
• Risk factors -men, age over 65, smoking, family history, hypertension, atherosclerosis, connective tissue disorders. Women are affected less often but their aneurysms rupture at smaller sizes.
• Usually symptomless -found on screening or by chance; sometimes a pulsatile, expansile mass above the umbilicus; back or abdominal pain (symptomatic -urgent).
• NHS AAA Screening Programme -a single ultrasound for men in their 65th year; older men can self-refer.
• Surveillance by size (NICE NG156):

  Diameter	Action
  3.0–4.4 cm (small)	Ultrasound every 12 months
  4.5–5.4 cm (medium)	Ultrasound every 3 months
  5.5 cm or more, or growing over 1 cm a year, or symptomatic	Refer to vascular surgery -within 2 weeks (large) or urgently (symptomatic) -consider repair

• Best medical therapy -stop smoking, statin, antiplatelet, BP control; driving rules (DVLA -car drivers should inform the DVLA at 6 cm or more, and must not drive at 6.5 cm or more).
• Repair options for unruptured AAA (NICE NG156):
  • Open surgical repair -preferred for most fit patients (fewer later re-interventions).
  • EVAR (endovascular aneurysm repair -a stent graft through the groins) -lower early risk but needs lifelong imaging surveillance (endoleaks) and more re-interventions; NICE advises against EVAR for unruptured AAA except when open repair is unsuitable (e.g. hostile abdomen, anaesthetic risk) -complex local decision.

Ruptured AAA and EVAR

• Ruptured AAA -sudden severe abdominal, back or loin pain, collapse, shock, a pulsatile mass (not always felt). Mortality is very high (most die before reaching hospital).
• Often misdiagnosed as renal colic (an older man with first-ever "renal colic" has a AAA until proven otherwise), diverticulitis, or MI.
• Management:
  • Call the vascular team immediately; two large-bore cannulas; crossmatch (activate major haemorrhage protocol).
  • Permissive hypotension -keep systolic around 70–90 mmHg if the patient is conscious (avoid over-filling -it worsens bleeding).
  • CT angiography if stable enough -guides EVAR suitability; if unstable with a known AAA -straight to theatre.
  • EVAR (if anatomy suits -NICE favours EVAR for ruptured AAA, especially in women and men over 70) or open repair.
  • Some patients are too frail -palliative care discussion with family.
• Complications after repair -bleeding, AKI, MI, abdominal compartment syndrome, colonic ischaemia (bloody diarrhoea -inferior mesenteric artery), spinal cord ischaemia (paraplegia), limb ischaemia (trash foot from emboli), multi-organ failure.
• Endoleaks after EVAR -blood still filling the aneurysm sac:
  • Type I -leak at the ends of the graft (seal failure) -treat.
  • Type II -back-filling from side branches (lumbar arteries, IMA) -commonest; watch unless the sac grows.
  • Type III -graft components separate or tear -treat.
  • Type IV (graft porosity) and V (endotension -sac growth without visible leak).
• Aorto-enteric fistula -GI bleeding (often a small "herald bleed") in a patient with an aortic graft -emergency.

Other Aneurysms and Aortic Dissection

• Popliteal aneurysm -the commonest peripheral aneurysm; often bilateral and linked with AAA (check both); risk is thrombosis or embolism (acute limb ischaemia) rather than rupture; repair if 2 cm or more or with thrombus.
• Femoral false aneurysm (pseudoaneurysm) -after arterial puncture (angiography, IV drug use); a pulsatile groin lump; ultrasound-guided thrombin injection or surgery; in injecting drug users, may be infected -risk of torrential bleeding.
• Mycotic (infected) aneurysm -endocarditis, salmonella, staphylococcus; fever, rapid growth; antibiotics and surgery.
• Thoracic and thoracoabdominal aneurysms -Marfan, Ehlers–Danlos, bicuspid aortic valve, syphilis (historic); TEVAR or open repair (risk of paraplegia).
• Visceral and splenic artery aneurysms -risk of rupture in pregnancy.
• Aortic dissection -a tear in the inner lining:
  • Sudden tearing chest or back pain, BP difference between arms, pulse deficits, new aortic regurgitation, stroke, limb or gut ischaemia.
  • Stanford type A (involves the ascending aorta) -emergency cardiothoracic surgery.
  • Type B (descending only) -BP control (IV labetalol, target systolic about 100–120 mmHg and heart rate under 60), with TEVAR if complicated (rupture, malperfusion, uncontrolled pain).
  • See the Aortic and Peripheral Arterial Disease chapter.

