Royal Preston Hospital | Vascular Surgery | Last update 28th November 2018

Please read and follow our referral pathway guidelines. This will prevent repetition and variability, and ensure concise and rapid responses.

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Intravenous Drug Use Complications

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Vascular Injuries

 

Background

Vascular injury can be sustained through  trauma (such as a road traffic accident) or iatrogenic trauma sustained when other medical surgical procedures are taking place.

 Trauma induced vascular injury – Key Agreements

For patients with vascular injury sustained through  trauma, trauma pathways should be followed which allow

  • Transfer direct to vascular centre

  • Prompt investigation

  • Surgical and IR intervention as appropriate

Iatrogenic Vascular Injury

Incidences of iatrogenic trauma are more prevalent in certain specialities and procedures. These include:

  • Cardiac surgery – particularly TAVI procedures

  • Orthopaedic cases

  • Obstetric procedures

  • Catheter laboratory procedures

  • Interventional radiology procedures

The vascular injury may require immediate treatment (active  haemorrhage) or treatment after some time has elapsed (e.g. bleeding into the pelvis or pseudo-aneurysm ).  

In case of vascular injuries at any sites, consultant level communication is essential to achieve a robust response appropriate for each particular case.

 

Specialist Vascular Surgical Response Iatrogenic Vascular Injury – Key Principles

In the majority of these cases the patient will be in an operating theatre under anaesthetic.

 

Step 1   If there is a vascular surgeon on the hospital site they should attend the theatre where the iatrogenic vascular injury is happening.

Step 2   If there is not a vascular surgeon on the hospital site where the iatrogenic vascular injury is happening, the Surgeon of the Week at the Vascular Centre should be contacted during working hours so that the most appropriate action can be taken. Out of hours and weekend is covered by consultant vascular surgeon on call at centre.

  The on call vascular surgeon will either

  •  travel to the hospital site where the iatrogenic vascular injury is happening

  • or the patient should be transferred to the vascular centre

If interventional radiology is deemed the most appropriate course of action the patient will be transferred to the vascular centre.

Other Points

In the case of TAVI lists taking place at the cardiothoracic centre at Blackpool the service will  schedule that there is a vascular surgeon working on site .

In the case of forearm injury, the involvement of the plastics team should be considered.

A specific emergency arterial theatre kit should be in place at each hospital site so that the Surgeon of the Week at the Vascular Centre will have the appropriate theatre trays and equipment having travelled to the hospital site (as required for Step 2).

The vascular surgeons should have  a  practical knowledge of how to get to the different hospital sites in the region or ask for local guidance at the spoke hospital to direct them to theatre in shortest possible time.

Thoracic Acute Aortic Syndrome (AAS)

 

Key agreements

There has been increasing number of referral to vascular centre for patient with acute intrathoracic aortic pathology (Acute Aortic syndrome). These patients attend the local A&E/surgical department with different presentations. This document intends to provide a clear pathway and way of referral to cardiothoracic/ vascular centre.

This pathway has been designed following detailed discussion of all involved parties regarding the best treatment of acute aortic syndrome.

The pathway is only to be followed for acute and emergency presentation and does not intend to cover the incidental findings (asymptomatic ascending or descending aneurysm, dissection , penetrating ulcer, intramural thrombus), For asymptomatic incidental findings  the referral pathway to Lancashire Teaching Hospital Major vascular centre should be followed.

  

Definition:

Acute aortic syndrome (AAS) describes a range of severe, painful, potentially life-threatening abnormalities of the aorta, which includes:

  • Acute Aortic dissection (Type A, Type B)

  • Acute intra mural thrombus

  • Ascending or descending  ruptured aneurysm

  • Symptomatic penetrating atherosclerotic aortic ulcer

Presentation:

 

The patients presentation could be different depending on the background pathophysiology and could be:

                Severe chest and back pain, aortic insufficiency, collapse, pulse differential , myocardial ischemia , neurological signs , hypotension , hypertension mesenteric or lower limb acute ischemia

 

I

  • Seen by middle grade/consultant at A&E or Ward

  • History (co-morbidities, confirm diagnosis)

  • Bloods (FBC, U/E, LFTs, amylase, CRP, clotting, cross-match, D-Dimer) and ECG

  • Good venous access (CVP not always necessary), urinary catheter and arterial line

  • CT angiogram whole aorta

  • Diagnosis is confirmed

  • Contact the on call cardiothoracic team at Blackpool Victoria Hospital (middle grade/Consultant

 

Based on patient’s Presentation and possible treatments available, appropriate advise will be given by cardiothoracic team regarding admission.

