Carotid Disease

Urgent referral indicated for:

• Any TIA or stroke – should be referred to on call surgeon or directly to emergency department.

Non urgent referral:

• TIA or stroke more than 6 months ago
• High grade asymptomatic carotid stenosis.

As vascular surgeons, we are concerned with any patient who has had a TIA or stroke due to carotid stenoses. Generally, all patients with a >50% stenosis on ultrasound are considered for carotid endarterectomy. In the interim, while awaiting review these patients should be on a statin and aspirin. Asymptomatic disease is usually managed non operatively in the first instance. Most large studies quote the risk for asymptomatic disease >60% around 11% over 5 years. Similarly, the surgical management of asymptomatic disease in females is quite often also managed conservatively as many of the early large studies failed to demonstrate any benefit for women to undergo carotid intervention.

Currently, the Statewide Referral Criteria state that disease less than 70% percent does not require specialist (in hospital) review in the absence of symptoms. Patients can be reassured that generally this situation is safe. However, if they would like a specialist opinion this could always be facilitated. It would also be reasonable to perform surveillance duplex on these patients annually for two years, and if there is no progression of stenosis then this can cease.

Finally, vertigo and dizziness are not associated with carotid disease and an alternate cause should be considered. Further, carotid endarterectomy is not a proven treatment for these complaints. Isolated stenoses of the external carotid artery (which supplies the face) do not require surgical treatment. These patients should also be treated with best medical therapy (aspirin/statin/blood pressure and smoking cessation).

Varicose veins

This area is potentially one of the most confusing areas for GPs to navigate. There are a wide variety of polices and practices across Melbourne and Victoria. Similarly, some hospitals have adopted modern minimally invasive techniques and treatments for varicose veins which allow them to  be treated in some instances under local anaesthethic, while some hospitals are still only provided traditional open surgery. It is important to realise that especially due to COVID-19, wait times are likely escalating in many centres. Similarly, the ubiquity of varicose veins make it simply impossible for the public sector to be able to manage everyone. The reality is, for those with varicose veins with skin changes or visible ankle oedema that their best option is often to consider private treatment. 

Again, there are referral criteria for varicose veins. These are veins that are classified greater than C3 severity. This means varicose veins causing visible ankle oedema, haemosiderin deposition or previous ulceration. Superficial thrombophlebitis is also considered an indication for surgery in the public sector. Many public institutions receive referrals for patients with varicose vein, where the referral states “patient would like to consider surgical options” or “for surgical opinion.” Some hospitals are more strict than others. Some will reject these referrals for insufficient information, or others will accept these referrals but understandbly they go to the bottom of the queue. Patients, even uninsured ones should be given the option to pay to see a surgeon in their rooms for an opinion. This generally takes the stress out of the public sector and will allow the patient to at least get an opinion without having to wait several months (or even years).