Vascular surgery referrals

• Aortic aneurysm — emergency if any of:
  • Ruptured
  • Symptomatic (painful / tender / distal embolism)
  • Very large (>8 cm)
  • Infected, or infective in aetiology
• Acute limb ischaemia — sudden onset with loss of sensation or power; the 6 Ps: pain, pallor, pulselessness, paraesthesia, paralysis, perishingly cold
  
  
• Acute / critical mesenteric ischaemia — continuous abdominal pain on a background of chronic mesenteric ischaemic symptoms ("mesenteric angina")
  
  
• Vascular trauma — associated with haemorrhage or ischaemia
  
  
• Complicated diabetic foot infection — defined by:
  • Clinically or radiologically apparent abscess
  • Gas-forming infection (gas on x-ray or palpable soft tissue crepitus)
  • Sepsis syndrome
  • In daytime, urgent clinical photography is helpful but should not delay referral.
    
    
• Acute thoracic aortic syndromes
  • Acute Type B aortic dissection (not involving ascending aorta) 
  • Acute aortic intramural haematoma 
  • Acute symptomatic penetrating aortic ulcer 
    
    
• Type A dissection (ascending aorta / arch) → cardiac surgery, Golden Jubilee National Hospital: 0141 951 5000. If in doubt, discuss with on-call vascular team first.
  
  
• Acute proximal DVT (<14 days) with severe symptoms — common femoral / iliac vein, IVC, or subclavian. Severe symptoms defined as:
  • Severe pain (especially calf and groin)
  • Severe swelling and tenderness
  • Inability to weight-bear / use limb
  • Concern about venous ischaemia or compartment syndrome
  • Concerning imaging (e.g. hanging IVC clot)

• Acute femoral false aneurysm — usually in the context of IV drug use. Perform CT angiogram locally before transfer.
  
  
• Acute haemodialysis vascular access problems — thrombosed or bleeding arteriovenous fistula

• Chronic limb-threatening ischaemia (CLTI) — defined by either:
  • Gradual onset of ischaemic rest pain in foot or toes (worse at night, relieved by dependent position)
  • Ischaemic tissue loss — non-healing ulcer below the knee >2 weeks, or gangrene

See also the Peripheral Vascular Disease pathway for assessment and primary care management.

• Symptomatic carotid artery disease — recent TIA / minor stroke with carotid territory symptoms. Specific referral guideline exists for urgent carotid revascularisation — refer to that separately.
  
  
• Large aortic aneurysm: 5.5 – 8 cm
  
  
• Chronic mesenteric ischaemia — "mesenteric angina" (post-prandial abdominal pain, weight loss, food avoidance)

• Intermittent claudication
  • Refer if quality of life severely affected, claudication distance <40 m, or failed first-line treatment after 3 months
  • Most referrals are forwarded to the community claudication service — refer there directly if available locally
  • See the Peripheral Vascular Disease pathway for full assessment, ABPI thresholds, and primary care management
    
    
• Complicated varicose veins — defined by:
  • Skin change (varicose eczema, brown skin staining, ulceration)
  • Recurrent thrombophlebitis
  • Venous haemorrhage

• Asymptomatic small-to-medium aortic aneurysm (<5.5 cm) — surveillance referral
  
  
• Vascular malformations
  
  
• Suspected vascular neoplasms — usually carotid paragangliomas
  
  
• Suspected thoracic outlet syndrome