Carotid Artery Disease

• Carotid stenosis -atherosclerosis at the carotid bifurcation; a cause of TIA and ischaemic stroke (emboli).
• Symptoms (in the carotid territory) -weakness or numbness of the face, arm or leg on the opposite side, speech problems (dominant hemisphere), amaurosis fugax (temporary loss of vision in one eye -"a curtain coming down").
• Investigation -carotid duplex ultrasound for everyone with a TIA or non-disabling stroke who would be fit for surgery; CTA or MRA to confirm.
• Carotid endarterectomy (NICE NG128):
  • Offer for symptomatic stenosis of 50–99% (NASCET criteria) in suitable patients.
  • Timing -assess within 1 week of symptoms and operate within 2 weeks (the risk of a further stroke is highest early on).
  • Plus best medical therapy -antiplatelets, high-dose statin, BP control, stop smoking.
  • Carotid stenting -an alternative in selected patients (higher early stroke risk, especially in older people).
  • Asymptomatic stenosis -usually best medical therapy alone; surgery only in selected cases.
• Complications of endarterectomy -stroke (about 2–3%), MI, neck haematoma (airway risk), cranial nerve injury (hypoglossal -tongue deviates towards the side of injury; marginal mandibular -droopy lip; recurrent laryngeal -hoarseness; glossopharyngeal), hyperperfusion syndrome (headache, seizures, bleeding -control BP).
• Carotid dissection -neck pain, Horner's syndrome, stroke in a younger person (after neck trauma or manipulation) -antiplatelets or anticoagulation (see the Neurology chapters).

Mesenteric and Renal Artery Disease

• Acute mesenteric ischaemia -severe abdominal pain out of proportion to the examination, often with AF, raised lactate (late); CT angiography; revascularisation (embolectomy, stenting) and resection of dead bowel -see the Acute Abdomen page.
• Chronic mesenteric ischaemia ("intestinal angina"):
  • Pain 15–60 minutes after eating, fear of eating, weight loss, often with widespread atherosclerosis and smoking; may have an abdominal bruit.
  • Usually two of the three main gut arteries (coeliac, SMA, IMA) are narrowed.
  • CT angiography or duplex; stenting (or bypass) -treat to prevent acute bowel infarction.
• Median arcuate ligament syndrome -compression of the coeliac artery; post-meal pain and weight loss in younger people.
• Renal artery stenosis:
  • Atherosclerotic (older, vascular disease) -resistant hypertension, flash pulmonary oedema, worsening kidney function (especially after starting an ACE inhibitor or ARB -creatinine rise over 30%), asymmetric kidneys.
  • Fibromuscular dysplasia -young women, "string of beads" on imaging -angioplasty works well.
  • Atherosclerotic disease -mostly best medical therapy; stenting only for selected cases (flash pulmonary oedema, rapidly declining kidney function).

