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VASCULAR SURGERY – A MEDICO-LEGAL OVERVIEW PART II

By Mr Michael Gaunt MA, MD, FRCS. Consultant Vascular Surgeon, Cambridge

As discussed in the last issue, focussing on arterial conditions, vascular surgery is a high risk speciality for medicolegal claims, primarily because when problems occur within the vascular system they can do so quickly and with severe limb and lifethreatening complications. This article will concentrate on conditions of the venous and lymphatic systems.

Venous Conditions

The veins are the low pressure vascular structures that return blood to the heart. One of the commonest venous conditions is varicose veins which can affect up to 1 in 4 of the adult population and their treatment is one of the commonest procedures performed in UK hospitals and clinics. Varicose veins occur when the one way valves inside the veins become incompetent resulting in abnormal blood flow which produces a spectrum of symptoms from mild cosmetic issues to non-healing venous ulcers. Treatment ranges from injection sclerotherapy to surgical ‘stripping’ of the veins. Traditional surgery can be associated with significant complications such as damage to nerves, major arteries and veins and deep vein thrombosis. Newer techniques include the less invasive endothermal ablation techniques such as the endovenous laser (EVLA) or VNUS Closure methods which appear to be associated with a lower incidence of such problems, however complications and poor outcomes still occur.

Thrombosis can occur in arteries or veins. Thrombus forms in flowing blood whereas clot forms in blood that has ceased to flow. Thrombosis can occur to block or partially block an artery or vein in one part of the body and then a piece of thrombus can break off and be carried in the blood stream to lodge

in another part of the body – an embolus. One of the commonest examples of this process is deep vein thrombosis (DVT) where thrombus forms in the major veins of the legs or pelvis. Frequently, an embolus or several emboli breakaway from the DVT and lodge in the lungs causing a pulmonary embolus. DVTs can occur spontaneously or be ‘provoked’ by surgery, immobility or trauma. The National Institute for Health and Clinical Excellence (NICE) guidelines state that any DVT or PE occurring within three months of surgery, immobility or trauma should be considered as provoked. The risk of DVT/PE can be reduced by the appropriate use of blood thinning medication such as heparin, warfarin or one of the novel oral anticoagulants and other mechanical measures. All patients admitted as an inpatient should have a DVT risk assessment and receive thromboprophylaxis according to published guidelines. A major DVT affecting the veins in the leg can permanently damage the deep veins resulting in lifelong leg swelling, pain and venous ulceration. Pulmonary emboli can cause symptoms ranging from mild chest pain and shortness of breath to sudden death or long term pulmonary hypertension. Some decades ago, in order to try and prevent pulmonary emboli, clinicians began inserting metal filters into the main vein leading to the heart and lungs; the inferior vena cava. Many of these caval filters were designed to be removed once the risk had decreased but many were left in situ. These are now causing problems such as migration, fracture of the struts, perforation of the vena cava and occlusion of the cava. Failure to assess DVT risk, failure to provide adequate thromboprophylaxis and caval stent complications can give rise to claims, as can DVT occurring after accidents and trauma.

Lymphatic Conditions

Lymphoedema is the accumulation of fluid in a limb due to damage to or gradual deterioration of the lymphatic vessels. Lymphoedema can be primary with no underlying cause or secondary caused by trauma, cancer, infection, radiotherapy or surgery. Swelling can range from minor foot, swelling restricting choice of footwear, to enormous leg swelling, causing lifelong disability. Claims arise from failure to give informed consent to patients undergoing interventions that carry a risk of lymphoedema, failure to investigate underlying causes, and iatrogenic or accidental damage to the lymphatic vessels. Finally, a wide range of iatrogenic or accidental injuries can give rise to vascular damage with significant consequences. Generally, in any circumstances resulting in damage to or conditions affecting the arteries, veins or lymphatics anywhere in the body, apart from the heart or brain, then a vascular surgeon may be able to provide advice and an opinion.