 

1. Admission

 

  • Patients who are fit for open surgical intervention will be transferred to Blackpool Victoria Hospital cardiothoracic centre.

  • If the best treatment of option is endovascular procedure, the case should be discussed between cardiothoracic consultant on call at BVH and vascular and interventional radiologist consultant on call at Lancashire teaching hospital. The patient will be transferred to Royal Preston Hospital for urgent IR procedure.

  • Stable asymptomatic Type B dissection (with no mesenteric renal or acute lower limb ischemia)should be admitted under cardiology team at the local hospitals for blood  pressure control and symptomatic management  with a plan for repeat CT angiogram at Day 1, 3 and 7 post presentation. Any changes in these scans should be discussed with on call cardiothoracic team at Blackpool Victoria Hospital .

  • If patient is palliative – admit and refer to palliative care team at local hospitals.

2. Surgery

If patient requires immediate surgery:

  • Plan immediate surgery

  • Theatre category 1 with vascular/cardiothoracic  anaesthetist

3. Post Operative

  • Admit to critical care or ward as per patient’s need.

 

4. Discharge

This cohort of patients is likely to have co-morbidities, medical complications and often social  issues. The principle of daily review, prompt referral to other specialty teams as appropriate and repatriation to the local trust once the vascular condition has been resolved should be adhered to.

 

5. Surgical Follow Up

Post op surgical review 6 weeks following surgery at local trust. Patient then discharged from the service or referred to appropriate surveillance program.

Thoracic Aortic Emergency

Intravenous Drug Use Complications

 
 

 

Vascular Management of IVDU complications

Key agreements

There has been increasing number of referral to vascular centre for patient with intravenous drug user (IVDU), these patient attend the local A&E/surgical department with different presentation. This document intend to provide  a clear pathway and need for referral to vascular centre for IVDU patients with acute presentation.

Presentation

1.Majority of the patients present with signs of deep vein thrombosis( sudden onset of pain, warm swollen legs)

  • Seen by middle grade/consultant at A&E

  • History (co-morbidities, confirm diagnosis)

  • Bloods (FBC, U/E, LFTs, amylase, CRP, clotting, cross-match, D-Dimer) and ECG

  • Venous Duplex scan

  • DVT pathway should be followed

2. Patients presented with signs of Acute limb ischemia:

Please follow the pathway for acute limb ischemia

3. Abscesses

Seen by Middle grade/consultant at A&E

•             History (co-morbidities, confirm diagnosis)

•             Bloods (FBC, U/E, LFTs, amylase, CRP, clotting, cross-match,) and ECG

  • Arrange for CT angiogram, the CT scan is reported by local radiologist.

  • If there is evidence of bleeding, pseudo-aneurysm, AV fistula  within the abscess cavity then refer to vascular middle grade at centre and arrange for transfer.

If the CT scan shows evidence of abscess with no connection to blood vessels referral to local surgical or orthopaedic team to arrange for incision and drainage of abscess.

4.Patient presented with major haemorrhage

•Seen by middle grade/consultant at A&E

•Rapid assessment and resuscitation

•History (co-morbidities, confirm diagnosis, quality of life)

•Bloods (FBC, U/E, LFTs, amylase, CRP, clotting, cross-match) and ECG

•Good venous access , urinary catheter

  • Apply compression dressing

•Contact vascular middle grade/ consultant surgeon on call and arrange immediate admission.

Admission

Arrange admission to vascular ward

  • SB vascular middle grade and vascular surgeon on call

  • Contact IR team if needed

Surgery

If patient requires immediate surgery:

  • Plan immediate surgery

  • Theatre category 1 with vascular anaesthetist

  • Undertake incision and drainage +/- tie the involved artery

Post Operative

  • Admit to critical care or ward as per patient’s need.

Discharge

This cohort of patients is likely to have co-morbidities, medical complications and often social  issues. The principle of daily review, prompt referral to other specialty teams as appropriate and repatriation to the local trust once the vascular condition has been resolved should be adhered to.

Surgical Follow Up

Post op surgical review 6 weeks following surgery  at local trust. Patient then discharged from the service.

