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Vascular Surgery




The purpose of this booklet is to orientate junior doctors working on the vascular ward (ward 53) at the Countess of Chester hospital (COCH). Since becoming a centre for vascular surgery, working on the vascular ward at COCH has presented several new challenges in terms of discharge planning and provision of care. This booklet aims to inform you about common surgeries performed at the SMArt centre; common problems with vascular patients; some of the specific challenges associated with discharging patients to a large geographical area and generally to help ease the transition to working on the vascular unit. It is not intended to be fully inclusive of all information required to work on this ward, merely a source of reference, so it is important to ask if you have any queries. The team is very supportive of junior staff and are happy to help. We hope you find this attachment both educational and enjoyable.


The SMArt Centre

The South Mersey Arterial (SMArt) centre was established in April 2014 with a view of improving outcomes from major vascular surgery. This reflects the decision to centralise vascular units seen elsewhere in the UK e.g. Liverpool Vascular and endovascular service (LiVES). All patients undergoing vascular treatment (elective and emergency) from West Cheshire, Deeside, Wirral and Warrington areas have surgery at the Countess of Chester hospital (COCH). The SMArt centre includes the provision of integrated Interventional Radiology across the three sites.

Clinic appointments, outpatient investigations and day case treatments e.g. angioplasty take place in Arrowe park (APH), Warrington (WGH) and COCH.

Covering such a large geographical area presents many challenges for discharge planning, follow-up and social care; however, ultimately the goal is to improve patient outcomes by combining a wealth of vascular knowledge and experience.


Contributions and acknowledgements

Dr H Reader

Mr Ghatwary


The Vascular team


The vascular team comprises 11 consultants all of whom rotate on a rolling on-call rota, which runs Friday-Friday.

The VCOW (Vascular Consultant Of the Week) is responsible for all new admissions to the ward that week.

The 6 Registrars also rotate on-call weeks as VROW (Vascular Registrar of the Week), running Monday-Monday to allow some overlap between registrar and consultant, in order to maintain continuity of care.



Vascular Consultants

Mr Arun Balakrishnan

Clinics: Chester

Secretary: Chelsea Foster-Lovell Ext: 5464



Mr Colin Chan

Clinics: Arrowe park

Secretary: Louise Rule Tel: 0151 604 7530



Mr Ramasubramanyan Chandrasekar (Clinical lead)

Clinics: Arrowe park

Secretary: Sue Wilson Tel: 0151 604 7054


Mr Sameh Dimitri

Clinics: Chester

Secretary: Nikki Price Ext: 5465



Mr Gareth Harrison

Clinics: Arrowe Park

Secretary: Sue Wilson Tel: 0151 604 7054


Mr Ragai Makar

Clinics: Chester

Secretary: Chelsea Foster-Lovell Ext: 5464



Mr Thomas Nicholas

Clinics: Widnes and Warrington

Secretary: Davina Cieslar- 01925 275266


Mr Deji Olojugba

Clinics: Warrington

Secretary: Sharon Dobson 01925 662 075


Mr Nee- Beng Teo

Clinics: Warrington and Halton

Secretary: Sharon Dobson 01925 662075

Email: or

Mr Leith Williams

Clinics: Arrowe park

Secretary: Louise Rule Tel: 0151 604 7530



Mr Hussain Rabee (Locum Consultant)

Clinics: Warrington

Secretary: Louise Rule Tel: 0151 604 7530


Vascular registrars x6



Other medical staff

Two FY1s Rotate on general surgery On-call

One CT2 Rotate on general surgery On-call

Four SHOs/F2s on the ICU on-call rota

Vascular specialist nurses (SMART MDT co-ordinators) Ext: 3255

Dominic Turburville

Victoria Taylor


Vascular Specialist nurse (Chester specialists nurses) Ext: 3255

Carys Humphries

Rachel Koppack

Rute Bromley

Vascular co-ordinators

Emma Sands

Vascular Pathway Coordinator

Gemma Bennion

SMArt Administration Assistant


Ward Sisters

Karen Owen

Dawn Simon

Ward clerk


Physiotherapy team




Vascular Pharmacist


The Ward



Analysis of the unit’s morbidity and mortality is a very important quality improvement process. There is a database on the shared (S Drive) to record this information. The consultants/registrars will tell you which patients need to be added to this database which will be presented in regular audit meetings throughout the year.


TCI (To Come In) Patients

The Ward Clerk will usually warn the juniors if there are any TCI patients that day. These are elective patients who require:

· Full clerking including examination (incl. peripheral pulses)- the ward has a new clerking proforma in circulation

· Bloods including a coagulation screen and 2x G&S (If pt has a blood bank history at COCH only one pink bottle is needed) and a cannula


NB. Be cautious when cannulating/bleeding bypass patients as, if their saphenous veins are unsuitable, they will often have their cephalic/basilic veins harvested. Check with seniors before proceeding.



