GP Clinical Practice Guidelines
Having previously managed the outpatient referrals for a busy public vascular clinic, I understand the difficulty there is for GPs in trying to navigate through the mine field which is vascular outpatient care. Similarly, access can appear as sometimes restricted due to the COVID-19 pandemic. This page is meant to guide GPs through understanding the management of key and common vascular issues as well as to when to refer patients but also how.
Ways to refer
- 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).
Management of asymptomatic carotid disease
Asymptomatic carotid disease is defined as a presence of a carotid stenosis without an ipsilateral TIA or stroke within the proceeding 6 months. The treatment of asymptomatic disease is first and foremost "best medical therapy". This includes:
- Statin/lipid lowering therapy (even if serum levels normal ie seeking plieotropic effects of statins)
- Smoking cessation
- Optimisation of glycaemic control
- Control of hypertension
The management of asymptomatic carotid disease remains controversial for a number of reasons, but mostly as a number of the pivotal trials (ie ACAS and ACST) were conducted in area of vastly different medical therapy - in particular prior to the widespread adoption of statin therapy. However, what we do know from these studies, is that the likely benefit from surgery on an asymptomatic carotid is cumulative over time and modest at best. These larger studies (although outdated) suggest an absolute stroke risk reduction of 1% per year. An alternative summary of the statistics is that the number needed to treat is 33. Further, the benefit in women is even more modest. As such, the statewide referral criteria do not recommend specialist review for a stenosis of less than 70% for these reasons. GPs can be rest assured that the lesions are generally safe. What
Should I performing regular ultrasound surveillance of carotid lesions?
In short, the answer to this question is again controversial. Studies have failed to demonstrate any benefit of on going ultrasound surveillance of asymptomatic lesions. Some studies have demonstrated various "high risk" features of plaque which may indicate that they may not behave benignly, but again these are subtle features that cannot be reliably reproduced. In short, some surgeons will use progression on duplex ultrasound as an indication for surgery and if an asymptomatic carotid stenosis has been detected >70% it would be reasonable to counsel the patient about risks and benefits, and if appropriate perform surveillance for a short period of time (around 2 years) and if stable consider discharge.
I've heard a carotid bruit what should I do?
Generally carotid bruits are found during clinical examination. This may have been precipitated by a complaint of dizziness or vertigo. In almost all instances these will be associated with a diagnosis of asymptomatic carotid disease. In this instance, it would be reasonable to perform an initial carotid duplex, but management should follow the previously described pathway for asymptomatic disease.
- Acute thrombophlebitis
- Active venous ulceration with infection – may benefit from acute hospital admission to control symtpoms
Non Urgent – Public referral
- Chronic ulceration
- Skin changes
- Venous eczema
- Venous oedema
Non Urgent – Private referral
- No complications
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).
- Telangectasia: <1mm
- Reticular viens: 1-3mm
- Varicose veins: >3mm
Management options for varicose veins in the last few years have changed drastically. In particular we have seen the explosion in endovenous options that permit patients to pursue more minimally invasive options than ever before. Despite this, there is still a role for open surgery in some patients, and some patients are not best treated with endovenous options. Consequently, the vascular surgeon is still best to advise patients on best course of action going forward.
What is the preferred treatment modality?
Universally, most will prefer to offer patients minimally invasive treatments first and foremost. Typically the ‘axial’ incompetence is dealt with primarily- meaning the long or short saphenous vein feeding the incompetence needs to be ablated. In most centres, either radio frequency ablation (RFA) or endovenous ablation (EVLT) is offered. Despite popular belief this treatment is available to most patients in the public hospital system if they meet certain requirements. In particular, they need to have C3 or greater disease. Anatomic factors are usually the rate limiting step in whether or not a patient is suitable for endovenous treatment. The long or short saphenous vein needs to be at least 2mm wide, and no more than 20mm wide. It needs to be at least 5mm deep to the skin, or within a subfascial plane as to avoid skin burns. Similarly, if the vein is too tortuous the radiofrequency ablation or laser probe cannot be advanced through the target vein.