Mesenteric Angina

 

 

Vascular Management of Chronic Mesenteric Angina

Key agreements

There has been increasing number of referral to vascular centre for patient with chronic mesenteric angina  . This pathway intend to provide a guideline for treatment of these patients.

Facts

  • Mesenteric angina is a slow progressing vascular disease which develops as result of significant stenosis in at least two of the three vessels responsible for the circulation of the guts.

  • The predisposing factors are identical to cardiovascular disease.

  • Typical patients with mesenteric angina  is suffering from post-prandial pain which could last for several hours following each meal. The patients develop phobia of eating and subsequently loose considerable amount of weight.  

  • Other disease could cause similar symptoms and the diagnosis could only be made, based on careful evaluation of the patients and their history as well as excluding other cause of the pain such as( Coeliac disease, peptic ulcer, GORD, Hiatus Hernia , malignancies ….)

Recommendation of the pathway

 

1. All patients with symptoms described above should be seen by gastroenterologist at local trust and investigation should be made to exclude other cause of the disease.

2.  If there is strong suspicious of mesenteric angina then a CT angiogram(including arterial phase) of Abdominal aorta should be done at local trust and urgent referral to be sent to vascular centre.

3. The patients will be seen urgently at first available vascular clinic. The clear history is taken by vascular consultant and antiplatelet (Aspirin) and cholesterol lowering agent will be started if indicated. The case then is referred to vascular Regional MDT.

4. The images will be transferred to vascular centre and patient will be discussed in first regional vascular MDT.

5. If the diagnosis of mesenteric angina confirmed then mesenteric angioplasty/Bypass will be performed within 2 weeks following MDT.

Treatment:

Angioplasty/stenting

  • The patient is reviewed by interventional radiologist, the risk and benefit of the procedure will be explained and the written consent will be taken.

  • Following the procedure, the patient will be admitted to vascular ward for overnight observation.

  • The patient is reviewed by vascular consultant and discharged home if there is no concern within 24 to 48 hours following angioplasty/stenting

  • Outpatient appointment will be arranged in 6-8 weeks in vascular clinic close to patient’s residential address(local Trust).

Bypass surgery

  • Patient will undergo a formal pre op assessment.(these group of patients are frail with multiple co morbidities, Anaesthetic review by vascular anaesthetist prior to surgery) 

  • Following surgery patient is admitted to HDU/ICU as appropriate and transferred to vascular ward once haemodynamically stable.

Discharge

This cohort of patients is likely to have co-morbidities, medical complications and often socialissues. The expected discharge from hospitalfollowing mesenteric bypass surgery is variable. The principle of daily review, prompt referral to other specialty teams as appropriate will help the discharge as early as 5-10 days following surgery.

Surgical Follow Up

Post op surgical review 6 weeks following surgeryat local trust by vascular surgeon. Patient then discharged from the service.

Acute Rupture of AAA

 

Management of Acute Rupture of AAA

 

Key agreements

 

1. Presentation

 

1a) When patient presents at A&E at vascular centre:

The A&E acute abdomen pathway will be followed – for patients with suspected acute rupture of AAA.

  • Seen by middle grade/consultant at A&E

  • Rapid assessment and limited resuscitation

  • History (co-morbidities, confirm diagnosis, quality of life)

  • Bloods (FBC, U/E, LFTs, amylase, CRP, clotting, cross-match) and ECG

  • Good venous access (CVP not always necessary), urinary catheter and arterial line

  • Contact vascular middle grade/ consultant surgeon on call and arrange immediate admission.

  • If systolic > 80mmHg to CT scanner. Undertake imaging as required immediately.  NB CT should be undertaken according to protocol shown in appendix 1

  • If systolic < 80mmHg consider  straight transfer  to emergency theatre

  • If patient is palliative – admit and refer to palliative care team

 

1b) When patient presents at A&E in a spoke site:

The A&E acute abdomen pathway will be followed – for patients with suspected acute rupture of AAA.

  • Seen by Middle Grade/consultant in A&E 

  • Rapid assessment and limited resuscitation

  • History (co-morbidities, confirm diagnosis, quality of life)

  • Bloods (FBC, U/E, LFTs, amylase, CRP, clotting, cross-match*) and ECG

  • Good venous access (CVP not always necessary), urinary catheter and arterial line

  • Contact vascular middle grade/consultant on call at vascular centre and if clinically appropriate, arrange immediate admission to the vascular centre. Agree whether imaging should be undertaken locally (prior to transfer) or centrally. If systolic > 80mmHg consider local CT . NB CT should be undertaken according to protocol shown in appendix 1

  • Arrange for immediate transfer of images to centre.

