Surgery: Vascular surgery

• Arterial disease: Vascular Assessment and ABPI | Peripheral Arterial Disease and Claudication | Chronic Limb-threatening Ischaemia | Revascularisation — Angioplasty and Bypass | Acute Limb Ischaemia | Compartment Syndrome and Reperfusion | Abdominal Aortic Aneurysm | Ruptured AAA and EVAR | Other Aneurysms and Aortic Dissection | Carotid Artery Disease | Mesenteric and Renal Artery Disease
• Feet, veins and access: The Diabetic Foot | Amputation | Leg Ulcers | Varicose Veins and Chronic Venous Disease | Upper Limb, Thoracic Outlet and Raynaud's | Vascular Access and Vascular Trauma
• Revision: Vascular Conditions at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 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?

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

• 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

• 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