Vascular Surgery Nursing Guide for GCC

🌎 GCC Epidemiology Alert UAE, Saudi Arabia, and Kuwait rank in the top 10 worldwide for diabetes prevalence (~19–25% of adults). This drives an epidemic of peripheral arterial disease, diabetic foot, and vascular complications that dominate vascular surgery workload across GCC hospitals.

Peripheral Arterial Disease (PAD)

🧠 Pathophysiology & Risk Factors

PAD results from atherosclerotic narrowing of peripheral arteries, reducing blood flow to the limbs. In GCC populations, diabetes and smoking (particularly in male expatriate workers) accelerate the process significantly.

Key Risk Factors

Diabetes mellitus (strongest GCC risk factor)
Smoking — high prevalence in GCC male populations
Hypertension (>40% adult prevalence in Gulf states)
Dyslipidaemia, hypercholesterolaemia
Chronic kidney disease (linked to dialysis access)
Age >65, male sex, positive family history

📈 Clinical Spectrum

Asymptomatic
ABI <0.9 but no symptoms — detected on screening

Intermittent Claudication
Cramping calf pain on walking, relieved by rest — reproducible distance

III

Rest Pain
Burning forefoot pain at rest, worse at night — limb elevation worsens

Tissue Loss / CLI
Ulceration, gangrene — critical limb ischaemia, amputation risk

📋 Rutherford Classification of PAD

Category	Grade	Clinical Description	Typical ABI
0	0	Asymptomatic	0.7–0.9
1	I	Mild claudication	0.5–0.8
2	I	Moderate claudication	0.5–0.8
3	I	Severe claudication	<0.5
4	II	Ischaemic rest pain	<0.4
5	III	Minor tissue loss (ulcer/focal gangrene)	<0.4
6	III	Major tissue loss (extending gangrene)	<0.4

Abdominal Aortic Aneurysm (AAA)

☣ Definition & Screening

AAA is defined as aortic diameter ≥3 cm (infrarenal). Rupture risk increases sharply above 5.5 cm. GCC screening programs mirror NICE/ACC guidelines.

Screening Protocol

One-time ultrasound screening: men ≥65 years
Women with risk factors (smoking, family history) — consider at 65
3.0–4.4 cm: rescan every 12 months
4.5–5.4 cm: rescan every 3 months
≥5.5 cm (men) / ≥5.0 cm (women): refer for repair
Symptomatic (pain, tenderness): emergency referral regardless of size

🚨 Ruptured AAA — Emergency

Haemodynamic Emergency Classic triad: severe tearing back/abdominal pain + pulsatile mass + hypotension. Mortality without surgery >90%. Permissive hypotension (SBP 50–70 mmHg) prior to operative control preserves clot.

Elective vs Emergency Repair

Elective EVAR/open: planned, optimised, 30-day mortality <2%
Emergency open: midline laparotomy, aortic cross-clamp, 30–50% mortality
Emergency EVAR (EVAR-2): if anatomy suitable — faster, less physiological insult

Carotid Artery Disease

🧠 TIA & Stroke Prevention

Carotid stenosis is a major source of embolic stroke. Atherosclerotic plaque at the carotid bifurcation sheds emboli to the cerebral circulation.

Surgical Thresholds

Symptomatic stenosis ≥70%: CEA within 2 weeks of TIA/minor stroke
Symptomatic 50–69%: CEA if life expectancy >5 yrs
Asymptomatic ≥60–70%: individualised — TCAR or CEA
TCAR (TransCarotid Artery Revascularisation): flow reversal + stenting — lower cranial nerve risk

🚨 Post-CEA Monitoring Points

Neurological assessment q1h — new deficit = emergency CT
BP control: SBP target <150 mmHg (hyperperfusion risk)
Expanding neck haematoma = airway emergency — call surgeon immediately
Cranial nerve assessment: hoarseness, dysphagia, tongue deviation
Drain output: >100 mL/hr = return to theatre
Duplex USS at 1 month, 6 months, then annually

Deep Vein Thrombosis (DVT)

🌊 Virchow's Triad

🛒

Stasis

Immobility, surgery, long flights, Hajj pilgrimage, construction workers standing

🧰

Hypercoagulability

Malignancy, thrombophilia, oral contraceptives, dehydration (heat exposure in GCC)

🔴

Endothelial Injury

Trauma, surgery, central lines, vascular procedures

📋 Wells Score for DVT

Clinical Feature	Score
Active cancer (treatment within 6 months)	+1
Paralysis, paresis, or immobilisation of leg	+1
Bedridden >3 days or major surgery <4 weeks	+1
Local tenderness along deep venous system	+1
Entire leg swollen	+1
Calf swelling >3 cm vs asymptomatic side	+1
Pitting oedema (greater in symptomatic leg)	+1
Collateral superficial veins	+1
Alternative diagnosis as likely as DVT	−2

≤0 Low 1–2 Moderate ≥3 High

Pulmonary Embolism (PE)

🤴 Clinical Presentation

Sudden dyspnoea, pleuritic chest pain, haemoptysis
Tachycardia (HR >100), tachypnoea (RR >20), hypoxia (SpO₂ <95%)
Massive PE: haemodynamic collapse, RV failure, cardiac arrest
ECG: sinus tachycardia (most common); S1Q3T3 pattern (right heart strain)
ABG: hypoxaemia + hypocapnia (type 1 respiratory failure)
CTPA: gold standard imaging

📈 PESI Score & Treatment

Pulmonary Embolism Severity Index stratifies 30-day mortality risk to guide treatment intensity.

