Vascular Diseases

The heart pumps blood to the body through arteries, and sometimes these can become stretched in one or more places due to a gradual loss of elastic tissue in the artery wall to contain the blood pressure. This process will lead to a section of the artery being significantly larger than it should be, which is an aneurysm.

Aneurysms can occur in any artery but are only common in the abdomen (aortic aneurysm) or behind the knee (popliteal aneurysm). Occasionally they can occur in the chest (thoracic aortic aneurysm) and very rarely elsewhere in the body.

The vessel wall thins as it stretches and eventually will split or rupture, leading to sudden internal bleeding. This is usually catastrophic, and few patients survive.

As the aneurysm grows slowly, it can become lined by clot, and occasionally this may cause problems with the circulation in the leg(s). This may be because pieces break off from the aneurysm and travel into the leg arteries, or because the entire aneurysm clots off suddenly which prevents blood flowing to the legs. This is more a feature of aneurysms behind the knee, and is rare in aortic aneurysms.

There are generally no symptoms during the gradual enlargement, though you or your doctor may notice an increased pulse or a swelling at the site of the aneurysm. Although many patients have their aneurysm detected when they see a doctor about abdominal pain, it is very seldom the aneurysm that causes it.

When an aneurysm is near rupture, there may be some back or abdominal discomfort, or tenderness over the aneurysm.

Rupture is accompanied by severe lower back pain, and patients often collapse or faint due to low blood pressure.

If the circulation to the legs is cut off by clot, the leg becomes cold, white and painful, then loses feeling and becomes weak or paralysed. If this is left too long, even successful treatment of the aneurysm may not save the leg.

This depends on the size of the blood vessel and your fitness, particularly the heart and lungs. The risk goes up as the vessel gets larger, but operating on the circulation is potentially dangerous and the risk of surgery has to be balanced against the risk of not operating.

For aortic aneurysms, the main risk is of rupture, which becomes significant when the aorta reaches 5.5cm or more. Regardless of the size, patients with symptoms should also be considered for surgery. In ladies, although aneurysms are less common, surgery may be indicated slightly earlier as they generally have smaller blood vessels to begin with.

Traditionally, aortic aneurysms have been treated with open repair under general anaesthetic, where the abdomen is opened and the aneurysm is replaced with a strong fabric tube. It takes at least a couple of months to recover your strength fully, but there are very few later problems with this operation and for many patients it remains the best and most suitable procedure.

With the advent of keyhole techniques, endovascular repair (EVAR) is now a real option for up to two-thirds of patients. Potentially this can be performed under local or epidural block instead of a general anaesthetic, and there is less stress on the heart and lungs during the operation. However, this involves lifetime followup scans, and quite a lot of patients need secondary interventions to make sure the aneurysm remains sealed off. This can often be accomplished in the Xray department.

You will be seen in the clinic to discuss the options. A CT scan of the aneurysm will be required to determine the anatomy precisely, and this will be discussed in our meeting to decide whether are possible. Some tests of your heart and lungs will be arranges (CPET) to assess your overall fitness for surgery which will be discussed with our Vascular Anaesthetist. Based on this multi-disciplinary assessment, either an open or endovascular repair will be recommended.

Yes. Your health will affect the risk of surgery, and the anatomy of your aneurysm may favour one or other operation so your Vascular Surgeon will have an opinion on the matter, but patient preference is important in the decision. Some patients prefer to have a one-off procedure with a slightly longer recovery period, others favour the minimum risk surgery and are happy to be followed up in case they need a second procedure. The final decision should be one that you reach with your surgeon.

Aneurysms of the brain arteries can occur but are looked after by the neurosurgeons.

Aneurysms of the popliteal artery occur behind the knee. Here the risk is more about clotting than rupture, and aneurysms over 3cm are considered for repair which may be either a bypass operation or a stent.

A different sort of aneurysm called a pseudo-aneurysm can occur following surgery or treatment on the arteries. This is usually at the site of a bypass graft or where the vessel has been injured or had a needle put in. It is due to a small hole that does not seal and gradually gets larger. These usually require surgery if they enlarge or cause symptoms but we won’t discuss them further here.