The Diabetic Foot

• Why feet ulcerate in diabetes -neuropathy (loss of protective feeling; deformity; dry skin), peripheral arterial disease (often below the knee and calcified -pulses and ABPI may mislead), and infection.
• Neuropathic ulcers -at pressure points (under the metatarsal heads, heel), painless, with callus, warm foot with good pulses.
• Ischaemic ulcers -on the toes and edges of the foot, painful (unless neuropathy), cool foot, poor pulses.
• Diabetic foot infection -from mild cellulitis to deep abscess and osteomyelitis (suspect if a probe touches bone, an ulcer won't heal, or a "sausage toe"); X-ray, MRI; send deep tissue samples (not swabs) where possible; antibiotics by severity (NICE NG19).
• Charcot foot (neuropathic arthropathy) -a hot, red, swollen foot in a person with neuropathy, often without much pain and sometimes after minor injury -mistaken for cellulitis or gout; the foot collapses (rocker-bottom deformity) -urgent offloading (non-removable cast) and specialist foot team; MRI.
• Emergency referral to the multidisciplinary foot team (NICE NG19) -ulcer with fever or sepsis, limb ischaemia, deep infection, suspected gas gangrene, new Charcot foot.
• Management -offloading, debridement, wound care, antibiotics, glucose control, revascularisation if ischaemic, surgery (drainage, debridement, minor amputation).
• Prevention -annual foot check for all people with diabetes (sensation with 10 g monofilament, pulses, skin, deformity) -risk-stratified follow-up; good footwear; podiatry; patient education.

Amputation

• Indications -"dead, dangerous or a damn nuisance":
  • Dead -gangrene, irreversible ischaemia, revascularisation impossible.
  • Dangerous -spreading sepsis (wet gangrene, necrotising infection), malignancy.
  • Damn nuisance -intractable rest pain, a useless painful limb, non-healing wounds.
• Levels -toe or ray (forefoot), transmetatarsal, below-knee (transtibial) -best chance of walking with a prosthesis, above-knee (transfemoral) -heals more reliably but walking is much harder; through-knee.
• Choosing the level -healing potential (blood supply, skin, infection) versus function; preserve the knee where possible.
• Before surgery -counselling, analgesia (epidural or nerve catheters may reduce phantom pain), physio and occupational therapy input, VTE prophylaxis, antibiotics.
• Complications:
  • Wound breakdown and infection, stump necrosis, need for re-amputation at a higher level.
  • Phantom limb sensation and pain -common; gabapentin, amitriptyline, mirror therapy.
  • Flexion contractures (hip and knee -stop prosthesis use) -early positioning and physio.
  • VTE, MI, falls, depression, high mortality (poor overall health).
• Rehabilitation -limb-fitting centre, prosthetics, wheelchair assessment, home adaptations.

Leg Ulcers

Feature	Venous ulcer	Arterial ulcer	Neuropathic ulcer
How common	Commonest (about 70%)	About 10–20%	Diabetes
Site	Gaiter area -above the medial malleolus	Toes, heel, pressure points, shin	Pressure points -under metatarsal heads, heel
Appearance	Large, shallow, irregular edges, sloughy or granulating base, exudate	Small, deep, "punched out", pale or necrotic base	Punched out with surrounding callus
Pain	Mild to moderate, eased by elevation	Painful, worse at night and on elevation	Painless
Surrounding skin	Haemosiderin staining (brown), lipodermatosclerosis (hard, "inverted champagne bottle"), varicose eczema, atrophie blanche, oedema	Cold, pale, shiny, hairless, absent pulses	Warm, dry, reduced sensation
Treatment	Compression (after ABPI over 0.8), elevation, exercise, treat venous reflux	Revascularisation; no compression	Offloading, debridement, glucose control

• Always check ABPI before compression -compression on an ischaemic leg can cause pressure necrosis and amputation (full compression usually with ABPI 0.8–1.3; reduced compression with specialist advice for 0.5–0.8; none under 0.5).
• Mixed ulcers -venous and arterial disease together -common in older people.
• Other causes -pyoderma gangrenosum (rapid, very painful, purple undermined edges -IBD, rheumatoid; avoid debridement -it worsens), vasculitis, squamous cell carcinoma (Marjolin's ulcer -in a long-standing ulcer; biopsy non-healing or unusual ulcers), basal cell carcinoma, sickle cell disease, infection, trauma.
• Refer if not healing after 2 weeks of treatment, or atypical features (NICE CKS); biopsy ulcers not healing after about 12 weeks or with atypical features.

