Conditions & treatments covered

The Vascular Unit provides an essential link between the Wellington Hospital's specialist cardiac and neurosurgery units. Vascular symptoms can often be an early warning of larger health problems. The Unit's role is therefore both one of essential support to other surgical specialists and of early intervention, for example to clear a blood clot or narrowing of an artery, to help avoid more difficult or life threatening conditions later, such as a major stroke or heart attack.

Vascular Disease Screening

Although most people understand and are aware of the major health risks such as heart attacks, cancer and strokes, the role of the vascular system in a wide range of health issues is far less understood. This is despite the fact that many vascular diseases are an early warning of very serious conditions, not least stroke. Although the heart is the centre of the vascular system, vascular disease outside the heart causes many deaths and more than any single cancer.

In most cases, early screening and detection, typically using a non-invasive ultrasound procedure, can be particularly effective if you are in a high risk group, for example if you are:

  • over 55
  • diabetic
  • have high blood pressure
  • a smoker
  • have high blood cholesterol
  • have a family history of atherosclerotic and circulatory problems

The Wellington offers a full range of diagnostic services to provide a highly effective vascular health evaluation.

 

 

What is an Aortic Aneurysm?

An aneurysm is a dilatation of an artery as a result of weakening of the wall and when one occurs in the aorta it is usually in that part of the aorta that passes through the abdomen (abdominal aortic aneurysm). As the aorta is the largest artery in the body and carries all the blood pumped from the heart to the various parts of the body, any weak spot is at risk of bursting. The risk increases relative to the size of the aneurysm, with low risk if less than 5cm wide and increasingly greater risk of rupture as the aorta increases in size over time.

What symptoms may I have?

You may have an aortic aneurysm for some years without experiencing any symptoms, and when they do occur the symptoms will vary depending on the location of the aneurysm. You may have an aortic aneurysm for some years without experiencing any symptoms, and when they do occur the symptoms will vary depending on the location of the aneurysm. If the aortic aneurysm is in your abdomen you may feel a pulsating sensation there, with abdominal or back pain. If the aneurysm bursts, pain will intensify severely and emergency surgery is vital to stem the severe internal bleeding that would result.

An aneurysm is one of the manifestations of arterial disease as a result of weakening of the structure of the arterial wall and you are more likely to develop this if:

  • You are male and over 60
  • You smoke
  • A close relative had an aortic aneurysm
  • Your blood pressure is high
  • You are overweight and engage in little physical activity

Diagnosis

If, during physical examination, your doctor feels a pulsating mass in your abdomen accompanied by tenderness in that area, this may mean a large abdominal aortic aneurysm is present. Further imaging tests will be able to confirm this, ultrasound or CT scan to define exact size and position of the aneurysm (see Imaging Services section for details).

Treatment/Surgical Intervention

The symptoms you are experiencing and the size of your aneurysm will indicate what treatment is best for you. Early diagnosis is vital to avoid the risk of the aneurysm rupturing as the majority of people do not survive this.

It may be possible to live with an abdominal aortic aneurysm of less than 5cm for several years as the risk of death from very small aneurysms is less than that from surgery in some cases. Regular ultrasound checks are an advisable precaution to monitor if the aneurysm is growing and elective surgery may then be best advice. Lifestyle choices - such as better diet, stopping smoking, exercise - will help you manage the risk better. The better your general health, the more suitable you will be for surgery if the aneurysm grows to be larger than 5cm.

There are two usual surgical options - open surgery or minimally invasive (Dacron or Goretex). You may be offered the minimally invasive technique of placing a stent graft into your aorta via a small cut in your groin, through which the stent then travels up your leg artery until it reaches the aneurysm in your abdomen. This method avoids the need for open surgery but is not suitable for everyone.

What is Carotid Disease?

Oxygenated blood is carried from the heart to your brain by the two carotid arteries, one on each side of your neck. This blood supplies the part of your brain where thought, speech, personality and your sensory and motor functions reside. Like other vital blood vessels, the carotid arteries can develop fat and cholesterol deposits - called plaque - on their walls which over time will narrow the artery and limit normal blood flow to the brain. This can lead to a stroke if:

  • this narrowing becomes extreme, or
  • a piece of plaque breaks away and travels to a smaller and more easily blocked artery of the brain, or
  • a clot may form and block a narrowed artery.

What symptoms may I have?