Intermittent Claudication is really a symptom, and not a disease. It is a sign that the blood flow to the muscles is being restricted, usually by furring up of the arteries in the leg due to Peripheral Arterial Occlusive Disease (PAOD, or PVD).

The classic symptom of IC is pain, often described as a cramp, in the calf muscles which occurs on walking. It will come on every time you exercise, usually occurs at a very similar distance each time, but may come on sooner if walking uphill or quickly. It always settles quickly when you rest. It is never present at rest, or while in bed.

The same symptoms can occur in the heart, where it is called angina. Arterial disease rarely affects the arms for some reason, so these can be affected but it is unusual. Occasionally the pain may affect the thigh or buttock muscles, if the arteries are blocked above the groin. Usually however this is more tiredness and heaviness than a cramping pain. It can be difficult to tell circulation symptoms from other causes.

The arteries to your leg are probably narrowed or blocked. This is called atherosclerosis. The same problem can affect the arteries to the heart and would cause angina. The cause of the arteries furring up (atherosclerosis) is a combination of smoking, high blood pressure, diabetes, high cholesterol, your family history and just getting older. Not everyone has every risk factor, some of these can be improved, some can’t.

Probably not, if you can follow the advice. Regular exercise has been shown to increase the distance people can walk before the pain comes on but this process may take up to a year to complete. Very few people improve significantly unless they stop smoking. If you are overweight, you will see a difference by losing weight, as the muscles don’t have to work as hard with each step and can go on for longer before needing a rest.

Probably not, if you follow the advice. The chances of you losing your leg are less than 1% if you manage to give up smoking, unless you are diabetic or have kidney disease.

Stop smoking, take regular exercise and avoid being overweight. If you have high blood pressure or diabetes you should make sure these are well controlled. Aspirin is very important at preventing heart attacks, but doesn’t really affect intermittent claudication.In the long term, reducing your cholesterol with a statin is also beneficial.

Not usually. Intervention can be an operation or a balloon stretch, but is only needed when the symptoms do not imporve over a few months and are significantly impacting on your lifestyle.If you have an operation and continue smoking, it will fail and you may get much more severe symptoms including a risk of losing the leg.

Claudication is not a sign that any harm is being done to the muscles or tissues. It is a sign that you have arterial disease and this may also affect other parts of the circulation such as the neck or the heart. nly a very small number of people go on to constant pain, and are in danger of amputation. The major complication that patients with PAOD are prone to is a heart attack, but the same measures that are recommended for claudication will also offer some protection against this occurring.

If your pain comes on when you’re not exercising, or affects more than just the muscles, or doesn’t settle quickly on resting then it may not be circulation related. Nerve pain (sciatica), joint or muscle problems (arthritis, fibromyalgia) can also cause pain in the leg.

Lumpy, swollen veins under the skin that usually occur on the inner thigh or on the calf.

The valves in the vein that usually guide blood back to the heart have failed. Although blood still flows up the vein when you are walking, when you rest it flows back (reflux) down the vein under gravity. Because the pressure is slightly higher, the veins get larger and more obvious over time. The main reason for the valves failing is genetic, and there is a family tendency in many patients. Pregnancy or being overweight are secondary causes that may contribute.

No.

No.

If they are not causing any symptoms, then no treatment is needed. If they cause aching, itching or swelling then elastic socks or stockings are usually very effective, although they have to be the right size, worn regularly and replaced periodically. Surgery is usually possible but not often recommended.

This depends who you ask. The NICE guidelines indicate that surgery is appropriate for patients with skin changes such as ulceration or eczema. Fortunately these are rare. Surgery may also be recommended for recurrent thrombophlebitis or ‘intolerable symptoms’. Cosmesis is not an NHS indication as it is not a health risk.

There is a risk:benefit balance to be considered. The risk of the veins causing a serious problem is very small, and there is an unavoidable small risk of serious complications with any operation including vein surgery. Not all patients having vein surgery will see their symptoms improve, because there are other causes of aching or swollen legs. As a result, in this era of cost saving, varicose vein surgery has been seen as a way of reducing expenditure, without compromising patient safety. It has become a low priority for the NHS providers.