How do I assess patients in the GP office?
It is first important to realise that varicose veins a generally a progressive disease. In the first instance a detailed history noting any previous operation is always worthwhile. The mainstay of preoperative treatment is always compression stockings. However, one needs to ensure correct arterial perfusion prior to placing a patient in compression. Generally young fit and healthy patients do not have peripheral arterial disease, but it is always worth while clearly documenting lower limb pulses. For more elderly patients with potential PAD it is important to again check pulses and perform an ankle brachial index. We are comfortable ordering class II compression if the ABI is >0.9 and class I if the ABI is between 0.8 and 0.9. Patients can obtain stockings from many providors, but generally they can be readily obtained at a local pharmacy.
Patients often have difficulty wearing compression, particularly if they are overweight or elderly. Thigh high over knee high compression does not add a lot of benefit, but our general advice is, if patients are fit and young then thigh high are appropriate, other wise knee high are suitable. We would also recommend patients apply them first thing in the morning after they get up or shower. They do not need to be worn at night. The benefit of compression is undeniable. It is as effective as surgery, and patients should experience immediate relief of discomfort once worn. In our practice we do not see much added benefit of over the counter varicose vein creams, and do not recommend them for our patients.
We would recommend a venous incompetence study for any patient with varicose veins. The USS can be time consuming and involves examining superficial and deep veins for reflux. The patient is examined both lying and sitting and the flow in the veins is augmented by manual compression. The sonographer then looks for retrograde flow (or flow towards the feet). If retrograde flow is seen exceeding 500ms this is considered diagnostic. Usually the source of reflux is the saphenofemoral junction for primary varicose veins, and the incompetent vein is long saphenous vein feeding the varicose veins which are seen clinically. In a lab with experience planning patients for varicose vein treatment, they may note the size and depth of the vein as well as tortuosity.
Sclerotherapy involves injecting a chemical directly into a vein to induce damage and subsequent occlusion or collapse. In Australia Aethoxysclerol is the main sclerosant in use. It is a detergent agent that can either be injected directly or as a foam into any vein: telangectasia, reticular vein or varicose vein. It avoids the need for the traditional ‘stab avlusion’). However where is struggles is for the primary treatment of long saphenous and to a lesser extent short saphenous incompetence. There is a doseage limit per sitting, and complications related to embolisation of the sclerosant has been seen. The risks go up as the dosage increases. Similarly, it has a much inferior success rate when compared to endovenous ablation or open surgery.
Non surgical treatment centres & the public system.
As outlined in this article, there are various treatment options available to patients. Currently, there is a role for each treatment strategy whether that be open or endovenous. Patients need to be assessed by a vascular surgeon prior to treatment who can offer all options. We would emphasise this to be especially important if ultrasound revealed long or short saphenous vein incompetence. Typically, despite most public hospital networks introducing minimally invasive options wait times to get into clinics are still long. Some hospitals in Victoria have introduced varicose vein only clinics to help expedite getting patients seen.
What about deep system incompetence?
Deep system incompetence is an especially difficult treatment scenario. Often these patients have a history of lower limb trauma or deep venous thrombosis. Depsite many authors from around the world attempting methods of deep venous reconstruction, they have failed to offer the longevity required for a durable procedure. Patients with varicose veins and superficial incompetence as well as deep venous incompetence are still candidates in some situations for treatment, as research shows that they can still have some symptom benefit from treating their varicose veins.
Peripheral Vascular Disease
- Significant forefoot ulceration or gangrene
- New or sudden onset rest pain
Non Urgent Referral
Peripheral vascular disease is a spectrum of chronic arterial disease that can manifest as asymptomatic stenoses or occlusions within the vasculature to significant gangrene and ulceration. In the first instance, identification in the primary care setting of peripheral vascular disease should prompt commencement of risk factor modification. This includes:
- Statin therapy
- Smoking cessation
- Optimisation of blood pressure
- Commencement of aspirin as an antiplatelet (note there is no additional benefit of clopidogrel over aspirin in the acute setting).