You may not experience any obvious symptoms of carotid artery disease until the warning signs of a transient ischemic attack (also called TIA or "mini-stroke"). If you experience a TIA you will have a temporary episode lasting a few minutes or a few hours, with symptoms including:

  • blurring or no vision in one or both eyes;
  • weakness and/or numbness in one side of your body, affecting your arm, leg or face;
  • speaking becomes harder or slurred, swallowing may be difficult and you may not understand what others say;
  • loss of coordination, with dizziness or confusion

As the progress of a TIA is impossible to predict, treat your symptoms as a medical emergency as fast treatment could be lifesaving or greatly increase your prospects of a full recovery.

Diagnosis

Abnormal blood flow (bruit) in the neck may be occasionally heard with a stethoscope, but duplex scanning is the most reliable and least invasive way to diagnose carotid artery disease. Diagnostic imaging tests include:

Duplex - uses high-frequency sound waves to view the blood vessels in the neck and highlight any narrowing in the carotid arteries. Recommended if you are over 60 or have heart disease.

Computerized Tomography (CT Scan) - this is most likely to be used following a TIA or larger stroke to see what possible damage to the brain may have occurred.

Angiography - using Digital Subtraction Angiography a computerised image of your arteries is built up following injection of a harmless contrast dye into your blood vessels. Rarely used now other than in circumstances to corroborate findings from other imaging modalities.

Treatment/Surgical Intervention

Like other arterial disease, that affecting your carotid arteries results from lifestyle choices and likewise is treatable through lifestyle changes, such as giving up smoking, reducing intake of saturated fats and cholesterol, control high blood pressure and diabetes and exercise more.

Blood thinning medications may also be prescribed to reduce blood clotting risk. These can range from a simple daily aspirin, to warfarin medications and most recently statins which target and reduce cholesterol to check or possibly reverse atherosclerosis. You should be checked regularly to ensure proper dosing for your condition.

Surgical intervention may be recommended, to restore adequate blood flow to the internal carotid artery, and prevent strokes. The two usual surgical options are:

  • Carotid endarterectomy - an operation during which your vascular surgeon removes the inner lining of your carotid artery if it has become thickened or damaged. This procedure eliminates a substance called plaque from your artery and can restore blood flow.
  • Carotid artery stenting - this is a newer treatment with a growing body of evidence to support its use in some suitable patients. Your vascular surgeon together with a radiologist inserts a slender, metal-mesh tube, called a stent, which expands inside your carotid artery to increase blood flow in areas blocked by plaque.

What is Poor Circulation?

If the circulation of blood around your body is restricted, most usually as a result of hardening of your arteries (artherosclerosis), your feet and legs in particular may not receive enough blood flow. This is called peripheral vascular disease, and may cause pain when you walk or cuts and bruises may take longer to heal or turn into ulcers.

Diabetes is the most common cause of peripheral vascular disease. The symptoms that you experience can depend on which artery is affected and how much the blood flow is reduced. You may also develop poor circulation through lack of exercise, smoking, high blood pressure and high cholesterol in your blood.

What symptoms may I have?

The dull cramp in your calf muscles - called Claudication - is a common symptom after walking. Poor circulation may also mean you experience:

  • Numbness or tingling in your feet or toes
  • Your skin colour becomes paler, bluish or reddish
  • Your feet feel colder
  • Skin irritations, infections or sores do not heal properly
  • You may develop gangrene

Duplex- The causes of peripheral vascular disease are, like heart disease, risky to ignore. Exercise, good diet and being a non-smoker will help you avoid poor circulation but if you are diagnosed as diabetic, good control of your blood glucose level is vital. Medical examination may need to be followed up with diagnostic imaging tests  to show more clearly what is causing your poor blood circulation.

These may include:

Ultrasound - uses high-frequency sound waves to view the blood vessels and highlight any narrowing in the arteries. Recommended if you are over 60 or have heart disease.

Angiography - using Digital Subtraction Angiography a map of your arteries is built up following injection of a contrast dye into your blood vessels. CTA or MRA may also be used to give a computerised image of your arteries.

Treatment/Surgical Intervention

The vast majority of patients with this condition should be on treatment to thin the blood (antiplatelet agents or anticoagulants) and reduce cholesterol (statins). In some patients it may be appropriate to recommend intervention directly at the site of the arterial stenosis or occlusion. In some cases the area can be opened up with angioplasty ( +/- a stent) performed under local anaesthetic, but in others bypass surgery may be needed. This is usually reserved for more severe cases and involves bypassing the diseased artery in the leg either using a prosthetic tube or one of the leg veins which is attached to healthy artery above and below the occluded area.

What are Varicose Veins?

As arteries carry oxygenated blood pumped from the heart to your legs, so do veins carry the depleted blood back via the action of the calf and thigh muscles in your legs. In doing so, the blood must overcome gravity, with one-way valves within your veins preventing blood from flowing back to your feet. When veins become varicose these valves or the vein walls weaken so that blood bulges or pools within the vein, causing swellings (usually on the legs) that are easily visible on the skin as bluish and lumpy areas.