Varicose Veins and Chronic Venous Disease

• Varicose veins -dilated, tortuous superficial veins due to faulty valves (reflux), usually in the great or small saphenous system.
• Risk factors -age, female sex, pregnancy, family history, obesity, standing occupations, previous DVT (post-thrombotic).
• Symptoms -aching, heaviness, itching, swelling, cramps, worse at the end of the day and after standing.
• CEAP classification -C0 (no signs) to C6 (active ulcer); C4 skin changes (pigmentation, eczema, lipodermatosclerosis), C5 healed ulcer.
• Referral to a vascular service (NICE CG168):
  • Symptomatic primary or recurrent varicose veins.
  • Skin changes (pigmentation, eczema), superficial vein thrombosis with suspected venous incompetence.
  • Venous ulcer (healed or active -a non-healing ulcer over 2 weeks).
  • Bleeding varicose veins -urgent (lie down, raise the leg, direct pressure).
• Investigation -duplex ultrasound confirms reflux and maps veins.
• Treatment (NICE CG168):
  • 1st -endothermal ablation (radiofrequency or laser) under local anaesthetic.
  • 2nd -ultrasound-guided foam sclerotherapy.
  • 3rd -open surgery (ligation and stripping).
  • Compression stockings -only if interventional treatment is unsuitable (not as a substitute for referral); in pregnancy, compression for symptom relief (intervention avoided).
• Complications of treatment -bruising, phlebitis, nerve damage (saphenous and sural nerves -numbness), skin staining, DVT (rare), recurrence.
• Superficial thrombophlebitis -a tender, red, hard cord along a vein; ultrasound if near the saphenofemoral junction (DVT risk); anticoagulation (fondaparinux) for longer segments or close to the deep system.
• Post-thrombotic syndrome -chronic swelling, pain and ulcers after DVT; compression, leg elevation.

Upper Limb, Thoracic Outlet and Raynaud's

• Thoracic outlet syndrome -compression of structures as they pass between the neck and arm (cervical rib, scalene muscles, first rib):
  • Neurogenic (commonest) -pain, paraesthesia (often the ulnar side of the hand), weakness, wasting of the small hand muscles.
  • Venous -Paget–Schroetter syndrome -effort-induced axillary or subclavian vein thrombosis in a young, active person (swimmers, weightlifters) -swollen, blue, heavy arm; anticoagulation ± thrombolysis and first rib resection.
  • Arterial (rare) -subclavian aneurysm or narrowing, emboli to the hand.
• Subclavian steal syndrome -subclavian stenosis before the vertebral artery; arm exercise "steals" blood from the brain (dizziness, syncope); BP difference over 15–20 mmHg between arms.
• Raynaud's phenomenon -episodes of fingers turning white, then blue, then red with cold or stress:
  • Primary (Raynaud's disease) -young women, both hands, no tissue damage, normal nailfold capillaries.
  • Secondary -older onset, one-sided, ulcers or gangrene, features of systemic sclerosis (sclerodactyly, abnormal nailfold capillaries), SLE, vibration tools, beta-blockers, cervical rib -check ANA and autoantibodies.
  • Keep warm (gloves), stop smoking, avoid triggers; nifedipine (modified-release) if needed; specialist referral for secondary cases or digital ulcers (iloprost, sildenafil, bosentan).
• Hand ischaemia -emboli (AF, subclavian aneurysm), arterial injection (IV drug use), vasculitis, trauma -urgent vascular review.
• Hyperhidrosis -excessive sweating; topical aluminium chloride, iontophoresis, botulinum toxin; thoracic sympathectomy rarely (compensatory sweating elsewhere).