Massive PE Treatment Systemic thrombolysis (alteplase 100 mg over 2h) if haemodynamically unstable. Surgical embolectomy if thrombolysis contraindicated or failed.

Treatment Ladder

Low-risk: DOAC outpatient (rivaroxaban, apixaban)
Intermediate: LMWH/UFH bridge, consider IVC filter
High-risk: systemic thrombolysis or catheter-directed
Massive/arrested: surgical embolectomy (sternotomy, bypass)

Varicose Veins

📈 CEAP Classification

Class	Clinical Description	Management
C0	No visible or palpable signs of venous disease	Reassurance, lifestyle
C1	Telangiectasia / reticular veins	Cosmetic sclerotherapy
C2	Varicose veins >3 mm	Compression + EVLA/foam
C3	Oedema (venous origin)	Compression stockings
C4	Skin changes (lipodermatosclerosis, eczema)	Compression + wound care
C5	Healed venous ulcer	Long-term compression
C6	Active venous ulcer	4-layer compression + referral

Additional Vascular Conditions

🧈 Renal Artery Stenosis

Atherosclerotic (90%) or fibromuscular dysplasia (young women)
Presents as resistant hypertension, flash pulmonary oedema, worsening renal function
Diagnosis: renal duplex, CTA, or MRA
Treatment: angioplasty ± stenting; medical (ACEi/ARB — monitor K⁺/creatinine)
GCC: relevant due to high chronic kidney disease burden

🌏 Mesenteric Ischaemia

Acute: sudden severe abdominal pain out of proportion to examination
Causes: embolism (AF), thrombosis, non-occlusive (low flow states)
Lactate rises → bowel infarction → peritonitis → high mortality
Chronic: post-prandial pain ('intestinal angina'), weight loss
CT angiography: diagnoses acute and chronic forms
Treatment: emergency revascularisation ± bowel resection

🇦🇪 GCC Vascular Context

Diabetes Epidemic

UAE (19.3%), Kuwait (23.1%), Saudi Arabia (18.7%) — among world's highest. PAD prevalence in diabetics is 3–4× non-diabetics. Vascular surgery units in GCC are predominantly managing diabetic foot complications.

Construction Worker DVT

Millions of blue-collar workers in UAE/Qatar/Saudi stand for 10–12 hour shifts in extreme heat, leading to dehydration and venous stasis — a significant but underreported DVT risk population.

Hajj Thromboembolism

2–3 million pilgrims annually; prolonged standing, cramped conditions, dehydration, and long-haul flights create a perfect storm for DVT/PE. Anticoagulation counselling for at-risk pilgrims is essential.

Open & Endovascular AAA Repair

⚒ Open AAA Repair

Midline laparotomy or retroperitoneal approach. Proximal aortic clamping, aneurysm sac opened, Dacron graft inserted.

Aorto-Bifemoral Graft

Used when iliac arteries are diseased
"Trouser graft" configuration — limbs to both femoral arteries
Gold standard for aortoiliac occlusive disease
Operative time 3–5 hrs; ICU post-op mandatory

Key Nursing Pre-Op Points

Bowel prep, IV access (large bore ×2 + arterial line)
Group & save / crossmatch (6–8 units PRBC)
Epidural insertion for post-op analgesia
Cardiac/renal optimisation

📈 EVAR (Endovascular Aneurysm Repair)

Stent-graft deployed via femoral access under fluoroscopy. Requires suitable neck anatomy (>15 mm infrarenal neck, <60° angulation).

Advantages vs Open

No laparotomy — shorter ICU/hospital stay
Lower 30-day mortality (especially in high-risk patients)
No aortic cross-clamp — less cardiac/renal stress

EVAR-Specific Complications

Endoleak: blood flow outside graft — Types I–V
Type II endoleak (retrograde lumbar/IMA flow) — most common
Graft migration, limb thrombosis
Post-implantation syndrome: fever + elevated CRP (self-limiting)
Requires lifelong CT surveillance (1, 6, 12 months then annually)

Carotid Endarterectomy (CEA)

⚒ Surgical Technique

Patient supine, neck extended and rotated. Regional (cervical block) or general anaesthesia.
Longitudinal incision along anterior border of sternocleidomastoid.
Carotid bifurcation identified, common/internal/external carotid arteries controlled with slings.
Systemic heparin administered (100 units/kg). Carotid vessels clamped.
Shunt inserted if using intraoperative cerebral monitoring (EEG/stump pressure) shows ischaemia.
Arteriotomy along carotid, plaque removed under direct vision.
Closure: patch angioplasty (vein or synthetic) reduces restenosis vs primary closure.
Haemostasis, layered wound closure. Drain optional.

