Question 1

You mentioned a case where a patient initially appeared to have an arterial pain problem but ultimately did not need a vascular intervention. Can you say more?

Dr. Biswarup Purkayastha · Accepted Answer

It is a vascular disease, but the vascular problem is not what is causing the pain in this elderly lady — and if medicines can manage the condition, there is no need to intervene, even if that is commercially a loss rather than a win. There has been a silent shift from a doctor-patient relationship to a doctor-hospital relationship, where a patient's data no longer stays with the treating doctor once they change hospitals. Old-school medicine — operating only when needed, never when not needed — is what should endure through that change.

Question 2

This is similar to a past case where eye pain turned out to be a neurosurgical problem — the presenting complaint pointed one way but the real cause was elsewhere. You made a related point about not confusing varicose veins with cellulitis.

Dr. Biswarup Purkayastha · Accepted Answer

Never confuse varicose veins with cellulitis and simply give a course of antibiotics to send the patient away — that is the wrongest possible thing to do, and it is not a constructed scenario. This happens regularly in real-life GP clinics, and any swollen leg deserves at least a Doppler ultrasound before it is written off as a skin infection.

Question 3

How does the quality of the information a referring doctor sends you change the outcome for the patient?

Dr. Biswarup Purkayastha · Accepted Answer

Out of roughly 25 healthcare facilitators sending referrals, only one or two send a report in a structured format. A recent case arrived with mismatched patient names, ages and even genders across different files for what turned out to be the same patient — a PDF here, a broken image file there, no consolidated record. I would rather give no advice than wrong advice built on poorly collated information.

Question 4

Can a patient with DVT have a normal D-dimer?

Dr. Biswarup Purkayastha · Accepted Answer

Absolutely, yes — particularly if the D-dimer is done after the acute phase, in a subacute presentation of a few days. Despite the test's high sensitivity, the result can come back in the low hundreds, nowhere near diagnostic. DVT is an anatomical problem, and for an anatomical problem the answer is to see it directly on ultrasound, not infer it from a blood marker. Vascular ultrasound is learnable within three to four months, and we train nearly all our trainees to do it routinely.

Question 5

What are the key prognostic factors for endovascular laser ablation of varicose veins?

Dr. Biswarup Purkayastha · Accepted Answer

Laser ablation for superficial spider veins or one or two perforators has an excellent prognosis, and works well up to the perforator level. But if the saphenofemoral junction itself is regurgitant, open surgery to ligate the SFJ and clip the draining tributaries is usually the better option rather than relying on endovascular ablation alone.

Question 6

A 78-year-old patient has arterial disease in the below-knee territory. Some doctors suggested angioplasty, while top vascular surgeons felt nothing needed to be done and that intervention carried risk. What is your view?

Dr. Biswarup Purkayastha · Accepted Answer

In a fragile patient, angioplasty is best avoided below the knee — it gives reasonable short-term results but nothing very promising long-term. If intervention is genuinely needed, it is more often approached surgically, favouring a reverse femoro-tibial bypass using the patient's own saphenous vein over a prosthetic graft, and favouring open surgery over an endovascular approach in this territory. Below the knee: use the simpler, older, better-proven option, and know when not to intervene at all.

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