When to Refer to a Vascular Surgeon

When a general practitioner suspects a vascular problem, the time to refer to a vascular surgeon is once the image is in hand: a CT angiogram for arterial disease or an aneurysm, a Doppler study for varicose veins and an ultrasound for a suspected deep vein thrombosis. Biochemistry alone is not a referral. Acute arterial occlusion is the exception: it goes straight to the nearest emergency department.

That is the organising principle Dr. Biswarup Purkayastha, Consultant – Heart & Lung Transplant and Vascular Surgery, Artemis Hospitals, Gurugram, India, set out for general practitioners in his masterclass on vascular surgical problems, from the GP's clinic to the specialist's office. His argument runs in two directions. Referring doctors can do far more of the diagnostic work than they usually do, and do it in a form a vascular surgeon can act on. Specialists, for their part, must be willing to say that a patient with genuine vascular disease does not need an operation. This guide covers the conditions a GP will meet, what to send with each referral, why the quality of the records matters as much as the tests, and when the right decision is not to intervene. Arterial disease and aneurysms are covered in depth in peripheral arterial disease treatment and aneurysm repair, and venous disease in DVT diagnosis, varicose veins and anticoagulation.

Common vascular conditions in general practice

The vascular conditions a GP sees fall into two families, arterial and venous, in Dr. Purkayastha's grouping of the caseload of a general practice or surgical clinic.

Arterial conditions:

• Peripheral arterial disease (PAD): narrowing or blockage of the arteries supplying the limbs, usually from atherosclerosis, which typically presents as leg pain on walking.
• Hypertension-related vascular disease: damage to the arterial wall driven by long-standing high blood pressure.
• Aneurysms: abnormal, permanent widening of an artery, whether in the abdominal aorta, the thoracic aorta or the femoral artery and the vessels below it.
• Acute arterial occlusion: a sudden blockage of a limb artery, usually by an embolus or a thrombus.

Venous conditions:

• Varicose veins: dilated, tortuous superficial veins caused by failing valves.
• Deep vein thrombosis (DVT): a clot in the deep veins, most often of the leg.
• Chronic venous insufficiency: long-term venous hypertension in the leg, with swelling, skin changes and, at its worst, ulceration.
• Superficial thrombophlebitis: an inflamed, clotted superficial vein.

In his assessment, most of these can be managed by a general practitioner in a reasonable and rational way before the patient is sent on to a specialist. The skill lies in knowing which investigations to complete first, which treatments to start, and which single condition must never wait in a clinic.

Acute arterial occlusion goes to the emergency department, not the clinic

Acute arterial occlusion is the one vascular presentation for which Dr. Purkayastha wants nothing sent to him. The patient should go immediately to the nearest emergency department. "That's not a clinic thing" was his summary.

The reason is time. An acutely ischaemic limb classically presents with the six Ps: pain, pallor, pulselessness, paraesthesia, paralysis and a cold limb (poikilothermia). Viability is measured in hours, and restoring blood flow, by surgical embolectomy (removal of the clot from the artery), catheter-directed treatment or bypass, is an emergency. Arranging imaging, compiling a referral or waiting for a specialist opinion only consumes the window in which the limb can be saved.

How to refer to a vascular surgeon: the image comes first

A referral to a vascular surgeon should lead with imaging, not blood results. The referral Dr. Purkayastha most often receives starts with a poorly written prescription listing the patient's sodium, potassium and latest cholesterol. Those values may matter to the patient's overall care, but they do not move a vascular decision. "More often than not, the story starts with the image," he told the audience. For almost every disease presented to a specialist today, the first thing to send is imaging.

His logic applies across specialties. Someone referring a coronary case should send a coronary angiogram; someone referring an arterial case should send a peripheral CT angiogram. The table sets out what he asks for in each vascular scenario.

The details behind each line, including why the viral serology and creatinine clearance come before the angiogram, sit in the two in-depth articles linked above.

Why the image outweighs the report

A radiology report that reads "infrarenal abdominal aortic aneurysm" (an aneurysm of the abdominal aorta below the arteries to the kidneys) makes no sense to a vascular surgeon, in Dr. Purkayastha's words. A single image makes all the sense. It shows him the landing zones (the healthy segments of artery where a stent graft or a surgical anastomosis can be secured), the maximal diameter of the aneurysm and the repair he would prefer. A written report compresses all of that into one line, and the line rarely carries the information on which the choice of repair depends.

