Vascular surgery

Consultants:

Ms Alison Guy
Mr Rob McCarthy
Mr David Birchley
Ms Sophie Welchman
Mr Tom Hardy (Clinical Lead)
Ms Hannah Travers 

Clinical Nurse Specialists (Torbay Hospital):

Helen Broom
Louise Davis

Diagnostic Duplex:

Marie Hanley
Sara Jinks
Louise Wilcox

MDT Co-ordinator:

Chloe Phillips

Main Hospital Switchboard 01392 411611

Exe Ward (vascular ward) 01392 402700

Secretaries RDUH

Gail Foss (Ms Travers, Mr Cowan) 01392 402702

Jill Britton (Mr Birchley and Ms Welchman) 01392 402748

Abby Turley (Mr Hardy and Ms Guy) 01392 402793

Secretary Torbay

Freya Vickridge (Mr McCarthy, Mr Hardy and Ms Welchman) 01803 654154

You will normally be referred by your GP, but this can be from another speciality that asks for our advice also.  Our outpatient clinics are held in Royal Devon University Hospital, Budlake Community Hospital, and Torbay Hospital.  We may ask for a scan on the day, and in some cases review certain patients in the Emergency Surgical Assessment Clinic (ESAC).  You will receive a letter or a phone call to give you the correct information for you.

Our main scanning department in Exeter is called Clinical Measurements and is located on the 2nd floor in area G

This is a swelling of the main blood vessel in the tummy.  In most cases, this will just require surveillance with a jelly ultrasound scan either every year (aneurysm 3.0-4.4cm) or every 4 months (aneurysm 4.5-5.4cm).  Men will be invited to screening in their 65th year through the National AAA Screening Programme (NAAASP).  The risk of any symptoms or rupture at <5.5cm is very small and less than the risk of a major operation.

When you aneurysm is at 5.5cm or larger, we will instigate:

1. A clinic appointment, either face-to-face or on the telephone to get an understanding of your fitness and explain further investigations
2. A CT scan of your aorta to assess your anatomy
3. A fitness test called CPEX - this involves an exercise test to see how strong your heart and lungs are to give an indication of how you would react to fixing your aneurysm

With this information, we discuss your case at our multidisciplinary meeting to assess safety and choices of management.  We will then meet face-to-face to discuss how to proceed.

It is recommended that if you have a AAA >6.5cm, you will need to contact the DVLA to revoke your license until repair (if you are a heavy goods vehicle driver, the threshold is 6.0cm)

There are 3 main options in management:

1. Conservative - in some cases we opt not to treat AAA, we may continue surveillance for driving purposes
2. Stent repair - this is a minimally invasive approach and is possible dependent on your anatomy. We can undertake simple stents (EVAR) in Exeter, or in some cases send patients to Bristol for assessment for a complex stent (FEVAR/BEVAR).  An EVAR is a less invasive procedure but requires yearly surveillance to ensure the stent is sealing the aneurysm.  In about 15% cases we may need to re-intervene to seal a small leak.
3. Open repair - this is a major undertaking but is a very durable repair as we replace the damaged section of artery with a fabric tube. This does not require any further surveillance.

When we meet, we will talk through all the options, the risks and benefits and come to a shared decision for your ongoing care.

Further information can be found through NICE

Or the Vascular Society

This is a range of issues with the leg or legs due to furring of the arteries over time.  There are risk factors for developing PAD including high blood pressure, smoking and diabetes, and it is the same disease process that can lead to heart attack and stroke.  The most benign form of PAD is claudication which is pain in the calves, thighs or buttocks on exercise which is relieved with rest.  This is not dangerous and we would try and manage this without intervention if at all possible. 

When patients develop symptoms of pain in the foot waking them from sleep, pain in the foot at rest or non-healing ulceration we refer to this as Chronic Limb Threatening Ischaemia (previously Critical Limb Ischaemia).  This means that the leg is at significant risk of amputation and requires urgent review, investigation and intervention if appropriate.  Patients will usually be reveiwed with the benefit of an ultrasound to the limb to assist in efficient decision making.  Review may be in our outpatient clinic (night pain/rest pain), or the emergency surgical assessment clinic (ESAC) if ulceration is present.

Further investigation may be required with a CT scan.  In terms of treatment options, there are usually 4 options:

1. Endovascualar treatments - these are minimally invasive treatments undertaken as day case procedures under local anaesthetic. not all cases are suitable for this approach and will depend on patient specific anatomy and other medical issues. 
2. Open Surgery - this can be to core out a diseased blood vessel, or re-routing the blood with a bypass
3. Hybrid Intervention - a combination of open and endovascular procedures undertaken simultaneously.
4. Conservative - in some patients, the risks of intervention may be too high and it may be that optimising pain relief is the safest option.

