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The circulation consists of three systems named venous, arterial, and lymphatic. Each of these systems consists of interconnecting pipes known as vessels that carry blood and blood products around the body. The arterial system carries blood rich in oxygen from the heart to all the organs and tissues in the body. The venous system returns that blood once its oxygen has been delivered, back to the heart and lungs in order to be enriched again with oxygen. The lymphatic system works in conjunction with the venous system in returning any residual fluid from the tissues back to the heart. In general terms the circulation can be affected by conditions that cause the vessels to narrow down (stenosis), block off (occlude) or even expand in an abnormal fashion (aneurysm). Patients with circulation problems should see their primary care physician (GP) and may require referral to the Vascular Surgeon. A description of some of the more significant conditions that can cause problems with the circulation is provided below.
Problems with the Venous System:
1. Varicose veins and chronic venous insufficiency:
Varicose veins are large distended superficial veins which are not properly returning blood from the lower leg to the heart. Normally veins have valves that open to allow the flow of blood to the heart and close to prevent backflow or reflux of blood to the foot. When these valves fail to function properly and become "leaky", blood overfills and distends these veins which can be seen bulging under the skin, otherwise known as varicose veins. They affect 50% of people aged 50 and over. Varicose veins are commoner in women, particularly during pregnancy and can be hereditary. Symptoms include, aching pain, heaviness and itching which are wore towards the end of the day. Chronic venous insufficiency is a term used when varicose veins become severe, and if left untreated can cause skin ulceration that can be very difficult to manage. Ultrasound assessment of varicose veins, know as venous duplex scan can be useful in assessing the levels of valve reflux which can help in planning surgery. Standard surgery for varicose veins is performed under general anaesthesia and involves stripping of the affected vein and its complete removal from the leg. Newer techniques have been developed including endovenous laser therapy or EVLT. This procedure can be performed under local anaesthetic. Through a small puncture in the leg a laser fibre is passed up the affected varicose vein. Laser energy is passed through the fibre and into the vein causing the vein to close thus negating the need to remove the vein. Other treatment options for varicose veins include radiofrequency ablation and foam injection sclerotherapy.
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2. Deep vein thrombosis:
Deep vein thrombosis (DVT) is the development of a blood clot known as thrombus in the deep veins of primarily the legs and pelvis. This is different from clots forming in the superficial veins referred to as superficial thrombophlebitis, also commonly known as "phlebitis". This distinction is important as blood clots in superficial veins rarely cause serious problems whereas clots in deep veins require immediate medical attention. DVT tends to present with localised pain or tenderness within a calf or thigh muscle, usually associated with ankle and calf swelling. Blood clots in deep veins can grow in size, break loose, and then travel through the bloodstream to the lungs resulting in life-threatening pulmonary embolism (PE). Symptoms relating to PE include breathlessness, chest pain, palpitations, increased heart rate and coughing. Risk factors for DVT include smoking, obesity, the contraceptive pill, having had a DVT before and pregnancy. In addition, there are a few rare medical and inherited conditions that are associated with an increased tendency of the blood to clot. Long-haul flights can predispose to DVT because of dehydration and lack of activity, both of which cause the blood in the circulation to become more sluggish and form clot in the vein. It is therefore important to drink adequate quantities of non-alcoholic fluids and exercise the feet either while sitting or by getting up and walking in the cabin of the plane. Elastic compression stockings also improve the circulation in the legs thus protecting from DVT. The most commonly used test to diagnose DVT is an ultrasound scan of the veins in the affected limb (venous duplex scan). Occasionally a special X-ray test, known as a venogram may be required. Treatment of this condition is mainly by drugs that thin out the blood known as anticoagulants, such as heparin and warfarin. Rarely if the clot is too extensive, it may have to be dissolved with other drugs or even surgically removed.
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Problems with the Arterial System:
1. Carotid disease and stroke:
Stroke is the third commonest cause of death in the western world. It usually presents as an either permanent or transient weakness of the limbs on one side of the body or with speech disturbance. In its milder form also known as transient ischaemic attack (TIA) it can also present with a fleeting visual disturbance known as amaurosis fugax. Stroke occurs as a result of a disturbance in the blood flow through the brain. The carotid artery is the main blood vessel that carries blood from the heart to the brain. Disturbance in the blood flow through this vessel can result in a stroke or any of its milder forms as already mentioned. Most commonly this means that a narrowing has occurred in the carotid artery secondary to cholesterol, calcium and other factors depositing in its wall, also known as atherosclerosis. This can result in debri being carried off to the brain, often described as an embolic event, or less commonly subtotal or total occlusion of the carotid artery lumen thus depriving the brain of its oxygen supply. There are a number of predisposing factors to carotid disease and stoke, including undiagnosed or poorly controlled blood pressure or hypertension, smoking, diabetes, and hyperlipidemia or high cholesterol. The commonest tests used to diagnose carotid disease and stroke include ultrasound scan of the neck known as carotid duplex and CT scan of the brain which is a specialised X-ray scan. Blood tests are also important to check for high blood sugar and cholesterol. Long-term treatment measures include risk factor management such as control of blood pressure, diabetes, smoking cessation and diet modification. Low dose aspirin therapy and similar other drug-therapy that reduces clot formation may be of benefit as well as cholesterol lowering drug therapy. A proportion of patients will benefit from surgery to the carotid artery referred to as carotid endarterectomy, to remove the debri from its wall. This will primarily be dictated by the severity of narrowing in the carotid artery. Carotid endarterectomy is a very safe procedure and is considered the gold standard which can be performed either under full general anaesthesia or under local anaesthesia. Currently the role and safety of carotid stenting is being evaluated. This is a procedure whereby the narrow carotid artery is crossed by a wire over which an expandable metallic cage (stent) is deployed to open up the lumen of the vessel.