  • If patient is palliative – admit locally and refer to palliative care team

 

1c) When patient presents to GP:

  • If patient is collapsed with a known history of AAA contact surgeon on call at the vascular centre

  • If patient has mild – moderate symptoms with no history of AAA, the GP should call the local General Surgical middle grade and follow steps above in 1b

2. Admission

Arrange admission to vascular ward

  • SB vascular middle grade and vascular surgeon on call

  • Contact IR team

 

3. Surgery

If patient requires immediate surgery:

  • Plan immediate surgery

  • Theatre category 1 with vascular anaesthetist

  • Undertake open AAA repair or EVAR

4. Post Operative

  • Admit to critical care unit post operatively

 

5. Discharge

This cohort of patients is likely to have co-morbidities, medical complications and often social and mobility issues. The principle of daily review, prompt referral to other specialty teams as appropriate and repatriation to the local trust once the vascular condition has been resolved should be adhered to.

6. Surgical Follow Up

Post op surgical review 6 weeks for both EVAR and Open AAA patients undertaken at local trust. Patient then discharged from the service.

7. Imaging Follow Up

Post op imaging follow up for patients who had EVAR:

  • 30 days CT + XRay

  • 6 months CT

  • 1 year CT + XRay

  • Annually thereafter CT or US + XRay

*Take 2 cross match samples

Carotid Endarterectomy / Carotid Stenting (Urgent)

 

For High Risk* Patients Identified at TIA Clinic as Potentially Requiring Urgent Carotid Endarterectomy or Carotid Stenting

The National Stroke Strategy requirement (to be effected by 2017) re TIA to CEA:-

“Carotid intervention for recently symptomatic severe carotid stenosis should be regarded as an emergency procedure in patients who are neurologically stable, and should ideally be performed within 48 hours of a TIA or minor stroke”.

The current NICE guidelines recommend 2 weeks. A key factor affecting the timeliness of this pathway will be the speed with which the patient refers themselves to GP or A&E.

 

Suggested Steps Required Prior to the Referral to the Specialist Vascular Team

 

1. Patient attends local TIA clinic which will be in place 7 days a week (taking place in the morning) to receive patients from GP or A&E referral. The start of the timeline is when patient has TIA.

 

2. Duplex investigation undertaken at the TIA clinic and interpreted at the local trust by appropriately trained staff.

3. If duplex demonstrates 50% stenosis or above(based on NASCET criteria), undertake CTA at local trust (following agreed radiological protocol) on the same morning.

4. The stroke physician (or appropriate local co-ordinator) should refer the patient to the vascular surgeon on call and make sure that all the investigations are transferred to PACS system at centre  on the same day. The referral is sent using “Accompanying Information Form” (see appendix 1). These information will be sent electronically and in a protected format through the PACS system.

 

5. Only the referral with complete information (duplex scan, CTA images and appropriately completed Information form) will be accepted by vascular surgeon on call.

 

Key Agreements by the Specialist Vascular Team

 

6. CTA will be reported by Vascular Interventional Radiologist (IR) on call (Vascular IR of the week. If the CTA and accompanying information demonstrate that the patient might benefit from carotid intervention, The Vascular Consultant will feed back through a written report and where appropriate a phone call to the referring stroke physician (or appropriate local co-ordinator).

 

 

7. The patient will be assessed at centre  at a time arranged by the vascular surgeon and bed management team.

 

8. If indicated (following assessment  and surgical review), urgent carotid endarterectomy or carotid stenting undertaken. Surgery will be undertaken in next available emergency theatre  list at LTHT.

  • Enhanced Recovery Programme pathway followed for in patient stay.