📋 Patch vs Primary Closure

Patch Angioplasty Preferred Evidence supports patch closure (bovine pericardium, PTFE, or saphenous vein) to reduce risk of restenosis and perioperative stroke vs primary closure. Most centres use patch routinely.

Shunting Decision

Routine shunting: used by default in all cases
Selective shunting: based on stump pressure (<50 mmHg), EEG changes, or awake neurological testing (regional block)
Regional anaesthesia allows awake testing — gold standard for shunt decision

TCAR (TransCarotid Artery Revascularisation)

Flow reversal + carotid stent via mini-incision
Lower cranial nerve injury risk vs CEA
Suitable for high surgical risk patients

Peripheral Bypass Surgery

🥊 Bypass Conduit Selection: Vein vs PTFE

Autologous Vein (Saphenous)

Gold standard conduit for infrapopliteal bypass
Reversed or in-situ technique
5-year patency: 60–70% (femoro-popliteal)
Better in infected fields (groin infection)
Pre-operative vein mapping by duplex USS essential
Arm vein (cephalic) if GSV unavailable

Prosthetic (PTFE / Dacron)

Used above-knee femoro-popliteal if vein unavailable
Higher infection risk — especially in groin
5-year patency: 50% above knee, 30–40% below knee
Adjuncts: Miller cuff, vein patch at distal anastomosis
Requires antiplatelet therapy (aspirin ± clopidogrel)

Bypass Type	Indication	Preferred Conduit	Notes
Femoro-popliteal (above knee)	SFA occlusion, claudication/CLI	GSV or PTFE	Most common infrainguinal bypass
Femoro-popliteal (below knee)	Long SFA + popliteal disease	GSV preferred	PTFE with vein cuff if GSV unavailable
Femoro-distal (tibial/peroneal)	CLI, diabetic foot	GSV mandatory	Technically demanding; requires good runoff
Axillo-bifemoral	Aortoiliac disease, high-risk for aortic surgery	PTFE (8 mm ringed)	Extra-anatomic; infected aortic graft
Femoro-femoral crossover	Unilateral iliac occlusion	PTFE (8 mm)	Lower risk than aortobifemoral

Amputations

🔨 Amputation Levels

Level	Abbreviation	Indication	Rehab Potential
Toe / Ray	—	Isolated digit gangrene, adequate perfusion	Excellent
Syme's (ankle disarticulation)	—	Forefoot gangrene, adequate heel circulation	Good (end-bearing stump)
Below Knee	BKA / TTA	Foot/distal gangrene, popliteal pulse present	Good — prosthesis well tolerated
Through Knee	TKA	Rarely used in vascular	Moderate
Above Knee	AKA / TFA	Extensive ischaemia, BKA failed, knee contracture	Lower — more energy expenditure
Hip Disarticulation	HD	Extensive proximal disease, wet gangrene	Limited

📋 BKA Surgical Overview

Long posterior myocutaneous flap technique (skew flap / Burgess) to ensure vascular supply to stump.
Bone division at 10–14 cm below tibial tubercle (optimal prosthetic length).
Fibula divided 2 cm shorter than tibia, anterior tibial crest bevelled.
Muscles trimmed and fashioned over bone end (myoplasty/myodesis).
Meticulous haemostasis; drain inserted.
Wound closed without tension — crucial in ischaemic limbs.
Rigid dressing or cast applied to control oedema and shape stump.

GCC Note In GCC hospitals, BKA is common due to late-presenting diabetic foot. Many patients arrive with wet gangrene requiring urgent surgery. Rehabilitation planning (prosthetist referral) begins pre-operatively when possible.

Endovascular Procedures

📈 Angioplasty & Stenting (PTA)

Percutaneous transluminal angioplasty (PTA): balloon dilation of stenosis/occlusion
Stenting (bare metal or drug-eluting): for elastic recoil or flow-limiting dissection
Access: femoral artery (retrograde/antegrade), brachial, radial, pedal
Drug-coated balloon (DCB): reduces restenosis in femoropopliteal disease
Tibial angioplasty: preferred in diabetics for below-knee disease (angiosome concept)
Post-procedure: access site pressure, pulse checks q15min ×4

📈 Thrombectomy & Thrombolysis

Catheter-Directed Thrombolysis (CDT)

Infusion catheter embedded in thrombus — urokinase or alteplase
Duration 12–48 hours; nursing intensive: limb obs q1h, access site q4h
Contraindications: recent stroke, surgery <10 days, active bleeding
Monitoring: fibrinogen levels (stop if <1.0 g/L), INR, aPTT

Mechanical Thrombectomy

Aspiration thrombectomy (AngioJet, penumbra) — acute native vessel or graft occlusion
Often combined with CDT (pharmaco-mechanical)
Fogarty catheter embolectomy: open surgical technique for embolic occlusion

AV Fistula & Haemodialysis Access

💉 Brescia-Cimino Radiocephalic Fistula

Gold standard for haemodialysis access. Anastomosis between radial artery and cephalic vein at wrist (end-to-side or side-to-side).