Following investigations and multi-disciplinary meeting review, we will discuss the options available, the risks and benefits, alternative treatments and support this with patient information.  We will then come to a shared decision on how to proceed.

Further information can be found through NICE:

Or the Vascular Society

Transient Ischaemic Attacks (TIA )and Stroke are a major cause of disability and death in the UK.  This can be caused by a variety of pathologies.  In some cases, the cause is narrowing of the main artery in the neck leading the brain called the internal carotid artery (ICA).  This can be narrowed due to a build up of plaque (sometimes called furring of the artery) due to atherosclerosis.  The risk factors for this include high blood pressure, smoking, diabetes and increased age.  If the narrowing is <50%, there may be some benefit of coring out the artery called a carotid endarterectomy.  We do not intervene if the artery is already blocked off.

As part of your work-up following a stroke, you will undergo a CT of the head to outrule bleeding, and subsequently an ultrasound of the arteries in the neck.  If the artery in the neck is sufficiently narrowed, you may be referred to a vascular surgeon for further assessment.

You case will be reviewed and we will talk to you about the risks and benefits of an operation.  The operation itself can be done with you awake (local anaesthetic) or asleep (general anaesthetic) and aims to reduce your future stroke risk.  It will not affect your recovery from a stroke and is a preventative operation.

In the majority of cases, we only operate on patients that have had symptoms, and would not intervene if you had a significant narrowing but no symptoms.  This is because the benefit is very small in asymptomatic narrowing and we could cause a stroke from operating.

Further information is available through the Vascular Society Website.

Varicose veins are a very common issue and affect about 30% of the population.  However, the major concern is identifying patients who are at high risk of developing ulcers.  In patients who have already developed venous leg ulcers, the aim is to try and reduce healing time and try and keep ulcers healed for as long as possible.  As a result of this, there are regional and national restrictions on who we see and offer treatment for.  Based on our local CCG (Clinical Commissioning Guidelines), patients require skin changes (brown discolouration of the skin, eczema or skin tightening above the ankle called lipodermatosclerosis) to allow assessment and treatment.

If we see you, we will either ask for a jelly ultrasound of the affected leg prior to your appointment, or one of our Consultants may scan you on the day.  This will give us a clear picture of your anatomy to guide treatment options. 

The main problem is an increase in pressure in the damaged veins which leads to the skin damage and eventually ulceration.   The idea of treatments is to block of the damaged veins, to allow the healthy veins to drain the blood normally. 

In general, there are 3 main options offered in this hospital:

1. Radio-frequency ablation (RFA) - this is a heat treatment which essentially burns the vein to close it off. It is a minimally invasive day case procedure, and requires injection of anaesthetic around the veining treated to buffer the heat of the treatment.  This is all done under ultrasound guidance and usually with patients awake.  After the procedure, your leg will be tightly bandaged with dressings or sometimes a measured stocking.  You will then be able to walk straight away and should be able to get back to normal daily activities immediately. 
2. Foam Sclerotherapy - This is again a minimally invasive procedure which requires placing small needles into the damaged vein and injecting a soap-like solution which promotes closure of the vein. This is a useful option in recurrent veins.
3. Clarivein - This is a treatment which involves irritating the vein wall and injection of foam simultaneously to promote closure. The benefit of this is that it does not require any local anaesthetic as there is no heat.  Currently this is only offered by one of our surgeons (Mr Birchley).

As with any procedure, the surgeon will discuss the options including the risks and benefits to help you decide the treatment that works best for you.

In some patients, there is too much damage to the draining system and the mainstay of treatment may be compression with bandaging alone rather than a surgical intervention.

Further information is available through the Circulation Foundation Website.

Exeter is the regional centre for creating and adapting access for dialysis serving Exeter, Torbay, North Devon and Taunton.  We also have an on site renal team and offer dialysis at Wonford.  As vascular surgeons, we are involved in creating access points in the body to allow dialysis to clean the blood when the kidneys are not working well enough to do this. 

You will be referred to us by the renal team when they think you are close to needing dialysis, or if you have a line already and you are suitable to try a more permanent access point.  At this appointment, we will scan the arteries and veins in clinic to assess the best option for you and explain the risks and benefits.

Most patients will be suitable for a procedure under local anaesthetic either the wrist (radio-cephalic fistula) or at the elbow crease (brachia-cephalic fistula).  After the operation, it can take 6-8 weeks for the fistula to mature (grow to a size that is useable).  In some cases, we use prosthetic material to make an access point which is quicker to use.