Physician Referral Resources

Condition

Every year, 200,000 people in the U.S. are diagnosed with an abdominal aortic aneurysm (AAA), a dilation of the main artery within the abdomen.

A ruptured AAA is the country's 15th leading cause of death (~4,500 cases/yr) and the 10th leading cause of death in men older than 55. AAAs occur in up to 13 percent of men and 6 percent of women over the age of 65.

Because the mortality associated with elective aneurysm repair is drastically lower than following repair of a ruptured AAA, the emphasis must be on early detection and repair prior to the occurrence of rupture.

Death from AAA is preventable with early detection and appropriate, timely treatment.

When to Refer

The Society for Vascular Surgery (SVS) has created disease-specific guidelines to assist in the care of patients at risk of the diagnosis of AAA. Screening for AAA in specific patient populations has been shown to improve disease mortality and can be done without any patient risk using duplex ultrasound. The SVS recommends one-time screening for all patients >/= 65 years old with any history of tobacco use as well as first-degree relatives of AAA patients regardless of tobacco history. Any dilation of the aorta > 1.5 times its reference diameter is considered an aneurysm.

We recommend referral to a vascular surgeon at the time of diagnosis of any AAA. Specific features that may prompt repair include saccular morphology, size > 5cm in females, size > 5.5cm in males, or any symptoms such as back or abdominal pain or emboli to lower extremities that could be attributed to the AAA.

Source: Society for Vascular Surgery

Condition 

Stenoses in the carotid arteries are most commonly due to atherosclerosis, and these narrowings can lead to stroke. Stroke is the third leading cause of death in the United States and the leading cause of permanent disability. Approximately 25% of all strokes originate from an atherosclerotic plaque at the carotid bifurcation.

The mechanism of stroke from carotid stenosis is most often an embolic phenomenon and not strictly due to reduced flow. Multiple acceptable treatment modalities are available for symptomatic and asymptomatic patients, and care needs to be personalized with all options considered.

When to Refer 

 Any patient with a Transient Ischemic Attack (TIA) or stroke of potentially atherosclerotic origin warrants referral to a vascular surgeon. In addition, the Society for Vascular Surgery (SVS) has developed screening guidelines for patients at increased risk for asymptomatic carotid stenosis to help identify those who may benefit from prophylactic intervention to reduce stroke risk.

 We recommend screening for carotid disease with duplex ultrasound in any patient with a history of peripheral artery disease (PAD), regardless of age. People at increased risk for carotid atherosclerosis include individuals over 65 years of age with coronary artery disease, smoking history, or hypercholesterolemia. The presence of a >50% carotid stenosis by duplex ultrasound should prompt referral to vascular surgery.

Source: Society for Vascular Surgery

Condition

The incidence of peripheral artery disease (PAD) has increased over the years due to population aging and the global epidemic of diabetes. Some patients progress to chronic limb-threatening ischemia, an advanced stage of PAD. Chronic limb-threatening ischemia (CLTI) is associated with increased mortality, risk of amputation, and impaired quality of life. CLTI is a clinical syndrome defined by the presence of PAD in combination with rest pain, gangrene, or lower limb ulceration >2 weeks duration.

The recent Global Vascular Guidelines (GVG) have focused on defining, evaluating, and managing CLTI with the goals of improving evidence-based care patient outcomes and identifying critical research needs. Vascular surgeons are your partners in caring for your patients with CLTI with a shared goal to improve limb salvage survival and maximize the quality of life.

When to Refer

All patients with suspected CLTI should be referred urgently to a vascular surgeon for limb salvage efforts. All patients with rest pain, non-healing foot ulcers/wounds, or gangrene should have vascular testing to assess blood supply and potential for healing.

Source: Society for Vascular Surgery

Condition 

Claudication is defined as leg pain with walking that is relieved by rest. The pain occurs most commonly in the calf or the hips and buttocks. Claudication is due to reduced blood flow to the muscles during activity.