Pre-operative vein mapping (duplex) — cephalic vein ≥2.5 mm required
Regional anaesthesia (brachial block) preferred — vasodilation improves outcome
Vessel anastomosis under loupe magnification
Thrill palpated / bruit auscultated immediately post-creation
Maturation: 6–8 weeks before needling (vein must dilate to ≥4 mm)

GCC Relevance — High Volume UAE and Saudi Arabia have high rates of diabetic nephropathy → ESRD → dialysis. AV fistula creation is one of the highest volume vascular procedures in GCC hospitals.

📋 Fistula Complications & Nursing Care

Early Complications

Thrombosis: absent thrill — urgent surgical revision or thrombolysis
Haematoma: pressure, ice; avoid compression of fistula
Steal syndrome: hand ischaemia — burning, pallor distal to fistula

Late Complications

Stenosis (venous anastomosis most common): treated by angioplasty
Aneurysm formation: large pulsatile swellings along fistula vein
Infection: rare with native fistula; higher risk with grafts (PTFE)

Nursing Instructions Post-Creation

No BP, cannula, or venepuncture on fistula arm
Check thrill daily — absent thrill = emergency review
Elevate arm first 48 hours to reduce oedema
Avoid constrictive clothing or watches on fistula arm

Fasciotomy for Compartment Syndrome

⚠ Indications

Post-bypass reperfusion injury (most common vascular cause)
Compartment pressure >30 mmHg or within 30 mmHg of diastolic
Prolonged ischaemia (>6 hours) before revascularisation
Crush injury, tibial fracture, post-thrombectomy

Do Not Delay Compartment syndrome requires fasciotomy within 1–2 hours of diagnosis. Irreversible muscle necrosis begins at 6 hours. Pain on PASSIVE STRETCH is the earliest and most sensitive sign.

⚒ 4-Compartment Fasciotomy Technique

Two incisions: medial (posteromedial + deep posterior) and lateral (anterior + lateral compartments).
Lateral incision: 15–20 cm fibular shaft. Fascia of anterior and lateral compartments released.
Medial incision: 2 cm posterior to tibia. Superficial posterior fascia released. Deep posterior compartment opened via soleus bridge.
Wound left open — wound VAC applied or saline-soaked gauze.
Delayed primary closure at 5–7 days if swelling subsided; skin graft if not.

Post-Vascular Surgery Assessment: ABCDE + Vascular

📋 Systematic Assessment Framework

Component	Vascular-Specific Focus
A — Airway	Post-CEA: expanding neck haematoma = airway threat; have airway trolley at bedside
B — Breathing	Post-AAA: atelectasis, ARDS (aortic cross-clamp reperfusion); SpO₂ monitoring
C — Circulation	Haemodynamic stability, pulse quality, graft patency (assess q1h × 24h)
D — Disability	Post-CEA: NIHSS neuro check; post-AAA: leg movement (spinal cord ischaemia)
E — Exposure	Wound inspection: groin haematoma, graft limb pulses, wound dehiscence
V — Vascular	6 Ps assessment: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Poikilothermia

🚨 Graft Surveillance Protocol

First 24 hours: pulse checks every 1 hour (femoral, popliteal, DP, PT)
24–48 hours: pulse checks every 2 hours
Before discharge: duplex USS baseline graft surveillance
Follow-up: duplex at 1, 3, 6, 12 months then annually
Graft thrombosis signs: loss of previously felt pulse, limb cooling, pain
Action: loss of graft pulse → immediate vascular surgeon notification → return to theatre within 4–6 hours for best outcome

Interactive: 6 Ps Vascular Assessment Tool

📋 Acute Limb Ischaemia — 6 Ps Assessment

Enter your clinical findings for each of the 6 Ps to receive an ischaemia risk level and recommended action.