· Ensure they are consented by a senior

· Cross-match any units of blood they may require

· Prescribe regular meds

· VTE- fill out green form


NB. Please prescribe the appropriate dose of Tinzaparin as per weight. TEDs are often not appropriate for vascular patients as PVD is a contraindication.


If Pt. is usually Warfarinised e.g. for multiple PEs/DVTs, check the patient doesn’t need to be on Tx dose Tinz (i.e. 175 unit/Kg) as they will need bridging Tinz when you re-load them on warfarin between post-op and discharge.

If on warfarin for AF, prophylactic dose Tinz is adequate.


NB. Enoxaparin for renal Pts.


· Analgesia is important for vascular patients as they are often in a lot of rest pain- don’t be afraid to use regular zomorph (e.g. 20mg BD) and prn oramorph (10mg 1-2 hrly) alongside the usual paracetamol, codeine/tramadol etc. (Follow amputation pathway for patients coming in for elective amputation)


NB. If pain control is troublesome, the Pain nurse is happy to advise. Ask nurses to refer to pain team.

· PRN anti-emetics


NB. IR at COCH do not do angioplasties/CTAs on patients on Clopidogrel (should be stopped 7 days before- they should have been told this at pre-op)


NB. Emergency admissions from Chester, the Wirral or Warrington are admitted via the Registrar of the week from A&E or GPs and go under the VCOW unless already known to one of the surgeons. If admitted during normal working hours, the juniors will usually perform all of the above as though they are a TCI.

Discharge Summaries


Every in-patient requires a detailed discharge summary. This is particularly important for a tertiary centre when the discharge summary may be the only information the consultant has about that patient’s stay.

All discharge summaries should be checked by the Registrar/Consultant of the week and ask if you are unsure about any aspects of their management.


e.g. 75 YO male admitted with Left critical limb ischaemia. Background of IHD, AF on warfarin etc.

Include the results of any investigations they have had, typically CT peripheral angiogram (CTA), potentially an echo, CT head etc.

Any medications that have been stopped e.g. ramipril stopped due to AKI should be included and in the recommendations/comments put a note to the GP i.e. consider re-starting with regular U&E checks.

Any additional tasks should go in the recommendations/comments e.g. vein mapping to be arranged as an OP, Dual anti-platelets to continue for 6 weeks etc.

When it comes to follow-up, it is useful to ask the patient where they are from i.e. COCH, Arrowe park (APH) or Warrington (WGH) and if they are known to any consultant. Also any other professionals who have seen the patient may want to follow them up e.g. osteomyelitis sometimes have vascular and orthopaedic follow-up. Equally, a post-op stroke may be followed up by the stroke team or poorly controlled diabetes may need to be followed up at the appropriate local diabetes clinic.


NB. The patient is not automatically followed up by the VCOW. Sometimes if they are an emergency patient (known to no one) and the VCOW doesn’t work in their area, you may have to write “F/U with any Warrington consultant in 6-8 weeks”.



Discharging patients on warfarin

· Before discharging a patient on warfarin you need to ensure they have an appointment to get their INR checked

· It is usual procedure to get them an appointment at a hospital anti-coagulation clinic as some GPs are not happy to dose patients

· Referral to the COCH clinic is on the back of the yellow warfarin chart- fill it out and run it down to the clinic to get an appointment time

· Warrington and Arrowe park have referral forms that need to be faxed across to them, you can then ring and chase an appointment prior to discharge

· Very rarely, a patient goes to the GP/a district nurse who will do their bloods and the GP will dose them. You can ring the practice directly to ensure this is the case.


Regardless of how it happens all patients discharged on warfarin need to have arrangements made for them to have their INR checked.



Important protocols


Diabetes and surgery


A summary of the guidance available on the intranet (search under “Diabetes and Surgery”) Please check this information is the latest clinical guidance

There is little evidence that strict glycaemic control is necessary and therefore bloods glucose should be kept between 4 and 12mmol/l.

The junior doctors largely prescribe the insulin on the wards and responsibility to maintain BMs 4-12 falls on their shoulders. Although the diabetes specialist nurse (DSN) is happy to advise, they should not be relied upon for day-to-day adjustments in insulin. The DSN Bleep is 2796.

Professionals referring patients for surgery should make sure they have a HbA1c <69mmol/mol and if control is worse than this, they should refer to the diabetes specialist team.