Vascular Access and Vascular Trauma

• Arteriovenous fistula (AVF) for haemodialysis -an artery joined directly to a vein (radiocephalic at the wrist, brachiocephalic at the elbow); takes 6–8 weeks to mature; a thrill and bruit mean it is working.
• Protect the fistula arm -no BP cuffs, blood tests or cannulas in that arm (and the non-dominant arm in pre-dialysis patients -"save the veins").
• Fistula complications -thrombosis (loss of thrill -urgent), stenosis, infection, aneurysm, bleeding (pressure; can be life-threatening), steal syndrome (cold, painful hand -ischaemia), high-output heart failure (large fistulas). See the Dialysis and Transplant chapter.
• AV grafts (synthetic) and tunnelled dialysis catheters when veins are poor.
• Vascular trauma:
  • Hard signs -pulsatile bleeding, expanding haematoma, absent distal pulses, bruit or thrill, signs of ischaemia → straight to theatre (or angiography/hybrid suite).
  • Soft signs -reduced pulses, small stable haematoma, nerve injury near a vessel, history of significant bleeding → CT angiography; ABPI under 0.9 in the injured limb suggests arterial injury.
  • Control bleeding -direct pressure, wound packing, tourniquet for life-threatening limb bleeding; temporary shunts; repair or graft.
  • Knee dislocation and supracondylar fractures (children) -high risk of popliteal and brachial artery injury -check pulses and ABPI.
  • Watch for compartment syndrome after repair (consider prophylactic fasciotomy).
• Iatrogenic injury -groin false aneurysm, dissection or bleeding after angiography and catheter procedures; retroperitoneal haematoma (back pain and falling Hb after femoral puncture).

Vascular Conditions at a Glance

Condition	Key clues	Management
Intermittent claudication	Calf pain on walking eased by rest; ABPI 0.5–0.9	Stop smoking, statin, clopidogrel, supervised exercise
CLTI	Rest pain at night, ulcers, gangrene; ABPI under 0.5	Urgent revascularisation or amputation
Acute limb ischaemia	6 Ps; AF (embolus)	IV heparin, embolectomy or revascularisation
Compartment syndrome	Pain out of proportion, pain on passive stretch	Remove dressings, urgent fasciotomy
AAA	Pulsatile expansile mass; 3 cm or more	Surveillance; refer at 5.5 cm or growing fast
Ruptured AAA	Back pain, collapse, shock in an older man	Permissive hypotension, CT if stable, EVAR or open
Popliteal aneurysm	Prominent popliteal pulse; acute ischaemia	Repair if 2 cm or more; check for AAA
Symptomatic carotid stenosis	TIA or amaurosis fugax; 50–99% stenosis	Endarterectomy within 2 weeks
Chronic mesenteric ischaemia	Post-meal pain, fear of eating, weight loss	CTA; stenting
Charcot foot	Hot, swollen foot in neuropathy	Urgent offloading cast, foot team
Venous ulcer	Medial gaiter, shallow, haemosiderin	Compression after ABPI; treat reflux
Arterial ulcer	Punched out, painful, toes	Revascularise; no compression
Varicose veins	Symptomatic dilated veins, skin changes	Duplex; endothermal ablation
Paget–Schroetter	Swollen blue arm after exertion	Anticoagulate ± thrombolysis, rib resection
Fistula thrombosis	Loss of thrill in dialysis fistula	Urgent declot or revision