Pain

Pallor

Pulselessness

Paraesthesia

Paralysis

Poikilothermia

Post-CEA Monitoring Protocol

🧠 Neurological Monitoring

Neurological observation every 1 hour for first 6 hours, then q2h × 18h
NIHSS elements: facial droop, arm drift, speech, visual fields, level of consciousness
New neurological deficit = emergency — activate stroke protocol
CT head ± CT angiography immediately if new deficit
Reperfusion haemorrhage risk if BP uncontrolled after CEA
Hyperperfusion syndrome: severe ipsilateral headache, seizure, intracerebral haemorrhage — tight BP control critical

⚠ Critical Post-CEA Emergencies

Expanding Neck Haematoma = Airway Emergency Rapid expanding haematoma can compress trachea within minutes. Immediately: call surgeon, prepare airway trolley, consider early intubation before airway lost. In extremis: open wound at bedside to decompress.

BP Management Post-CEA Target SBP <150 mmHg. Use labetalol or GTN infusion. Hypertension → hyperperfusion / haematoma. Hypotension → graft thrombosis / cerebral ischaemia. Avoid both extremes.

Cranial Nerve Injury Signs

Hoarseness / voice change (recurrent laryngeal nerve)
Dysphagia (vagus nerve)
Tongue deviation (hypoglossal nerve)
Facial numbness (great auricular nerve — most common, usually recovers)

Post-AAA Monitoring

📈 Multi-System Post-AAA Assessment

Haemodynamic

Target MAP 65–85 mmHg
CVP / arterial line monitoring
Blood transfusion threshold Hb <80 g/L (vascular pts)
Vasopressor (noradrenaline) if refractory hypotension
Graft limb pulses q1h

Renal & GI

Urine output ≥0.5 mL/kg/hr — marker of renal perfusion
Urine output <30 mL/hr → review fluid status, check graft patency
Bowel sounds: absent initially; return within 48–72 hrs
Ischaemic colitis: bloody diarrhoea, left-sided pain, fever — early sigmoidoscopy
NG tube drainage: paralytic ileus common post-open AAA

Neurological

Spinal cord ischaemia: leg weakness/paraplegia post-TAAA repair
Monitoring: regular lower limb power and sensation assessment q2h
New lower limb weakness = emergency — spinal drain if in situ, CSF pressure management
Maintain MAP >85 mmHg if spinal cord ischaemia suspected

Wound Care & Anticoagulation

🩹 Vascular Wound Care

Groin wounds: highest infection risk — vascular anatomy, skin flora (MRSA)
Groin wound infection: can involve prosthetic graft → life-threatening
MRSA screening: pre-operative swabs in elective cases (GCC protocols vary)
Vacuum-assisted closure (VAC/NPWT): for complex/infected vascular wounds
Wound dehiscence in PAD patients: impaired healing due to ischaemia
Nutrition: adequate protein (≥1.2 g/kg/day) essential for wound healing

Prosthetic Graft Infection Mortality up to 50%. Signs: wound sinus, erythema, anastomotic pseudoaneurysm, sepsis. Requires graft removal + extra-anatomic bypass. MRSA, gram-negative organisms common in GCC.

💊 Post-Op Anticoagulation

Agent	Indication	Monitoring
UFH infusion	Immediately post-bypass (first 24–48h)	aPTT 60–80 sec (1.5–2× control)
LMWH (enoxaparin)	DVT prophylaxis, bridge to warfarin	Anti-Xa if renal impairment
Warfarin	Prosthetic graft, AF, hypercoagulable state	INR 2.0–3.0 (load gradually)
Aspirin 75–100 mg	All vascular surgery patients post-op	None routine
Clopidogrel 75 mg	Dual antiplatelet post-stenting, EVAR	None routine
DOAC (rivaroxaban)	DVT treatment, selected PAD (COMPASS trial)	Renal function

Pain Management in Vascular Patients

🩸 Multimodal Analgesia Approach

Regional Techniques

Thoracic epidural: gold standard post open AAA — improves respiratory outcomes
Spinal anaesthesia: peripheral procedures
Peripheral nerve blocks: femoral, popliteal sciatic block for lower limb surgery
Local infiltration analgesia: groin/wound infiltration

Systemic Analgesia

Paracetamol: base agent, 1g q6h (hepatic dose adjustment)
NSAIDs: use cautiously — renal impairment, gastric risk, anticoagulation interaction
Opioids (morphine/oxycodone): PCA or nurse-controlled; constipation management
Tramadol: weak opioid; seizure risk in elderly — use cautiously

Special Considerations

Vascular patients: frequently elderly, multiple comorbidities, polypharmacy
Renal impairment: avoid NSAIDs, reduce opioid doses, consider gabapentin for neuropathic pain
Phantom limb pain: gabapentin/pregabalin, amitriptyline, mirror therapy
Rest pain: ensure adequate analgesia — reassess after revascularisation

Peripheral Pulse Assessment Guide

📈 Pulse Grading 0–4+

Grade	Description	Clinical Significance
0	Absent — not palpable	Critical ischaemia likely; confirm with Doppler
1+	Barely palpable / thread-like	Severely reduced flow — urgent assessment
2+	Diminished but present	Reduced flow — monitor closely, investigate
3+	Normal / expected	Adequate peripheral flow
4+	Bounding / hyperdynamic	AV fistula, aortic regurgitation, high output states