Varicose veins are very common and may be inherited or result from increased pressures in the veins, typically as a result of pregnancy or if you become very overweight. Other factors such as prolonged standing, smoking and poor diet may contribute but there is a lack of scientific evidence for this.

What symptoms may I have?

Apart from the cosmetic aspect that varicose veins are not very flattering, there may be little or no symptoms apart from an aching or discomfort in your legs, itching of the skin of your legs, or swollen ankles.

However, varicose veins can also lead to more serious complications, which include:

Thrombophlebitis - veins close to the surface of the skin can become painful and reddened due to inflammation or blockage of the vein (see also Deep Vein Thrombosis)

Bleeding - if a varicose vein near to the surface is cut or bumped, the resulting bleed might become a medical emergency if it can't be stopped. If this happens, you should lie down, raise your leg, apply pressure to the bleeding area, and then get medical help.

Chronic venous insufficiency - over the long term, the poor blood flow that causes varicose veins can also damage the way the skin exchanges oxygen, nutrients and waste products with the blood. This can lead to brown or purple patches on the skin (venous eczema and lipodermatosclerosis) or venous ulcers around the shin or ankle.

Diagnosis

Varicose veins are easy for you to see but there are a number of tests which can help confirm what precisely is happening in your veins and how they could be treated. For example, ultrasound can be used to check blood flow and whether valves in your veins are working correctly. Duplex can also identify abnormalities in vein structure and assess the deep veins for signs of DVT.

Treatment/Surgical Intervention

At the simplest level, relief of swollen and aching legs can be achieved by wearing compression stockings, as they help blood flow back up to the heart. However, they do not prevent more varicose veins from developing and are only effective whilst being worn.

There are now a number of different treatments for varicose veins. Traditional surgery involves ligating the leaking veins and stripping out the diseased ones. With guidance from duplex scanning and more modern minimally invasive techniques, excellent functional and cosmetic techniques can be achieved. More recently, techniques under local anaesthetic have been developed, but not everyone is suitable for these.

The most common of these involves passing a probe inside the vein which is then heated (laser or radiofrequency) to destroy the wall causing the vein to close off preventing blood flow in it. Another technique uses an irritant foam substance injected into the vein (injection sclerotherapy) to achieve similar results. Your surgeon will advise you which technique is most suitable for you.

What are Thread Veins?

These are small veins just under the skin which have become dilated and, as you age and your skin thins and becomes more transparent, these veins become more noticeable. You may notice thread veins on your face, body or legs. They can be red, bluish or purple and typically about 1mm thick. They may be cosmetically embarrassing, but rarely cause any discomfort. Their cause is unknown but may be the result of smoking or alcohol, hormonal changes, prolonged standing, or possibly inherited.

What symptoms may I have?

It's very unusual for thread veins to cause localized pain, so if your thread veins hurt it's best to get checked out in case the vein is varicose or you have a more serious blood flow problem.

Diagnosis

Underlying medical condition, a medical consultation with duplex scan (a type of ultrasound) examination may help identify a treatment if you think your veins are unsightly.

Treatment/Surgical Intervention

If you also suffer from varicose veins, these should be treated first, otherwise the thread veins may reoccur after treatment. The same injection sclerotherapy can be used for both larger thread veins and varicose veins. For smaller thread veins, microsclerotherapy or laser treatment may be recommended to collapse the veins which are then gradually absorbed by the body and are no longer visible. Some people tend to produce new unwanted veins over time which may also require treatment.

What are Vascular Malformations?

The most common vascular malformations are known as birth marks. They are described as low-flow when present in the veins, capillaries or lymphatic system and as high-flow when arteries are affected. Capillary malformations - typified by a redish/purple "stain" - are now thought to be related to a gene defect in some cases tend to grow larger with age but then may spontaneously involute. Although these can occur anywhere on the body, the face is most common.

What symptoms may I have?

Apart from their cosmetic impact, capillary malformations rarely have any symptoms or complications. Malformations of lympatics, veins, arteries or combinations of these are rare but can be much more serious.

Diagnosis

It's relatively straightforward to see capillary malformations and most do not require treatment. Other malformations that are present at birth may not be noticed until much later as they can occur deep inside organs. These include:

Venous malformations - these affect veins and you may see a feint blue patch or swelling which may cause no symptoms but can sometimes a painful and swollen blood clot can form inside the patch.