Spot the Diagnosis

Clue	Diagnosis
Calf pain after 200 m, relieved by standing still for 2 minutes	Intermittent claudication
Leg pain on walking eased by sitting or bending forward, normal pulses	Spinal stenosis (neurogenic claudication)
Buttock claudication, erectile dysfunction and absent femoral pulses	Leriche syndrome (aorto-iliac occlusion)
ABPI 1.6 in a man with diabetes and CKD	Calcified arteries -falsely high ABPI
Foot pain at night relieved by hanging the leg out of bed	Ischaemic rest pain -CLTI
Sudden cold, white, pulseless leg in a woman with AF	Acute embolic limb ischaemia
Fixed mottling and a rigid calf 2 days after onset	Irreversible ischaemia (Rutherford III)
Severe pain on passively moving the toes after a tibial fracture	Compartment syndrome
High potassium and dark urine after embolectomy	Reperfusion injury and rhabdomyolysis
A 4.8 cm infrarenal aorta in a 70-year-old	Medium AAA -3-monthly ultrasound
First episode of "left renal colic" in a 72-year-old male smoker with hypotension	Ruptured AAA until proven otherwise
Bloody diarrhoea 2 days after open AAA repair	Colonic ischaemia
Growing aneurysm sac after EVAR with filling from lumbar arteries	Type II endoleak
Haematemesis in a man with a previous aortic graft	Aorto-enteric fistula
Pulsatile groin lump after coronary angiography	Femoral false aneurysm
Transient loss of vision in one eye like a curtain	Amaurosis fugax -carotid duplex
Tongue deviates to the right after right carotid endarterectomy	Right hypoglossal nerve injury
Weight loss and abdominal pain after meals in a smoker with PAD	Chronic mesenteric ischaemia
Creatinine rises 40% after starting ramipril, with flash pulmonary oedema	Bilateral renal artery stenosis
Hot, red, swollen, painless foot in a man with diabetic neuropathy	Charcot foot
Painless ulcer under the first metatarsal head with callus	Neuropathic ulcer
Shallow ulcer above the medial malleolus with brown staining	Venous ulcer
Rapidly growing painful ulcer with purple undermined edges in a patient with UC	Pyoderma gangrenosum
Raised, everted edge growing in a 20-year-old venous ulcer	Marjolin's ulcer (SCC) -biopsy
Tender red cord along the thigh near the groin	Superficial thrombophlebitis -scan for DVT
Swollen, blue arm in a young swimmer	Paget–Schroetter syndrome
Dizziness when using the left arm, left arm BP 30 mmHg lower	Subclavian steal syndrome
Cold, painful hand after a new brachiocephalic fistula	Steal syndrome

Exam-style Scenarios

1. A 66-year-old man who smokes has calf pain after walking about 150 metres, eased by resting for a few minutes. His foot pulses are weak and ABPI is 0.7. He has hypertension.
Answer: Intermittent claudication from peripheral arterial disease.

• Stop smoking (support and pharmacotherapy); atorvastatin 80 mg; clopidogrel 75 mg; BP and diabetes control.
• Supervised exercise programme first; naftidrofuryl if exercise doesn't help and he doesn't want intervention.
• Duplex imaging and angioplasty or bypass if symptoms remain limiting after exercise; warn about rest pain, ulcers or colour change (urgent review).

2. A 79-year-old woman with atrial fibrillation (not anticoagulated) has 3 hours of sudden severe pain in her right leg. The leg is cold and white with no pulses below the femoral; she has reduced sensation in the foot but can move her toes.
Answer: Acute embolic limb ischaemia (Rutherford IIb -immediately threatened).

• IV unfractionated heparin now, analgesia, oxygen, IV fluids; urgent vascular surgery review.
• Embolectomy (Fogarty catheter) urgently; CT angiography only if it won't delay surgery.
• After surgery -watch for compartment syndrome and reperfusion injury (potassium, CK, urine output); long-term anticoagulation for AF.

3. A 74-year-old man collapses at home with sudden severe back pain. In ED he is pale and sweaty, BP 80/50, pulse 120, and has a tender pulsatile abdominal mass. He is conscious and talking.
Answer: Ruptured abdominal aortic aneurysm.

• Call the vascular surgeon and anaesthetist immediately; activate the major haemorrhage protocol; two large-bore cannulas.
• Permissive hypotension (systolic 70–90 mmHg while conscious) -avoid over-filling.
• CT angiography if stable enough to plan EVAR; otherwise straight to theatre for open repair; frank discussion if very frail.