The perioperative plan for their diabetes treatment should be discussed with the patient to allay anxieties i.e. what is the anticipated starvation period, changes to their usual insulin and peri-operative treatment i.e. GKI or VRIII.

Ideally diabetics should be first on a theatre list and should not have an overnight stay prior to surgery where possible.


*See Trust Antibiotic guidelines on the intranet for empirical Abx choices- this requires some judgement on the severity of infection.


Contrast-induced AKI

Contrast-induced AKI (CI-AKI) is thought to be due to a combination of renal under-perfusion and direct effects of the contrast medium causing tubular toxicity.

CI-AKI is defined as:

· A rise in serum creatinine of >26umol/l within 48 hours

· Rise in serum creatinine >1.5 fold from baseline within 1 week

· Urine output of <0.5ml/kg/hr for >6 hours


Risk factors for AKI

· eGFR <40/ renal transplant

· Diabetes

· Heart failure

· Hypovolaemia

· Aged >75

· Intra-arterial injections

· Acutely ill patients

· Increased dose/multiple doses of contrast

· Nephrotoxic drugs: ACEIs, NSAIDs, aminoglycosides etc.



· Ensure patients have an up-to-date eGFR

· If the baseline eGFR is <60, check U&Es 48 hours post-study

· The decision to stop drugs like metformin an ACEIs is at the discretion of the referring clinician


Pre-hydration for everyone having contrast:

· eGFR >30 drink 2 Litres for 2 days before and 2 days after

· eGFR <30: Admission and IV re-hydration. 100ml/hr 3 hours pre and 6 hours post-contrast


NB. Full guidelines available on the intranet


Common vascular surgeries

Carotid Endarterectomy

Carotid endarterectomy involves the removal of the atheromatous plaque, situated at the carotid bifurcation.

Patients may be suitable for a Carotid EndArterectomy (CEA) if they have a >50% stenosis (according to NASCET- North American Symptomatic Carotid Endarterectomy Trial) of the Internal carotid artery (ICA) and a symptomatic event e.g. non-disabling stroke, TIA or amaurosis fugax.



· Suitable patients must have carotid imaging within 1 week of symptoms

· CEA should be done performed within 2 weeks of symptoms

· Best medical treatment should be in place (BP control, cholesterol, anti-platelet- clopidogrel 75mg is recommended by NICE, smoking cessation)

· Those with <50% ICA stenosis not for surgery and should receive best medical management

· Carotid imaging reports will state which criteria they have used i.e. American (NASCET)/ European (ECST)



· MI (<2%), perioperative stroke (<3% in symptomatic patients), post-op bleeding and consequences of a cervical haematoma (airway compromise), infection

· Nerve injury (<3% of pts):

· CN XII: check pts tongue pre-op

· CN VII: check facial symmetry pre-op

· CN X: check for hoarseness pre-op

· CN IX: dissection of this innervates the baroreceptor and can cause bradycardia and hypotension

· Sympathetic nerves: Horner’s syndrome

· Hyperperfusion syndrome: chronic ischaemia results in vasodilatation, when re-perfused, the arteries are unable to vasoconstrict and the increased pressure damages the capillary bed resulting in oedema and haemorrhage- HTN is a predecessor of this syndrome. Features include ipsilateral headaches, seizures including Todd’s paresis (mimicking stroke) and intracerebral haemorrhage. These symptoms occur in the first 2 weeks.


To monitor HTN adequately all CEAs have at least a 1-day stay on ICU post-procedure. Labile blood pressure is the result of interruption to the carotid baroreceptors.


Typical length of stay (LOS): 1-3 days.



Lower limb bypass surgery

Intermittent claudication is a reproducible discomfort induced by exercise and relieved with rest that is due to vascular insufficiency.

A patient presenting with chronic limb ischaemia can have a minimally invasive procedure such as angioplasty or stenting via Interventional radiology (IR) or they can undergo a bypass procedure using either autologous veins or synthetic graft.



Graft surveillance and graft failure


Post-bypass, patients will have graft surveillance with regular duplex scans as an OP. Failure of the graft is particularly important for autologous vein grafts.

There are 3 major time periods for graft failure:

· Immediately within 30 days- due an unrecognised hypercoagulable state, technical complications, inadequate inflow etc.

· 30 days to 1 year: usually due to myointimal hyperplasia within a vein graft

· Late graft failure usually due to progression of atherosclerotic disease


Typical graft surveillance


· Peri-operative

· 6 weeks post-op

· 3 monthly for 1 years




Patients presenting with critical limb ischaemia, at one year 25% will have an amputation and 25% will have a fatal CV event. Prognosis is worst amongst smokers and diabetics.