📈 Lower Limb Pulse Locations

Pulse	Location	Technique
Femoral	Mid-inguinal point (midway between ASIS and pubic symphysis)	2–3 finger pads, firm pressure; pulsatile mass in AAA/aneurysm
Popliteal	Popliteal fossa — knee slightly flexed	Both thumbs on tibial tuberosity, fingers wrap into fossa — requires firm pressure; easy to miss
Dorsalis Pedis (DP)	Dorsum of foot, lateral to extensor hallucis longus tendon	Light touch with 2–3 fingers; absent in 10% normal population
Posterior Tibial (PT)	Behind medial malleolus	Firm pressure posterior to medial malleolus; more reliable than DP for ischaemia assessment

📋 Handheld Doppler Technique

Apply ultrasound gel to pulse point. Angle probe at 45–60° to vessel.
Identify signal: triphasic (normal) → biphasic (mild disease) → monophasic (significant disease) → absent.
Triphasic: forward flow, brief reverse flow, secondary forward flow — indicates healthy vessel.
Monophasic: single forward flow only — significant proximal disease or collateral supply.
Document waveform character alongside pulse grade in post-vascular notes.

Diabetic Calcification In GCC diabetic patients, calcified vessel walls may produce a falsely high Doppler signal. A bounding signal with absent palpable pulse warrants ABI interpretation with caution — consider toe-brachial index (TBI) instead.

Ankle-Brachial Index (ABI) Calculator

📈 ABI Calculator

Enter the highest ankle systolic BP (dorsalis pedis or posterior tibial) and the higher brachial systolic BP. ABI = Ankle SBP ÷ Brachial SBP.

Ankle Systolic BP (mmHg)

Brachial Systolic BP (mmHg)

Calculate

ABI Reference Ranges

ABI Value	Interpretation	Clinical Action
>1.3	Non-compressible vessels (calcification)	Use toe-brachial index (TBI); common in GCC diabetics
0.9–1.3	Normal	Routine surveillance in at-risk patients
0.7–0.89	Mild PAD	Lifestyle, risk factor modification, antiplatelet
0.4–0.69	Moderate PAD	Vascular review, consider imaging + revascularisation
<0.4	Severe / Critical Ischaemia	Urgent vascular referral — limb-threatening

Compartment Syndrome

⚠ Causes in Vascular Patients

Post-revascularisation reperfusion: most common vascular cause — oedema on restoring flow to ischaemic muscle
Prolonged ischaemia (>4–6 hours) before bypass/embolectomy
Post-thrombectomy for acute limb ischaemia
Crush injury with vascular compromise
External compression: tight cast, circumferential dressings, prolonged positioning
Tibial fracture with haematoma

🚨 Signs & Monitoring

Earliest Sign: Pain on Passive Stretch Passively extend the toes/dorsiflex the foot — severe pain indicates anterior compartment involvement. This precedes other signs and is a clinical emergency.

Progressive Symptoms

1. Pain on passive stretch (earliest)
2. Tense, woody compartment on palpation
3. Paraesthesia (peroneal nerve — foot dorsum)
4. Weakness (foot drop — anterior compartment)
5. Pallor, pulselessness (late — arterial compromise)

Compartment Pressure Monitoring

Normal compartment pressure: <10 mmHg
Fasciotomy threshold: >30 mmHg or within 30 mmHg of diastolic BP
Stryker needle or arterial line transducer technique

Amputation Stump Care

📋 Residual Limb Management

Stump shaping: figure-of-eight bandaging or shrinker sock to create conical shape for prosthetic fitting
Bandaging applied immediately post-op (rigid dressing or semi-rigid cast preferred)
Elevation first 48 hours to reduce oedema
Wound inspection: sutures or staples at 10–14 days (longer if ischaemic healing)
Prosthetist referral: as soon as wound healed and stump mature (6–8 weeks BKA)
Early mobilisation: parallel bars, then rollator, then prosthesis

📉 Phantom Limb Pain

Occurs in 50–80% of amputees. Pain perceived in the absent limb — distinct from stump pain. Central sensitisation mechanism.