From a non-medical point of view, vein surgery is not cost effective either., because patient expectations are so high, there is quite a lot of dissatisfaction with the end result particularly if a routine complication such as a groin wound infection or skin nerve injury occurs. This leads to significant numbers of complaints and claims for compensation which all takes money from the NHS budget, even if few are successful. Because vein surgery is subject to the same waiting time rules as cancer or life-saving surgery, there are financial penalties for not meeting these targets and vein surgery ends up costing Trusts as much as it brings in, there is no incentive to offer it.

No. Effective surgery will remove the visible veins but since the tendency to get varicose veins is in the genes, quite a lot of people go on to develop more veins as other valves fail later.

Many people do so, but caveat emptor (buyer beware!). It is no safer or more effective in the private sector but here the choice about the risk:benefit balance is made by the patient and is often outweighed by cosmetic issues. It remains the commonest source of patient complaints, partly due to expectations and partly because it is such a common problem, but the private sector is much less likely to pay out for compensation claims unless something catastrophic has occurred. However it is not cheap, you can expect to pay significantly more than the NHS tariff would reimburse a hospital.

A stroke is what happens when a small area of the brain is damaged. It can affect strength or feeling in a limb, or particular actions such as speech or swallowing. Although significant improvement can occur, there is often some permanent effect. Some people will recover fully, but this may take some days or longer.

The same symptoms can occur if part of the brain is temporarily injured but recovers in less than 24 hours; this is known as a ministroke or Transient Ischaemic Attack (TIA). The symptoms always get better completely, usually in under an hour.

There are many causes of stroke but they amount to blockage of small arteries in the brain or by bleeding into the brain. The treatemnt of these is very different, and it is essential to know which sort of stroke has occurred. Blocked arteries can be due to a piece of clot that has travelled to the brain from elsewhere, or that has formed in the brain artery itself. It is important to tell these apart in order to reduce the risk of a further stroke.

A CT scan of the brain will show whether the stroke was due to a blockage or a bleed. If an artery has blocked then an ultrasound (Duplex) scan of the arteries in the neck and of the heart will identify possible sources. There will be other tests for other potential causes such as blood pressure, blood clotting problems or diabetes.

For about 1 stroke patient in 6, there is a significant narrowing of the arteries in the neck that feed the brain. This is a well recognised cause of further strokes and many patients will be recommended to have an operation to clear out the artery (carotid endarterectomy). If this is the case, then the stroke team will refer you to a Vascular Surgeon.

The main risk is of causing a stroke during or immediately after surgery. This risk is about 2%, which is much less than the chance of a stroke without surgery. There are also a couple of large nerves that affect the tongue and voice, which can be bruised or very occasionally damaged, particularly if the anatomy is a bit unusual. The symptoms of this are the tongue pointing to one side a little, or a hoarse voice. The risk is about 1% but most of these recover completely. There are also all the risks of any operation such as the anaesthetic, infection, bruising or numbness around the scar.

As soon as possible. The highest risk of a second stroke is in the first few days, and reduces steadily thereafter. This means the earlier you have the operation the less likely you are to have another stroke. We would like to operate within 2 days of a stroke but this is rarely possible. We aim to operate within 2 weeks of a stroke, but surgery is still beneficial up to about 12 weeks.

It is possible to stretch the narrowing with a balloon, similar to heart or leg arteries. However the risk of dislodging more clot and causing another stroke is much higher than with surgery, so this is reserved for high-risk patients.

You should be on a mild blood-thinning medication such as aspirin forever, and initially there may be more than one. You will also need to have a check kept on your blood pressure, cholesterol and any tendency to diabetes. You should never smoke again.

This is an interesting question, but as much a philosophical one as medical. The large international studies have shown no really clear benefit for surgery before a stroke. However, there is some evidence that patients under 70 years old, and particularly men, may get a slight reduction in their risk of stroke in later years. This is something that you should discuss with a Vascular Surgeon.