 

9. Patient will be reviewed 4- 6 weeks post op at the local vascular clinic.

 

*High risk patients identified in national ABCD2 risk scoring shown in Appendix 2

Acute Limb Ischemia

 

 

1. Presentation

For patients with suspected acute limb ischaemia (leg or arm) who have an acute presentation at presence of 6 P’s (pain, pallor, paralysis, pulse deficit, paralysis, poikilothermia)

1a) If patient presents at A&E (at hub or spoke site):

  • Seen by General Surgery Middle Grade (SB Vascular Middle Grade if patient presents at the vascular centre)

  • ECG and bloods

  • Consider heparin

  • Contact vascular registrar on call at vascular centre and discuss whether patient should be admitted to the vascular centre(that Vascular Registrar is on call 24 hours a day including weekends, bleep 7080)

  • Undertake imaging as instructed by vascular team (consider CT angiogram, duplex and / or full angiogram) within 24 hrs. For patients in spoke sites, agree whether imaging should be undertaken locally (prior to transfer) or centrally

 

1b) If patient presents to GP:

  • GP should call the vascular registrar  middle grade on call at  centre.

  • Follow steps above

 

2. Admission

Arrange admission to Ward 15 at RPH

  • SB vascular middle grade on call

  • Discuss with vascular surgeon on call

 

3. Consultant Review

Undertake consultant review

3a) If patient requires immediate surgery:

  • Plan immediate surgery

  • Theatre category 1 with anaesthetist

  • Undertake embolectomy or other required procedure(angiogram, angioplasty, Thrombolysis)

 

3b) If patient does not require immediate surgery:

  • Review on daily ward round

  • Plan appropriate imaging and intervention

 

4. Post Operative

  • Consider anticoagulation / anti platelets

  • Further investigation into the source of emboli

  • Prior to discharge undertake echo

  • Prior to discharge consider whether cardiology review should be undertaken (decide whether this needs to be as an inpatient and, if as an outpatient, should it be at the local trust)

5. Discharge

This cohort of patients is likely to have co-morbidities, medical complications and often social and mobility issues. The principle of daily review, prompt referral to other specialty teams as appropriate and repatriation to the local trust once the vascular condition has been resolved should be adhered to.

6. Follow Up

  • 6 week OPA at local trust

AAA elective pathway

 

 

(For Patients on a Surveillance Programme or Screening Pathway)

Key agreements

1. For patients on a local surveillance programme (i.e. picked up earlier as an incidental finding) undertake imaging as recommended in the AAA screening programme (see appendix 1).

 

2. For patients on a local surveillance programme or those found through screening, when AAA US shows AAA of 5.5cm the following should be undertaken. (This is the start of the timeline.)

  • Outpatient review

  • Request CT scan

  • CT scan should be undertaken within 2 weeks at local Trust

  • Complete the “Elective AAA Pre-op Safe for Intervention Checklist” (traffic light form) at local Trust

  • Request blood tests (FBC, U&Es, Clotting, LFTs, Group and Screen), ECG and Echo – at local Trust

  • Request CPEX which should be undertaken within 2 weeks at the centre.*

 

3. Preparation for MDT

  • Communicate patient details to the MDT co-ordinator and complete MDT form (email)

  • Liaise with MDT Co-ordinator to ensure all scans and manipulation of images are available

4. Discuss at MDT with all above information within 3 weeks

  • Recommended treatment options discussed

  • Any further investigations required identified

5. Patient seen in vascular surgery clinic within 4 weeks at local Trust

  • Options discussed – final decision re treatment made

  • Full explanation given by surgeon

  • Written information provided to patient

 

6. Pre-op session by appropriately trained specialist nursing staff within 6 weeks at local Trust

  • Consent taken (use pre-printed consent)

  • Specialist information and counselling re procedure

  • Date of surgery / IR intervention confirmed

 

7. EVAR or Open AAA repair undertaken within 8 weeks

  • Admitted on day of surgery

  • Enhanced Recovery Programme pathway followed for in patient stay

8. Post op surgical review 6 weeks for both EVAR and Open AAA patients undertaken at local trust

9. Post op imaging follow up for patients who had EVAR:

  • 30 days CT + XRay

  • 6 months CT

  • 1 year CT + XRay

  • Annually thereafter CT or US + XRay

*Anaesthetic pre-assessment will be undertaken at this point

Appendix 1

The local surveillance imaging protocol will match the national AAA screening imaging protocol which is essentially:

  • Ultrasound will be every year for a small aneurysm between 3 and 4.4cm wide

  • Ultrasound will be every three months for a medium aneurysm between 4.5 and 5.4cm wide

The full screening protocol can be found at http://aaa.screening.nhs.uk/