4. A 70-year-old man has 20 minutes of weakness in his right hand and slurred speech, now fully resolved. Carotid duplex shows 80% stenosis of the left internal carotid artery.
Answer: Symptomatic left carotid stenosis after a TIA.

• Aspirin (then clopidogrel long term), high-intensity statin, BP control, stop smoking (see the Stroke chapter).
• Urgent vascular referral -carotid endarterectomy within 2 weeks of symptoms.
• Consent for stroke (about 2–3%), MI, haematoma and cranial nerve injury (hypoglossal, marginal mandibular, recurrent laryngeal).

5. A 68-year-old woman has a 3-month shallow ulcer above her left medial malleolus with surrounding brown skin and varicose veins. Foot pulses are present; ABPI is 1.0.
Answer: Venous leg ulcer.

• Multilayer compression bandaging (ABPI 1.0 -safe), leg elevation, exercise, skin care (emollients, treat varicose eczema).
• Refer to a vascular service (NICE CG168) -duplex for superficial venous reflux; endothermal ablation speeds healing and reduces recurrence.
• Re-check ABPI regularly; biopsy if atypical or not healing (exclude Marjolin's ulcer); long-term compression stockings after healing.

Key Points

• Every vascular patient needs risk reduction -stop smoking, statin, antiplatelet, BP and diabetes control.
• ABPI 0.9–1.3 normal, 0.5–0.9 PAD, under 0.5 severe; over 1.3 means calcified arteries.
• Claudication -supervised exercise first; clopidogrel and statin; intervention if still limiting.
• Spinal stenosis is eased by bending forward; claudication by standing still.
• Rest pain eased by hanging the leg down, ulcers or gangrene -CLTI -urgent referral.
• Acute limb ischaemia -the 6 Ps; IV heparin and urgent revascularisation; paralysis and sensory loss mean the limb is at serious risk.
• Compartment syndrome -pain on passive stretch; pulses may be present; urgent fasciotomy.
• AAA -screening for men at 65; 12-monthly scans at 3.0–4.4 cm, 3-monthly at 4.5–5.4 cm; refer at 5.5 cm or growth over 1 cm/year.
• An older man with first "renal colic" -think ruptured AAA.
• Ruptured AAA -permissive hypotension, early vascular call, EVAR where suitable.
• EVAR needs lifelong surveillance; type II endoleaks are the commonest.
• Popliteal aneurysms threaten the limb by thrombosis -check for AAA too.
• Symptomatic carotid stenosis 50–99% -endarterectomy within 2 weeks.
• Post-meal pain, fear of eating and weight loss -chronic mesenteric ischaemia.
• Hot swollen foot in neuropathy -Charcot until proven otherwise.
• Check ABPI before compression; never compress an ischaemic leg.
• Varicose veins -endothermal ablation first-line; compression only if intervention is unsuitable.
• No cuffs, bloods or cannulas in a fistula arm.

Guidelines and Further Reading

• NICE CG147: Peripheral arterial disease -diagnosis and management
• Vascular Society of Great Britain and Ireland: Peripheral Arterial Disease Quality Improvement Framework
• Global Vascular Guidelines on the management of chronic limb-threatening ischaemia
• European Society for Vascular Surgery: Acute limb ischaemia; Abdominal aorto-iliac artery aneurysms
• NICE NG156: Abdominal aortic aneurysm -diagnosis and management
• NHS AAA Screening Programme
• NICE NG128: Stroke and TIA in over 16s -diagnosis and initial management
• NICE NG19: Diabetic foot problems -prevention and management
• NICE CG168: Varicose veins -diagnosis and management
• SIGN 120: Management of chronic venous leg ulcers; NICE CKS: Leg ulcer -venous
• BOAST: Diagnosis and management of compartment syndrome of the limbs
• DVLA: Assessing fitness to drive -aortic aneurysm
• BNF -for current doses