REFREC026
VASCULAR SURGERY REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
Vascular Surgery problems are
categorised under the following
headings:



Arterial
Extracranial head and neck
disease.
Upper Limb.
Thoracic.
Abdomen.
Lower Limb.
Venous
Peripheral.
Central.
Lymphatic
Congenital.
Acquired.
Last updated February 2006
Evaluation
Management Options
Referral Guidelines
A thorough history and examination is
required to determine a specific
diagnosis and its degree of urgency.
Some appropriate investigation by the
referrer will facilitate the referral
process.
Specific treatments depend on specific
problems identified, as noted below.
These guidelines are provided (below)
to give greater clarity in situations of
the primary/secondary interface of
care. Clear telephone/fax
communication would enhance
appropriate treatment.
Risk Factors include:
Extent of stenosis or occlusions

Smoking.

Hyperlipidaemia.

Diabetes.

Hypertension
Extent of symptoms and functional
impairment.
Presence of rest pain

Family history of aneurysmal
disease.
Previously diagnosed arterial disease,
eg coronary artery surgery.
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REFREC026
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Arterial
Extracranial:
Standard history.

History of TIAs (localising, global and
amaurosis fugax) or stroke.
Carotid Disease.
Commence Aspirin.
Manage other risk factors
Examination – evidence of:




Carotid bruit.
Peripheral pulses.
Neurological deficit.
Cardiovascular assessment.
Refer as routine – Category 4, patients
with isolated TIAs with stenosis less
than 70%, asymptomatic carotid bruit
with greater than 70% stenosis.
Investigations: Routine FBC and
routine lipids, glucose, creatinine,
electrolytes. Consider carotid
artery duplex scan as long as this
does not delay referral.
Upper Limb:

Vasospastic Disease.

Embolic/occlusive Disease.
Sympathetic?
Standard history.
Examination:

Blood pressure taken in both
arms.

Degree of ischaemia.

Trophic changes.

Check for cardiac arrhythmia
including AF.

Assess for connective tissue
disorder.
Investigations: Routine FBC and
routine lipids, glucose, creatinine,
electrolytes.
Last updated February 2006
Refer the following as Category 2 for
Vascular specialist assessment:
– Carotid bruit with recurrent
symptoms, critical carotid stenosis
(greater than 90% by ultrasound).
– Patient with Crescendo
TIAs/strokes.
Refer as semi urgent – Category 3
patients with TIAs and stenosis > 70%
Manage cardiac causes:
Advice in regard to precipitants, eg
cold exposure, machinery.
Avoid smoking.
Consider trial of medications such as
Nifedipine, nicotinic acid.
Where there is significant co-morbidity,
discussion with the Vascular Service is
appropriate prior to referral.
Acute ischaemia should be referred
immediately for admission – Category
1.
Refer as routine referrals – Category 4,
connective tissue disorders when
significant pain and/or disability not
responding to conservative measures.
Cases with trophic changes should be
referred semi-urgently – Category 3.
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REFREC026
Thoracic:
– Thoracic Outlet Syndrome.
– Hyperhidrosis.
– Thoracic Aortic Aneurysm.
Standard history.
Related to arterial and venous
insufficiency in upper limb and
neurological symptoms.
Investigations: Rule out all other
pathologies. Consider x-ray of cervical
spine, chest x-ray and thoracic outlet.
None.
Routine – Category 4. Referral for
consideration of surgery.
History of profound sweating of hands
and axillae unresponsive to
conservative treatment.
Investigations: Thyroid function tests.
Usually presents from routine chest
x-ray.
Routine – Category 4. Referral unless
neurological symptoms or prolonged
arterial or venous insufficiency when
patient should be referred urgently –
Category 2.
Control risk factors.
CT scan if radiological report
recommends.
Refer if large sacular aneurysm greater
than 5 cm as semi-urgent – Category
3. Otherwise, refer as routine referral.
Cardiovascular assessment.
Investigations: Routine FBC, glucose,
creatinine, electrolytes.
Abdomen:
– Aortic aneurysm.
Standard history and risk factors above
particularly positive family history.
Managing risk factors.
Referral to Vascular Clinic, in male if
greater than 3.5 cm and female if
greater than 2.5 cm, as routine
referrals – Category 4. Surveillance in
consultation with General Practice.
Abdominal examination: Most
significant abdominal aortic aneurysms
are palpable.
Investigations: Abdominal ultrasound.
Full blood count, glucose, creatinine,
electrolytes.
Last updated February 2006
Aneurysms 5 cm or greater or tender
aneurysms should be referred as semiurgent, Category 3, to the Vascular
Service.
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REFREC026
–
Renal artery stenosis.
–
Mesenteric angina
–
Other aneurysms
Referred usually from other specialty
services, eg General Medicine, Renal
Medicine, Cardiology.
Lower Limb
– Rest pain, ischaemic ulceration,
gangrene.
Standard history and risk factors
above.
Managing risk factors, particularly
smoking.
Refer urgently – Category 2.
Managing diabetes.
General foot care/podiatry
assessment.
Active foot sepsis – Category 2. Refer
Category 3 if any worsening of
ischaemic state or increasing pain.
Managing risk factors, especially
smoking.
Severe claudication less than 50
metres – refer as semi-urgent
Peripheral pulses.
Investigations: Full blood count,
glucose, creatinine, lipids, electrolytes.
– Diabetic foot disease.
Standard history and risk factors above
particularly genetic factors and
collagen disorders.
Peripheral pulses.
Investigations: Full blood count,
glucose, creatinine, lipids, electrolytes.
– Claudication.
Standard history and risk factors
above.
Peripheral pulses.
Investigations: Full blood count,
glucose, creatinine, electrolytes.
Last updated February 2006
Claudication more than 50 metres –
refer as routine – Category 4.
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REFREC026
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Consider graduated stockings.
Refer Category 3 / Category 4
Venous
Peripheral
Deep venous insufficiency.

Post phletic limb.

Pain of deep venous valvular
incompetence.
Standard history and examination,
particular reference to any history of
DVT and in relation to previous
surgery, accident or parturition, genetic
factors.
Varicose veins (long saphenous, short
saphenous, perforators).
DVT
Central
Eg. Pulmonary embolus.
Last updated February 2006
Only refer if symptomatic.
History of oestrogen therapy, family
history, intercurrent disease
(particularly malignancy).
None.
Immediate referral – Category 1 for
assessment and treatment.
Immediate referral – Category 1, to
hospital for most central venous
conditions.
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REFREC026
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Lymphatic
Acquired
Post surgery/trauma lymphoedema
lymphocoeles.
Congenital
Primary lymphoedema.
Last updated February 2006
Standard history and examination.
Early attention to wounds.
Refer as routine – Category 4.
Consider tropical infections.
Standard history and examination.
Refer as routine – Category 4.
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