He therefore urges referring doctors to become confident sharing DICOM files, the native digital format of CT, MRI and angiography studies. With the original data rather than a PDF, a specialist can review the study in real time in his own software and reconstruct three-dimensional images of the vessels, which is what allows him to tell the referring doctor exactly what the patient needs.

A clear request helps; a fancy one does not

Some GP clinics send a referral with a working diagnosis and a proposed plan, such as "peripheral arterial disease, acute occlusion, needs embolectomy". Dr. Purkayastha welcomes that clarity, while noting that the specialist remains the better judge of the intervention. For international patients, a referral of that quality also lets the treating team give an early view on practical questions such as cost.

What he cautions against is the very fancy recommendation, including ones suggested because a chatbot or another AI tool proposed them. A basic recommendation is useful; a sophisticated-sounding plan that the anatomy does not support is not. His view is that time-tested open repairs are, at times, still the modality of choice, and he summarised it as "old is gold". The aneurysm section of the arterial disease guide gives his examples and the cost consequences of choosing the wrong repair.

Accurate, collated records are a clinical safety requirement

A vascular referral is only as safe as the records behind it. Asked how important it is for referring doctors to put their own interpretation aside and share accurate medical information, Dr. Purkayastha answered with numbers from his own practice. Of the 25 or so healthcare facilitators he deals with, only one or two send reports in a structured format.

He described a referral from the day before the session. A report arrived under one name and age; another followed under a female name, with a note that the name and gender had been wrong the first time. His team reasonably assumed it was a different patient. Only after half a day's work did it become clear that both documents belonged to the same person, sent in different formats: one a PDF, the other a broken image, with no single collated document that could be opened and read through.

The risk is not inconvenience. When information is not properly collated, he said, "you tend to give a wrong advice to the right patient", and he would rather give no advice than advice built on wrong information. For referring doctors, his remarks translate into a short discipline:

1. Keep the patient's identifiers (name, age, sex) consistent across every document.
2. Send one collated file that can be read from start to finish, not scattered attachments.
3. Send imaging as DICOM files wherever possible, with the report as a companion, not a substitute.
4. State plainly the problem the patient is facing and the question you want answered.

Knowing when not to operate

The intellectual core of the session was restraint. "We need to at times understand when to intervene, and more importantly, when not to intervene," Dr. Purkayastha told the audience.

He illustrated it with a case referred to him: an elderly woman with pain and genuine arterial disease. Investigation showed that the arterial disease was real but was not what was causing her pain. When a suspected arterial cause is not confirmed, his rule is not to stop there but to pursue a neurogenic cause, with imaging of the lower back or a nerve conduction velocity study. At the time of the masterclass she was recovering, with about 95% of her pain resolved, and she had not needed any vascular intervention. The approach is the same in a frail patient with disease below the knee, where he would avoid angioplasty and, if intervention is truly needed, favour a vein bypass, as explained in the arterial disease guide.

He was candid about the commercial side. For an elderly patient whose condition medicines alone can manage, not intervening turns what could have been a commercially win-win decision into a lose-lose one. He is happy to make that decision every day of his life, he said, because of the trust placed in him.

He set this against a wider shift: a silent transition from the doctor-patient relationship to a doctor-hospital relationship. Early in his career he understood medical information as privileged communication between a patient and a doctor. Today a patient's data is the hospital's data, and when a doctor changes hospital, the records stay behind on the hospital's servers. He counts himself among the old-school doctors who will resist that change, and argues that the old-school approach has lasting value: respect the trust, operate only when needed, and never when not needed.

Where to go next

The two in-depth articles in this series cover the clinical detail:

• Peripheral arterial disease treatment and aneurysm repair covers the three-part arterial work-up, the medical options Dr. Purkayastha outlined before any operation, endovascular and hybrid surgery, below-knee disease in frail patients, and open versus stent graft repair of aneurysms, including the cost gap he described.
• DVT diagnosis, varicose veins and anticoagulation covers his case against D-dimer as the test for deep vein thrombosis, the CEAP classification and Doppler protocol for varicose veins, superficial thrombophlebitis, pulmonary embolism and pulmonary endarterectomy, and anticoagulation with rivaroxaban and apixaban.

The questions doctors put to him during the session, on D-dimer, laser ablation and below-knee disease, are collected in the Live Discussion from this masterclass. Dr. Purkayastha has also taught separate masterclasses on pulmonary hypertension, coronary artery disease, heart transplantation for foreign nationals, heart failure and coronary artery disease and valvular heart disease.