Management

Pharmacological: gabapentin/pregabalin (first-line), amitriptyline, duloxetine
Mirror therapy: visual feedback reduces central pain representation
TENS (transcutaneous electrical nerve stimulation)
Psychological support: CBT, relaxation techniques
Pre-operative analgesia: epidural or peripheral nerve block may reduce phantom pain incidence
GCC note: interpreter support crucial for pain assessment in non-English speaking patients

Post-Fasciotomy Wound Management

🩹 Open Fasciotomy Wound Care

Immediate (Days 1–5)

Wound left open — moist dressings (saline-soaked gauze or non-adherent dressing)
Wound VAC (NPWT): reduces oedema, promotes granulation, reduces infection
Elevation of limb to reduce oedema
Daily wound inspection: muscle viability, infection signs
Necrotic muscle: debridement may be needed at relook (48–72 hours)

Delayed Closure (Days 5–14)

Delayed primary closure if swelling resolved and wound edges approximate
Skin grafting if wound cannot close primarily (large fasciotomy defects)
Split-thickness skin graft (STSG) from thigh — common after fasciotomy
Post-graft: non-compressive dressing, immobilisation, VAC over graft
Long-term: scar management, compression hosiery when healed

🌎 GCC Diabetic Vascular Disease Diabetic foot disease is the #1 driver of vascular surgery workload across GCC hospitals. High rates of late presentation, inadequate outpatient surveillance, cultural barriers to foot self-examination, and suboptimal glycaemic control contribute to an amputation epidemic. KFSH, Cleveland Clinic Abu Dhabi, and Dubai Hospital operate dedicated diabetic foot multidisciplinary teams.

Multidisciplinary Diabetic Foot Team

👥 MDT Composition & Roles

Vascular Surgeon

Revascularisation planning (bypass / angioplasty)
Amputation level decision
Graft surveillance

Diabetologist / Endocrinologist

Glycaemic optimisation (HbA1c target)
Insulin management peri-operative
Cardiovascular risk reduction

Wound Care Nurse

Wound assessment (NERDS/STONEES criteria)
Dressing selection
NPWT management
Patient/carer education

Podiatrist

Nail / callus management
Foot orthoses / insoles
Skin care education
Biomechanical assessment

Orthotist / Prosthetist

Offloading devices (TCC, CAM boot)
Post-amputation prosthetics
Custom footwear

Infectious Disease / Microbiology

Antibiotic selection (bone culture)
Osteomyelitis management
MRSA / resistant organism protocols

Charcot Foot (Neuroarthropathy)

⚠ Recognition & Danger

Charcot neuroarthropathy is a devastating complication of peripheral neuropathy — rapid bone and joint destruction driven by unrecognised trauma and autonomic dysfunction.

Hot Swollen Red Foot in a Diabetic = Charcot Until Proven Otherwise The classical mistake is diagnosing cellulitis. In a neuropathic diabetic with a hot, swollen, red foot and no systemic signs of infection, Charcot is the priority diagnosis. Offloading is immediately critical.

Rocker Bottom Deformity

Mid-foot collapse (Lisfranc joint most common)
Creates plantar bony prominence → pressure ulceration → infection → osteomyelitis
Once deformity established: custom orthosis or surgical reconstruction

📋 Management Stages

Eichenholtz Stage	Features	Management
Stage 0	Hot, swollen foot; no X-ray changes yet; MRI shows bone oedema	Total contact cast (TCC) offloading immediately; no weight-bearing
Stage I	Fragmentation — fractures, dislocations visible on X-ray	Strict non-weight bearing; TCC; months of immobilisation
Stage II	Coalescence — bone repair begins; less warmth	Transition to removable cast boot (CAM walker)
Stage III	Consolidation — stable deformity	Custom footwear/orthosis; surgical reconstruction if unstable

Revascularisation in Diabetic Foot

📈 Angioplasty vs Bypass in Diabetics

Diabetic PAD tends to be tibial/below-knee in distribution, often with multi-level disease. The choice between bypass and angioplasty depends on anatomy, patient fitness, and available conduit.

Factor	Favours Angioplasty	Favours Bypass
Patient fitness	High anaesthetic risk	Good surgical candidate
Lesion length	Short (<10 cm), focal	Long occlusion, multi-segment
Conduit available	No suitable vein	Good quality GSV
Urgency	Acute/urgent limb	Elective planning
TASC classification	A and B lesions	C and D lesions

🌟 Angiosome-Directed Revascularisation

The angiosome concept maps foot territories to specific tibial arteries. Revascularising the artery directly supplying the wound ("direct revascularisation") improves healing rates vs indirect revascularisation.

Foot Territory	Supplying Artery
Heel (plantar)	Posterior tibial → medial/lateral plantar
Dorsum of foot	Anterior tibial → dorsalis pedis
Lateral forefoot	Peroneal → lateral calcaneal
Medial ankle	Posterior tibial → medial calcaneal

Where direct revascularisation is anatomically impossible, collateral circulation to the angiosome may be augmented by indirect revascularisation.