Peripheral Artery Disease (PAD), a blockage of the arteries, is the main cause of Claudication. About 6.5 million Americans over 40 years of age have PAD. The risk of PAD increases with age, cigarette smoking, and in people with diabetes.

Initial management of Claudication consists of lifestyle modification, smoking cessation, targeted medical management, and exercise therapy. Percutaneous or surgical intervention may be needed when symptoms are disabling and do not improve with conservative care.

When to Refer

The Society for Vascular Surgery (SVS) has created disease-specific guidelines to assist in the care of patients with lower extremity atherosclerotic occlusive disease, including Claudication. The SVS emphasizes a multidisciplinary approach to PAD, encouraging collaboration between Primary Care Physicians and Vascular Surgeons to tailor treatment for each patient.

Patients should be referred to a vascular surgeon when their symptoms are severe or progress. Individuals whose lifestyle is limited due to Claudication may be candidates for intervention. Because patients with PAD are at increased risk for myocardial infarction (heart attack) and stroke, treatment should be directed to address their overall vascular health.

Source: Society for Vascular Surgery

Condition

Diabetes currently affects over 382 million people and is one of the leading causes of chronic disease and limb loss worldwide. Every year, over one million people with diabetes lose a lower limb; 80% of diabetes-related lower 

limb amputations are preceded by a Diabetic Foot Ulcer (DFU).

A foot ulcer is a break of the skin of the foot to at least the level of the dermis that may result from trauma, neuropathy, ischemia, and/or infection.

The progression from ulcer to amputation lends itself to several key points in time during which intervention and coordination of care between foot/wound care specialists and vascular surgeons, relying upon evidence-based guidelines, can prevent major limb amputation.

Vascular surgeons are your partners in DFU care and amputation prevention.

When to Refer

Patients with diabetic foot ulcer or infection should have foot perfusion measured by ABI, ankle, pedal Doppler arterial waveforms, and either toe systolic pressure or transcutaneous oxygen pressure. If ischemia is detected, prompt referral to a vascular surgeon is recommended for ischemia assessment, WIfI (Wound, Ischemia, foot Infection) staging, and appropriate recommendations for limb salvage options.

Source: Society for Vascular Surgery

Condition 

Chronic kidney disease (CKD) is the ninth leading cause of death in the U.S., outpacing breast and prostate cancer.

About 37 million people in the U.S. have CKD. Hemodialysis is the most widely used form of kidney replacement therapy; over 500,000 patients receive hemodialysis. Adequate access to hemodialysis dramatically influences both the quality and longevity of life in patients on dialysis.

Because of its importance in maintaining the quality of life and survival in CKD patients, establishing a long-term plan for hemodialysis is an important aspect of their care.

 When to Refer

The SVS recommends referral of patients choosing hemodialysis as their preferred kidney replacement therapy once they have Stage 4 CKD (GFR < 30 ml/min/1.73m^2). Persistent albuminuria, with sustained levels > 30mg/mmol, also places patients at high risk for kidney failure. A referral is recommended once either of these conditions is met to allow adequate time for access creation and maturation before the patient needs dialysis. Patients referred to vascular surgeons more than 1 month before needing dialysis require temporary dialysis catheters less than 5% of the time. Reducing dialysis catheter use is associated with better long-term outcomes for CKD patients.

Source: Society for Vascular Surgery

Comprehensive vascular care for limb salvage requires close collaboration and communication between podiatrists and vascular surgeons. Such collaboration is especially important when treating patients with lower extremity wounds and diabetic foot ulcers, many of whom suffer from peripheral artery disease.

Working together, we develop patient-centered care plans based on our established, evidence-based care pathways, the latest research, and advances. Many of these pathways have been formulated through the collaboration of the Society of Vascular Surgery (SVS) and the American Podiatric Medical Association (APMA), including new insights into the prevention, diagnosis, and ongoing management of DFU and vascular disease.

We envision partnering with you to make comprehensive vascular care part of your patients' healthy future. Preventing unnecessary amputations and maintaining independent ambulation and high functional status for our patients is best accomplished by teamwork between podiatrists and vascular surgeons.

Source: Society for Vascular Surgery