I recommend review by a medical specialist for any patient with claudication. Note that some patients may have “asymptomatic disease” meaning that arterial disease has been identified but the patient is relatively free of symptoms. In this instance we usually recommend medical therapy. With any arterial intervention, there is often a significant rate of restenosis.
Diabetic Foot Ulcers
- Any clinical suspicision of significant infection.
Non Urgent Referral
- Asymptomatic below knee (tibial vessel) disease.
Diabetic foot disorders are an incredibly complex area of treatment and management for GP and specialist alike. Often patients who reach the stage of developing a diabetic foot ulcer also have a myriad of other issues to address apart from glycaemic control alone. Importantly, the management of diabetic foot disorders is becoming more multifaceted and multidisciplinary. It is also important to realise that that those with a diabetic foot ulcer have an annual mortality rate approaching 10%, with the mortality increasing to 20% annually if an amputation is performed.
SCOPE OF THE PROBLEM
- 1/4 patients have a lifetime risk of ulceration
- 85% presenting with a foot ulcer are at risk of a subsequent amputation
- Annual mortality rate of patients with a diabetic foot ulcer is 10%
- In all, the 5-year relative mortality rate for those with diabetes who undergo a major limb loss is 70%
- Among patients who have undergone a major lower extremity amputation, up to 40% will undergo amputation of the contralateral limb within 3 year
- The aetiology of diabetic foot ulceration is a well-understood, but multifactorial and complex process.
- Major risk factors associated with diabetic foot ulcer formation are diabetic peripheral neuropathy and peripheral vascular disease (PVD)
- Diabetes results in both somatic and autonomic neuropathy.
- The onset of somatic neuropathy is progressive, eventually resulting in the complete loss of foot sensation and placing the patient at a higher risk of unperceived foot trauma.
- Sympathetic autonomic nerve dysfunction results in reduced sweating accompanied by dry, fragile skin that is at a higher risk of cracking and fissure formation. This neuropathy can also result in arterial-venous shunting and impaired microvascular regulation of the skin
- As such, the insensitive diabetic foot may appear warm and well perfused, resulting in a false sense of security by both the patient and the provider as to the risk of diabetic ulcer formation
- Septic patients with severely infected wounds require admission for urgent surgical management to limit the spread of the infection and tissue destruction.
- In addition to removing nonviable tissue, debridement converts a stagnant wound into an acute healing wound by releasing platelet growth factors, inhibiting proteinases, and limiting the action of bacterial biofilm
- Different modalities for debriding a wound include sharp, surgical, enzymatic, autolytic, mechanical, and intraoperative with ultrasonic and hydrosurgical devices.
- The bacteria most likely to be involved in diabetic osteomyelitis are skin organisms, frequently Staphylococcus aureus and sometimes resistant strains
- The foot must also be offloaded to minimize pressure on the wound and to prevent ulcers from recurring. The likelihood of healing increases with the effectiveness of offloading and the compliance of the patient
- Referral to an orthotist for prescription footwear and orthoses is recommended
PERIPHERAL VASCULAR DISEASE AND THE DIABETIC FOOT
The indications for treating arterial occlusive disease in diabetics are similar to nondiabetic patients: lifestyle limiting claudication, rest pain, and tissue loss that is associated with nonhealing ulcers and gangrenous changes.
- Diabetic patients with tissue loss or nonhealing ulcers without palpable pedal pulses should undergo further testing for underlying arterial disease. Although ABI measurements are a standard component of the vascular workup, these value are often unreliable in diabetics because of medial calcinosis of the tibial vessels.
- Digital arteries are often spared the heavy calcification that occurs in the tibial arteries, and their measurements of flow more accurately reflect foot perfusion
- As such, toe-brachial index (TBI) measurements may be more useful in diabetic patients with a suspected falsely elevated ABI. A TBI greater than 0.6 is predictive of tissue healing.
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© Sam Farah 2022