Amputation Prevention Strategy

📋 Prevention Pathway

Primary Prevention

Annual foot examination for all diabetics
Diabetic foot screening: ABI, monofilament testing, vibration sense
Podiatry access: nail care, callus removal
Patient education: daily foot inspection, appropriate footwear
GCC challenge: cultural reluctance to self-examine feet, late presentation

Secondary Prevention (Active Wound)

Infection control: appropriate antibiotics (IDSA guidelines)
Offloading: non-removable TCC superior to removable devices
Wound debridement: sharp, enzymatic, or larval therapy
Advanced wound dressings: silver, PHMB, NPWT
Revascularisation if ischaemic component

Tertiary Prevention (Post-Amputation)

Contralateral limb monitoring — 50% of patients require contralateral amputation within 5 years
Rehabilitation: physiotherapy, occupational therapy, prosthetics
Psychological support: depression common post-amputation
Glycaemic optimisation: HbA1c <53 mmol/mol (7%) post-amputation

🇦🇪 GCC Amputation Crisis

High Amputation Rates: Saudi Arabia, UAE, and Kuwait report among the highest rates of diabetes-related lower limb amputation globally. Contributing factors include:

Late presentation — patients seek care only when gangrene is established
Inadequate primary care follow-up for diabetic foot
Cultural barriers: reluctance to show feet, reliance on traditional remedies
Language barriers: expatriate patients unable to communicate symptoms
Heat and footwear: going barefoot on hot surfaces → unnoticed burns

Major Centres:

KFSH (King Faisal Specialist Hospital): high-volume diabetic foot centre, dedicated MDT, limb salvage programme
Cleveland Clinic Abu Dhabi: comprehensive vascular surgery, EVAR, CEA, diabetic foot MDT
Dubai Hospital: major vascular surgery centre, high AV fistula volume
Hamad Medical Corporation (Qatar): developing dedicated vascular surgery programme

Nursing Role GCC nurses are frequently the first to identify diabetic foot complications on ward rounds. Proactive foot inspection at every hospital admission for diabetics — document and escalate any new break in skin.

Renal Transplant Vascular Complications

💉 Vascular Complications Post-Transplant

Renal transplant recipients — a large population in GCC due to high ESRD rates — face unique vascular complications relevant to nursing assessment. See also: Dialysis Nursing Guide.

Renal artery stenosis (TRAS): transplant renal artery stenosis — resistant hypertension, declining function; treated by angioplasty
Renal artery thrombosis: early post-op — sudden cessation of urine output; emergency re-exploration
Renal vein thrombosis: graft swelling, haematuria, pain over graft

Lymphocele: perigraft lymph collection — leg oedema, pressure on ureter; managed by aspiration/drain
Pseudoaneurysm: anastomotic disruption — pulsatile mass over graft, bleeding
AV fistula in transplant recipients: usually retained post-transplant as backup; thrill assessment ongoing

Quick Reference: Vascular Surgery Essentials

☣

6 Ps of Acute Ischaemia

Pain · Pallor · Pulselessness
Paraesthesia · Paralysis · Poikilothermia

📈

Critical ABI

ABI <0.4 = Critical Ischaemia
Urgent vascular referral

🧠

Post-CEA BP Target

SBP <150 mmHg
Prevent hyperperfusion / haematoma

🚨

Neck Haematoma Post-CEA

Expanding haematoma
= Airway Emergency
Call surgeon + prepare airway NOW

⚠

Compartment Syndrome

Pain on passive stretch
= earliest sign
Compartment pressure >30 mmHg → fasciotomy

🍴

AAA Repair Threshold

≥5.5 cm in men
≥5.0 cm in women
Symptom = repair regardless of size

💉

AV Fistula Arm Rule

NO BP / cannula / bloods
on fistula arm — ever

🌟

ABI Non-Compressible

ABI >1.3 in diabetics
= calcified vessels
Use Toe-Brachial Index (TBI)

🇦🇪 GCC-Specific Clinical Priorities

Diabetic Vascular Disease

UAE, Saudi, Kuwait top 10 worldwide for diabetes
#1 driver of vascular surgery workload in GCC
Inspect feet of ALL diabetic inpatients at admission
Late presentation = higher amputation rate

High-Volume Procedures

AV fistula creation (ESRD epidemic in GCC)
Below-knee amputation (diabetic foot)
Tibial angioplasty (diabetic infrapopliteal disease)
EVAR (aging GCC population, AAA screening uptake)

Construction Worker & Hajj DVT Risk

Heat + dehydration + prolonged standing = DVT risk
Millions of low-wage workers with limited healthcare access
Hajj: 2–3M pilgrims, counsel high-risk on anticoagulation
Consider DVT prophylaxis for high-risk pilgrims

Related Clinical Guides

💉 Dialysis Nursing Guide

AV fistula care, haemodialysis, peritoneal dialysis in GCC

🧠 Diabetes Nursing Guide

Glycaemic management, insulin protocols, diabetic foot care

🩹 Wound Care Guide

NPWT, dressing selection, vascular wound management

💌 Cardiology Nursing Guide

Anticoagulation, ACS, cardiac risk in vascular patients

🧠 Stroke Unit Guide

Post-CEA neuro monitoring, stroke protocols, NIHSS

🤮 Orthopaedic Nursing Guide

Amputation rehabilitation, prosthetics, compartment syndrome

Vascular Surgery Nursing Guidefor GCC Nurses