Lymphatic malformations - these affect the lymph system, and will usually be present at birth or will develop before the age of 2 and will not resolve spontaneously. They are equally common in boys and girls. Small blister-like marks or larger swellings in the neck, limbs or face, may be seen, sometimes with bleeding or infection.

Arterial and arteriovenous malformations - Involving arteries abnormally connected to veins these can be very difficult to treat. Enlargement may be triggered by trauma or puberty and complications such as bleeding, ulceration and pain may develop. There will usually be a visible swelling in the skin over the affected area which is often blue in colour. In some cases the affected area of the body, for example a leg, will hypertrophy (grow beyond normal proportions).

Treatment/Surgical Intervention

Most vascular malformations do not need treatment, but where indicated, sclerotherapy, embolisation or surgery may be appropriate. You should also ask about cosmetic treatment if the appearance of your malformation is troubling you.

What is Diabetic Foot?

If you are diagnosed with Type 1 or 2 diabetes, foot care is extremely important. You are at much greater risk of disability from foot ulceration, foot infection, foot and limb amputation and some forms of deformity. Foot ulcers can develop into serious lower body infections, with the possibility of amputation at an advanced stage. In the UK alone, 100 diabetic people every week have an amputation. Early and ongoing management of your diabetes - with particular attention to foot care - will mean you are less likely to develop such problems.

What symptoms may I have?

Diabetes is a serious disease and foot problems are a common symptom. Early signs may just be a red or swollen area on the foot, but this may progress to an ulcer which fails to heal for several weeks.

Over time, as a diabetic you may develop peripheral neuropathy, which means the sensory nerves in your legs become damaged and the extremities of your body may become numb. The immune system of diabetics may also work less well. Minor foot problems are then easily overlooked and the body's natural defences fail to alert you. Normal skin lubrication is lost and your feet may become dry and cracked and the pressure of walking and running may cause neuropathic ulcers.

Without attention, this may develop with more serious symptoms including discolouration of the toes, signs of necrosis, continual pain day and night, and coldness or lack of pulse in the foot with the danger of infection spreading quickly and even becoming gangrenous.

Diagnosis

Having been diagnosed with diabetes, you should be aware of the risk factors attached to foot care. Managing your diabetes responsibly will make foot ulcers far less likely but early inspection by your doctor is essential. Pressure on sensitive areas should be relieved, any wounds cleaned and dressed.

Treatment/Surgical Intervention

As mentioned earlier, it is a very good idea to receive a regular check-up from a health professional so that any problems with management of your diabetes will be detected at an early stage, and treatment should be relatively simple and painless. The choices you make in living with your diabetes will have a major impact on the risks of suffering foot problems in future.

If surgery does become necessary, it is sometimes possible to remove the ulcerated area or even a gangrenous toe without mobility being affected unduly. In only the most severe of cases, a more major amputation becomes necessary.

What is Excessive Sweating?

Sweating is the natural process that regulates your body's temperature. Over activity of the 2-4 million sweat glands you are born with (women have more than men but male sweat glands are more active) can be embarrassing but may also indicate other problems.

  • Excessive sweating of the hands, feet and armpits is called primary hyperhidrosis and no cause can be found. It tends to run in families.
  • Excessive sweating resulting from another medical condition is called secondary hyperhidrosis.

What symptoms may I have?

If sweating is accompanied by fever, weight loss, chest pain, shortness of breath, or a rapid, pounding heartbeat, talk to your doctor as these symptoms may indicate an underlying problem, such as hyperthyroidism. Your thyroid may be over-producing hormones, which affect many of your body's functions, not just sweating.

Excessive sweating may also be a symptom of menopause, accompanied by hot flushes and night sweating. Secondary hyperhidrosis is also symptomatic of a number of other medical conditions, so you should seek medical advice if you are affected.

Diagnosis

Your doctor will ask you about location and timing of your sweating as well as what triggers it. Also it's important to understand what other symptoms are present, such as cold, clammy hands, or fever, raised heartbeat or lack of appetite. Although often a neurological problem, sweating can also result from systemic and metabolic conditions.

Treatment/Surgical Intervention

If excessive sweating is identified as primary hyperhidrosis - with no other serious cause - there are treatments that can reduce the embarrassment of, for example, underarm sweating. Thoracoscopic sympathectomy is a keyhole technique to surgically interrupt the sympathetic nerves responsible for sweating. As with any surgery, however, it is not without risks and excessive sweating may subsequently occur in other parts of the body. Botox can also be used to provide a temporary block on the underarm sweat glands.

What is Facial Blushing?

