Peter Taylor, M.A., M.Chir., F.R.C.S.,
Consultant Vascular Surgeon, Guy's & St. Thomas' NHS FoundationTrust
Tel: 020 7403 3893 Fax: 020 7403 2323 e-mail:TAYLORVASC@aol.com

All patients who present with peripheral vascular disease should have aggressive management of their risk factors for atherosclerosis, e.g. smoking, hypertension, diabetes and hyperlipidaemia. They will also benefit from aspirin [and clopidogrel] together with a statin. All patients should be assessed by a vascular surgeon.

1. CAROTID DISEASE

Stroke affects 90-300 per 100,000 population and 60% of the survivors have serious morbidity. Any patient who suffers from a focal neurological deficit such as amaurosis fugax, transient ischaemic attack or a stroke from which they make a reasonable recovery should have a carotid duplex scan as soon as possible. If this shows a stenosis of the relevant internal carotid artery of 70-99% diameter reduction, then the patient should be referred for carotid surgery. Speed is important, as the highest risk of a recurrent event is within the first 3 months. Ideally, duplex scanning should be available in the outpatient department. Surgery should be performed with less than a 5% risk of stroke or death. Carotid artery stenting is now performed with good early results. Patient selection is crucial in this procedure.

2. ABDOMINAL AND THORACIC AORTIC ANEURYSMS

These are being diagnosed much more frequently owing to the increasing age of the population and the availability of ultrasound. Most infrarenal aneurysms can be diagnosed clinically, and all men aged 65 or older should have their abdomens examined for a pulsatile expansile mass. All aortas measuring 3 cm or greater should be followed up with six monthly ultrasound examinations. The small aneurysm study which randomised patients with aneurysms measuring 4-5.5 cm showed no advantage in early repair as long as the patient was kept under ultrasound surveillance. The newer technique for treating aortic aneurysms uses a femoral arteriotomy to insert a covered stent (stent graft). These are associated with a decreased hospital stay of usually 48 hours with the first night spent in HDU. The main drawback is the durability of the procedure and further intervention may be necessary to exclude the aneurysm sac from the circulation, although the stent grafts are undergoing improvements on a continuing basis. All patients with endoluminal grafts should be followed up for life. The EVAR [Endovascular Aneurysm Repair] trial reported in June 2005 and found that fit patients benefit from this type of repair with a 3% reduction in mortality. The technique is also very successful in the thoracic aorta especially for the treatment of dissections and aneurysms.

3. LOWER LIMB STENOSIS

The differential diagnosis of arterial claudication includes spinal claudication, cardiac claudication and venous claudication. If the arterial stenosis is in the aorto-iliac segment, then good results can be obtained with intervention which may be radiological [balloon angioplasty and/or stent] or surgical [vascular reconstruction]. Results of intervention below the inguinal ligament carry a risk of limb loss and are not as durable. These patients are usually treated conservatively and are encouraged to walk for at least one hour per day for five days a week. They should walk through the pain if they are able to do so. The risk of limb loss is 1% per year, although this increases in diabetic patients.

Critical limb ischaemia is rest pain, ulceration or gangrene associated with a Doppler pressure at the ankle of 50 mmHg or less. These patients should be assessed urgently and all will require intervention to preserve the limb. Acute ischaemia of the leg should be referred immediately, and may respond to thrombolysis.

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