Question 1

Your presentation included a case we referred to you. It initially appeared to be arterial pain, and there was arterial disease, but your investigations and management plan showed the pain was not vascular. Can you say more about that decision?

Dr. Biswarup Purkayastha · Accepted Answer

It is a vascular disease, but the vascular problem is not what is causing the pain. For an elderly lady, if medicines alone can manage the condition, you do not need to intervene, even if that turns a commercially win-win decision into a lose-lose one. I am happy to make that decision every single day of my life, because of the trust placed in me.

There has been a silent transition from the doctor-patient relationship to a doctor-hospital relationship. When I started in medicine, I understood it as privileged communication: your data and your condition stayed safe with me. Today your data is the hospital's data, and if I change hospitals, my patients' data stays with the hospital. Some old-school doctors like me will resist these changes. At times, the old-school way of approaching a problem, respecting the trust, operating only when needed and never when not needed, is the right one.

Question 2

We once had a patient with eye pain that first appeared to need an ophthalmology intervention but turned out to be a neurosurgical problem. Presentations often mislead, as you said about not confusing varicose veins with other conditions. How do you see this?

Dr. Biswarup Purkayastha · Accepted Answer

Never confuse varicose veins with cellulitis, give the patient a course of antibiotics and send them away. That is the wrongest possible thing to do. These are problems that happen in real-life GP clinics; they are not constructed scenarios.

Question 3

As a specialist you receive reports from many sources. How important is it for a referring doctor to set interpretation aside and share accurate, complete medical information with the specialist?

Dr. Biswarup Purkayastha · Accepted Answer

It is very important. Jivo is not the only one that does it well; perhaps one or two companies do. But of the 25-odd healthcare facilitators I engage with, only one or two send a report in a structured format. Only yesterday I had to gently reprimand a facilitator who sent a report with one name and age, then another report with a female name, saying the name and gender had been wrong the first time. We assumed it might be a different patient; after half a day's struggle I understood they were sending two reports for the same patient, in different formats, one a PDF and the other a broken image, with no collated PDF that could be opened and read through. That makes it very difficult for you to explain yourself and for me to understand. When information is not properly collated, you tend to give the wrong advice to the right patient, and I would rather not give advice on wrong information.

Question 4

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

Dr. Biswarup Purkayastha · Accepted Answer

Yes. If the test is not done on time, or is done after the acute phase, when the DVT has been present for a few days because the patient did not present on the day of the pain and tried some over-the-counter medicines, the D-dimer can come back in the few hundreds, not thousands, perhaps 150 or 200, despite the test's high sensitivity. That is not enough to diagnose a DVT. A D-dimer in a subacute DVT can be normal, and you will miss the thrombosis.

DVT is an anatomical problem, and for every anatomical problem the option is to see it. If a friend outside tells you there is a beautiful rainbow in the sky, you go out and see it yourself rather than listen to a description. If there is a deep vein thrombosis, I want to see it on an ultrasound. Ultrasound is an easy tool: it took me barely 3 to 4 months to pick up, and despite the challenges India's gender determination law creates around ultrasound, we still train almost all our trainees to do routine vascular ultrasound so they can identify these problems themselves.

In today's DVT pathway, if you suspect a DVT you get an ultrasound within 4 hours. If it is positive, you diagnose the DVT and start anticoagulation; you do not need a D-dimer. Only when the ultrasound is negative does a positive D-dimer suggest the person may have a DVT. A negative D-dimer makes DVT unlikely and points to other diagnoses, but a subacute DVT may give a negative D-dimer, and without an expert hand a scan may also miss it by reading partial recanalisation as no thrombosis. Maintain a very high index of suspicion; D-dimer alone cannot be the whole and sole means of identifying a DVT.

Question 5

What are the key prognostic factors for endovascular laser ablation?

Dr. Biswarup Purkayastha · Accepted Answer

Laser ablation is good for superficial spider veins and for one or two perforators, and it works well up to the perforator level. If the saphenofemoral junction (SFJ) is regurgitant, more often than not I would want to open a small segment at the junction and ligate and clip the tributaries that drain there. I perform endovenous laser ablation routinely; my most recent case was only two or three days ago. For perforators and superficial veins it has an excellent prognosis, and even when there are only superficial varicose veins and no leaking perforators, laser ablation may be the way forward.

Question 6

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

Dr. Biswarup Purkayastha · Accepted Answer

In a frail patient, angioplasty below the knee is best avoided. It gives reasonable short-term results, but nothing very promising in the long term. If you have to intervene below the knee, it is more often than not a surgical intervention, and if you create a bypass, it is more often than not a reversed vein bypass rather than an artificial graft. Below the knee, try to do the simpler, older, easier things. That is how I would look at it.

Live Discussion with Dr. Biswarup Purkayastha

Your presentation included a case we referred to you. It initially appeared to be arterial pain, and there was arterial disease, but your investigations and management plan showed the pain was not vascular. Can you say more about that decision?

We once had a patient with eye pain that first appeared to need an ophthalmology intervention but turned out to be a neurosurgical problem. Presentations often mislead, as you said about not confusing varicose veins with other conditions. How do you see this?

As a specialist you receive reports from many sources. How important is it for a referring doctor to set interpretation aside and share accurate, complete medical information with the specialist?

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

What are the key prognostic factors for endovascular laser ablation?

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

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In This Series: Vascular Surgical Problems: From the GP's Clinic to the Specialist's Office