Guidance for juniors

· Once the decision to bypass is made, the patient will need the usual pre-op work-up i.e. bloods including a coagulation screen and a G&S, they will also need an ECG. The consultant will also ask you to arrange vein mapping on MEDITECH via CRV Vasc US

· Do not give these patients TEDS stockings

· Avoid cannulating veins that the surgeons will use- ALWAYS ask

· Ensure patients are on a statin and an anti-platelet

· Surveillance will be arranged by the surgeon in OP clinic





Some of these patients will require re-hydration prior to IV contrast- see the summary of the protocol above or on the intranet.

If any of these patients require an inpatient stay, it is important to check their groin wounds for haematomas/signs of infection.


NB. Check the note from IR, if they have a stent in situ then the patient may require dual antiplatelets. Dual antiplatelets are given only for a specified duration. Following this, usually aspirin is stopped and clopidogrel is continued. Please check with the consultant on the duration of dual- antiplatelets. It is extremely rare that antiplatelets and anticoagulants are prescribed together. Enquire about the need for Lansoprazole.


NB. There is an interaction between omeprazole and clopidogrel so Lansoprazole is favoured on ward 54.



As of October 2015, we have an amputation pathway that should be commenced once the decision has been made for the patient to have a major amputation i.e. BKA, TKA, AKA. You should document the notes from the ward round in the booklet and not in the normal notes. Sign the front of the booklet so everyone knows has initialled to say things have been done. Compliance with this booklet is audited so please fill it out accurately. The idea behind the booklet is to enhance communication between medical and allied health professionals with a view of expediting discharge. It also acts as a useful reminder to comply with the analgesia required (as described above).

Abdominal aortic aneurysm repair (AAA)

An AAA is a focal, full-thickness dilation of the aorta >50% greater than its normal diameter. The infra-renal section of the aorta is the most common site, where a diameter of >3cm is considered aneurysmal. An AAA can be repaired as an emergency or as an elective case. Patients can undergo an open or an endovascular repair (EVAR). The goal of aneurysm surveillance and repair is to prevent death from rupture of the aneurysm whilst also minimising the morbidity and mortality associated with repair. An open repair has a higher peri-operative mortality (3-5%, compared with 0.5-2% for EVAR) but provides a more definitive repair. Decision for Open vs EVAR is made on a patient-by-patient basis taking into account patient co-morbidities, age, anatomy, life expectancy etc.

Indications for intervention:

· >5.5cm asymptomatic AAA

· Rapidly expanding >1cm/year or >0.5cm/6months

· Symptomatic AAAs; these usually present with pain and may indicate imminent rupture/ rapid expansion/compression of surrounding structures/inflammation


NB. It is important to optimise CV risk factors in these patients, including smoking cessation.


NB. National AAA screening: a single USS scan is offered to men when they reach their 65th birthday. Men with an aorta >4cm in diameter are recruited to the AAA surveillance program. Surveillance for AAAs generally involves an USS/CT every 6-12 months for aneurysms 4-5.4cm.




Useful contacts


Countess of Chester Hospital

To bleep someone: dial 82+ bleep + extension


VCOW VoIP 3800

On-Call SpR Bleep 3453


COCH Vascular Secretaries


Nicola Price x5465

Sec to DIMS

Chelsea x5464

Sec to MAKA & BAAR

Sophie Howard

Sec Support x3225


Regional SMart Secretaries


Louise Rule 0151 6047530

Sec to CCOL & WILE

@ Arrowe park (WUTH)


Sue Wilson 0151 6047054

Sec to CRAM & BAAR


@ Arrowe park (WUTH)


Davina Cieslar 01925 275266

Sec to NICT

@ Warrington (WHH)


Sharon Dobson 01925 662075

Sec to OLOD

@ Warrington (WHH)


Linzi Seaton 01925 662049

Sec to OLOD

@ Warrington (WHH)


Deb Toole

Sec to THAD

@Warrington (WHH)

Health Records

Health records x6460


Helen x6400

Cheryl x6434


SMart Management Team


Emma Sands x3509

Jayne James x6137

Laura Bennett x5125


Vascular/SMart Specialist Nurses


Vicky Taylor x3226

Dom Turburville x5477


Other Departments


Pre-asses Clinic x6435

Ward 54 x2054

Ward 54 manager x5496

Wd 54 MDT room x5582

TAU x6356 x5779

Admissions x4450

JDSC Recep x6045

Anaes Sec x5404 x5461


Moira Savage Renal unit @ APH 0151604 7543


Lucy Parry x3219 VOIP x2315


Emma Smith x4258


Vasc Sec FAX: 01244 365139


Anaesthetic Consultants


Matthew Van Miert

Mark Hughes

Craig Cowa

Suresh Singaravelu

Carl Wright


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