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2. Peripheral vascular disease:
Peripheral vascular disease (PVD) manifests itself primarily as atherosclerotic narrowing of the arteries that supply oxygen and blood to the muscles in the legs. It mainly affects the arteries in the legs such as the superficial femoral artery but also the abdominal aorta and iliac arteries in the pelvis. It is more likely to occur with increasing age and men are more frequently affected than women. Patients usually complain of calf and occasionally buttock pain on walking which improves with rest, known as intermittent claudication. Depending on the severity of the disease patients may be limited to the extent whereby they experience pain after only a few steps or even describe pain in their toes whilst in bed at night, known as nocturnal rest pain. If left untreated this may result in ulceration or gangrene of the feet also known as critical limb ischaemia. The most important risk factor for developing peripheral vascular disease is smoking. Others include diabetes, hypertension, obesity and hyperlipidemia. Blood tests are important to check for high blood sugar and cholesterol, as well as anaemia (low red blood cell count) or polycythemia (high red blood cell count). More specialist tests used to help in the management of peripheral vascular disease include treadmill testing, ultrasound scan of the peripheral arteries known as peripheral arterial duplex scan and angiography, an X-ray investigation which involves injection of a special dye in order to take pictures of the circulation. The most important aspect in the management of peripheral vascular disease involves risk factor modification. This includes stopping smoking usually with the help of smoking cessation clinics, control of blood pressure, diabetes, weight loss, and cholesterol lowering drug therapy. Low dose aspirin therapy has been shown to reduce the risk of heart attack and stroke in patients suffering from peripheral vascular disease. Supervised exercise programmes can improve walking distance over the course of weeks and months. In patients who experience debilitating symptoms that may significantly interfere with daily activity or if there is evidence of critical limb ischaemia, surgical intervention should be considered. This may be in the form of balloon angioplasty, stent insertion, or open bypass surgery. The type of intervention performed will to a large extent depend on how extensive the blockages in the arterial circulation are.
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3. Arterial aneurysms:
The term aneurysm refers to a permanent significant localised expansion of a blood vessel. The aorta is most commonly affected although other vessels can be affected as well. It is the main artery that originates from the heart and runs a long course through the chest and into the abdomen giving off branches along its course to every organ in the body. Depending on the anatomical location of the aortic aneurysm it is either described as thoracic when it is in the chest or abdominal. If it affects both sections then it is described as thoraco-abdominal aortic aneurysm. The abdominal aortic aneurysm also referred to as "triple A" is by far the commonest. There is an increased incidence with age and men are up to five times more commonly affected than women. Other predisposing factors include hypertension, smoking and positive family history. By end large they tend to cause no symptoms (asymptomatic) and are picked up as an incidental finding during abdominal examination or following an abdominal X-ray or scan. The few that do cause symptoms usually manifest with abdominal or back pain. Depending on the size of the aneurysm surgical repair may be indicated as there is an increased risk of rupture. Similarly if the aneurysm is causing symptoms surgical repair is indicated irrespective of size as again there is an increased risk of rupture. An abdominal ultrasound scan will accurately diagnose an aortic aneurysm and an abdominal CT scan will provide useful information with regards to its shape and extent. Standard open surgical repair requires an abdominal incision under general anaesthesia. The aneurysm sac is then isolated opened and replaced with a synthetic tube known as graft which is sutured onto the healthy aorta. There are a number of modifications of this technique including performing the procedure through a very small abdominal incision, otherwise known as mini-laparotomy. In recent years a new technique has been developed, known as endovascular aneurysm repair or EVAR, which can be performed if necessary under local or epidural anaesthesia. No abdominal incision is required and the aortic aneurysm is treated through a small incision in each groin. The new aortic graft is incorporated within a sheathed device that is pushed over a wire under X-ray control and passed up the groin arteries and into the segment of the aorta that contains the aneurysm. The aortic graft is then deployed through its sheath thus bridging the aneurismal aortic segment. In a recent multi-centre clinical trial this new technique has been shown to be at least as good as the standard open repair. However, at present only one third of all patients with abdominal aortic aneurysm are suitable for treatment using this technique. Patients should discussed treatment options with their vascular surgeon.
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Problems with the Lymphatic System:
1. Lymphoedema:
Lymphoedema is a condition that results in progressive swelling of a limb because the lymphatic circulation fails to transport fluid via the lymphatic vessels and lymph nodes. Traditionally lymphoedema has been classified into primary and secondary. Primary lymphoedema mainly occurs as a result of poor development or absence of the lymphatic system and can be hereditary. Secondary lymphoedema occurs when the lymphatic channels become blocked because of infection, following surgery, radiotherapy or as result of an obstructing lesion. Although the diagnosis of lymphoedema can usually be made following examination of the patient a number of tests are available to verify or classify the condition. These include, lymphangioscintigraphy, CT scan, MRI scan and contrast lymphangiography. Treatment will have to be tailored according to the cause and severity of the condition. The basic principle however is to reduce limb swelling. This can be achieved by using simple measures such as elevating the limb, compression hosiery, physiotherapy and manual lymphatic drainage. In the extreme cases debulking surgery may be required. Another important principle is minimising the risk of infection to the affected limb and prompt antibiotic therapy if infection occurs.
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