Facial blushing is the redness which develops in the face as a result of emotion, embarrassment, heat or sometimes spicy foods and excessive drink in some races. It results from dilation of the tiny capillaries in the face allowing blood to flow to the surface. Although a normal response, this can be excessive in some people and the situation exacerbated by their awareness of it. In some people the same nerves responsible for hyperhidrosis also lead to excessive blushing. The two conditions may also exist together. The stimulus is usually emotional and therapy may often help, but in severe cases, thoracoscopic sympathectomy can abolish the blushing response.

Diagnosis and treatment

If you do have rosacea, topical application of medication or taking an oral antibiotic can usually suppress the symptoms but it would not cure the problem completely.

Although rosacea tends to recur after 5-10 years, it then usually disappears all by itself. If your facial flushing is not diagnosed as rosacea, then it may respond to medications such as beta-blockers, and sometimes psychotherapy can help you overcome any anxieties that lead to emotional causes of blushing.

Laser treatment of thread veins may reduce your flushed appearance but their underlying cause may be the rosacea. Surgery to the nerves responsible for opening the facial blood vessels may also be considered.

What is a DVT (Deep Vein Thrombosis) check?

When normal blood clotting goes wrong, a potentially harmful clot or thrombosis may form. This can occur in a narrowed, blocked or damaged blood vessel or because of prolonged inactivity, such as being bed-ridden or taking a long flight. You are more likely to be at risk if you have damaged the deep veins in your legs in an earlier accident. If you are planning a long flight or are a frequent flyer, you may want to get advice about the risk factors of DVT relative to your medical history.

What symptoms may I have?

You may be one of the 50% of people with DVT who experience no symptoms. Or you may notice:

  • Your leg or a vein in your leg may be swollen
  • Your leg may be painful or tender, particularly if you walk or stand
  • The swollen or painful area may also feel warmer
  • There is red or discoloured skin on the leg

More seriously, if the clot has moved there is the danger of Pulmonary Embolism, the symptoms for which may be the first sign that you have a DVT. These symptoms include:

  • Unexplained shortness of breath
  • Pain with deep breathing
  • Coughing up blood
  • Rapid breathing and a fast heart rate also may be signs of PE.

Diagnosis

In a DVT check your doctor will look at your medical history - current health, prescriptions, recent surgeries or injuries, any cancer treatment - and then carry out a physical examination, checking blood pressure, heart and lungs. A blood test can also show if you have an inherited blood clotting disorder that could cause DVT. Further common tests to diagnose DVT are:

Duplex - a non-invasive ultrasound examination which is very accurate and gives a map of the deep and superficial veins as well as identifying any thrombus.

A D-dimer test - this can show whether the body's clot defence system has been activated, with high levels of D-dimer showing you may have a deep vein blood clot.

Other less common tests used to diagnose DVT include magnetic resonance imaging (MRI) and computed tomography (CT) scanning.

You may need blood tests to check whether you have an inherited blood clotting disorder that can cause DVT. You may have this type of disorder if you have repeated blood clots that can't be linked to another cause, or if you develop a blood clot in an unusual location, such as a vein in the liver, kidney, or brain.

Further tests may be necessary if you show symptoms of pulmonary embolism.

Treatment/Surgical Intervention

Immediate treatment will aim to stop any blood clot from expanding or breaking off and moving to more dangerous sites within your body, such as your lungs or brain. Medication will reduce your chance of further clots, the most common being anticoagulants to thin the blood and stop existing clots from getting larger. Warfarin and heparin are two blood thinners used to treat DVT.

Warfarin is given in pill form and Heparin is given as an injection or through an IV tube, but you may be treated with both at the same time. If you a pregnant woman, only heparin will be suitable. During treatment you should expect regular blood tests to check on your blood's ability to clot and monitor your medication.

If you are not suitable for blood-thinning medicines, or clots still form while you are taking them, a filter may be inserted into the vena cava vein to catch any clots that break away and move towards the lungs, preventing a pulmonary embolism from forming. This filter does not prevent new blood clots from forming.

Imaging for Vascular Services

The Wellington Hospital's Imaging Department is one of the most up-to-date in the country. We have a full range of state of the art equipment including, two MRI scanners, full range of x-ray machines, ultrasound equipment and an interventional radiology suite.

We have a team of 20 radiologists who are on hand to interpret and report on your scan, xray or ultrasound. They are backed by a team of highly specialised radiographers, nurses and vascular technicians. The department is available 24 hours for clinical emergencies.

Imaging services include:

  • Computer Tomography (CT) Scan
  • Digital Subtracted Angiography (DSA)
  • Ultrasound Scan
  • MRI Scan
  • X-Ray & Fluoroscopy

Visit our Imaging Department for more information