When should a patient be referred to vascular surgery?

When to Refer to Vascular Surgery

Patients with critical limb ischemia (CLI), acute limb ischemia with a salvageable extremity, or acute vascular emergencies require urgent referral to a vascular specialist, as timely intervention is essential to prevent amputation and improve outcomes. 1, 2

Emergent/Urgent Referrals (Within 24 Hours)

Critical Limb Ischemia

• Patients with CLI should be referred immediately to a vascular specialist, as most will require amputation within 6 months without revascularization. 1, 2
• CLI is characterized by ischemic rest pain, non-healing ulceration, or tissue loss in the setting of peripheral arterial disease 1, 2
• These patients require detailed arterial mapping and prompt consideration for endovascular or surgical revascularization 1

Acute Limb Ischemia

• Patients with acute limb ischemia and a salvageable extremity require emergent evaluation and prompt revascularization. 1
• Acute limb ischemia presents as rapid or sudden decrease in limb perfusion threatening tissue viability 1
• Do not pursue vascular evaluation or revascularization attempts in patients with nonviable extremities 1

Acute Intestinal Ischemia

• Refer immediately any patient with acute abdominal pain out of proportion to physical findings who has cardiovascular disease history or recent arterial interventions. 1
• Patients developing abdominal pain after procedures traversing the visceral aorta, those with atrial fibrillation, or recent myocardial infarction warrant urgent vascular evaluation 1

Large Vessel Vasculitis Emergencies

• Arterial vessel dissection or critical vascular ischemia in patients with large vessel vasculitis (giant cell arteritis or Takayasu arteritis) requires urgent referral to a vascular team. 1
• Patients with new-onset visual symptoms suggesting giant cell arteritis should be seen as soon as possible to prevent permanent vision loss 1

Semi-Urgent Referrals (Within Days to Weeks)

Symptomatic Carotid Disease

• Patients with symptomatic carotid stenosis >50% should undergo carotid intervention as soon as neurologically stable after 48 hours but definitely within 14 days of symptom onset. 3
• Symptomatic patients include those with recent transient ischemic attack or stable stroke (modified Rankin scale 0-2) 3

Renal Artery Stenosis with Specific Indications

• Refer patients with hemodynamically significant renal artery stenosis presenting with recurrent unexplained heart failure, sudden unexplained pulmonary edema, accelerated/resistant/malignant hypertension, or progressive chronic kidney disease. 1
• Percutaneous revascularization is indicated for these specific clinical scenarios 1

Worsening Limb/Organ Ischemia in Vasculitis

• Patients with Takayasu arteritis or giant cell arteritis experiencing worsening signs of limb or organ ischemia despite immunosuppressive therapy should be referred to vascular surgery, though medical therapy escalation should be attempted first. 1
• Surgical intervention should ideally be delayed until disease is quiescent 1

Elective Referrals

Severe Aortic Stenosis/Regurgitation

• Patients with bicuspid aortic valve and ascending aorta diameter ≥5.0 cm or progressive dilation ≥5 mm per year require referral for surgical repair or replacement. 1

Stable Peripheral Arterial Disease

• Patients with intermittent claudication significantly limiting quality of life may benefit from vascular evaluation for potential revascularization 1
• However, medical management should be optimized first in stable claudication 1

Large Vessel Vasculitis - Elective Interventions

• In patients with large vessel vasculitis, elective endovascular interventions or reconstructive surgery should only be performed during stable remission. 1
• The type and timing of surgical vascular intervention should be a collaborative decision between vascular surgeon and rheumatologist 1

Key Clinical Pitfalls to Avoid

• Do not delay referral for CLI hoping medical therapy alone will suffice—most patients require amputation within 6 months without revascularization. 1, 2
• Do not attempt to triage vascular referrals based solely on referral letters, as they often lack critical information about symptom severity, claudication distance, rest pain, and clinical signs of critical ischemia. 4
• Early treatment at a vascular referral center is independently associated with lower mortality compared to transfer after initial presentation elsewhere—consider direct admission when acute vascular disease is suspected. 5
• Do not perform surgical intervention in Takayasu arteritis patients with active disease—delay until quiescence is achieved to optimize outcomes. 1