Two Novant Health board-certified vascular surgeons share practical guidance on when to refer, what pre-referral workup is most useful and what referring physicians and clinicians can expect from their vascular care partners.

Rebecca Kelso, MD, is a vascular surgeon at Novant Health Heart & Vascular Institute -Elizabeth in Charlotte. With more than 20 years of experience, she specializes in aortic aneurysm repair, peripheral artery disease, carotid artery disease, deep vein thrombosis and vascular disease.

Christopher Wixon, MD, is a vascular surgeon at Novant Health Heart & Vascular Persimmon in Bluffton, South Carolina, with more than two decades of experience. His clinic offers preventive screenings as well as advanced treatment for peripheral artery disease, carotid artery disease, aortic aneurysms and vein disorders.

Peripheral artery disease (PAD) / Limb ischemia

Distinguishing vascular leg pain from musculoskeletal or neurological causes

Differentiating vascular leg pain from musculoskeletal or neurogenic complaints remains one of the most common diagnostic hurdles. It is no surprise that 10% to 20% of older adults have PAD; it is also no surprise that this same group experiences high rates of osteoarthritis and spinal stenosis.

“When a patient presents with vague lower extremity pain,” Dr. Wixon notes, “diminished pulses alone don't confirm a vascular cause. The key is isolating the behavior of the pain."

Four questions from the World Health Organization's Rose Angina Questionnaire should serve as your framework:

• Is the pain strictly brought on by walking?
• Is it completely absent when sitting or standing still?
• Is it exacerbated by a higher workload, like walking uphill?
• Does it completely resolve within 10 minutes of resting?

When the answers to these questions align, he says the clinical picture points to a vascular culprit.

Dr. Kelso offers a practical example to help differentiate the cause: “Claudication that reliably returns at the same walking distance each day and resolves with brief rest differs meaningfully from pain that varies by distance, is relieved by leaning forward on a grocery cart (suggesting a spinal cause) or improves with stretching or warming up (suggesting a musculoskeletal one).”

When to move beyond medical management

Primary care providers excel at managing the risk factors of PAD, such as antiplatelet therapy, statins and exercise programs. However, vascular surgeons can play a role earlier than many referring physicians might expect, such as offering help with medical management education like Supervised Exercise Therapy, similar to cardiac rehab programs, says Dr. Kelso.

Both surgeons recommend that a patient transition from medical management to a formal vascular evaluation when meeting any of the following four criteria:

• Lifestyle-limiting claudication: leg pain or fatigue that negatively impacts daily activities, independence or overall quality of life despite medical therapy
• Ischemic rest pain: severe pain in the toes or forefoot at nighttime when the legs are elevated in bed, often relieved by placing the foot in a dependent position
• Tissue loss or ulceration: any nonhealing lower extremity wound that requires urgent vascular assessment to ensure adequate perfusion for healing
• History of prior vascular interventions: patients with bypass grafts, angioplasty or stenting who develop new or changing symptoms

Helpful pre-referral testing for suspected peripheral artery disease

Pre-referral testing can be helpful but should not delay referral. If available, Dr. Kelso recommends including pulse volume recordings (PVRs), ankle-brachial indices (ABIs) and exercise PVRs, which provide useful physiological information.

Warning signs of limb-threatening ischemia that prompt fast referral

Acute ischemia requires immediate attention. To identify acute crises, Dr. Wixon says to watch for the classic 5 Ps:

• Pain
• Pallor
• Pulselessness
• Paresthesia
• Paralysis

For chronic disease, the ultimate red flag is any PAD patient who develops a lower extremity ulcer. Both scenarios demand immediate vascular evaluation to save the limb.

Abdominal aortic aneurysm (AAA)

Who should be screened for AAA

The U.S. Preventive Services Task Force and the Society for Vascular Surgery (SVS) are clear: We must screen men aged 65-75 who have ever smoked, as well as individuals with a strong family history. Beyond these recommendations, Dr. Kelso says to include women 65 and older with a family history, regardless of their smoking history.

Despite the SVS’s clear directives, Dr. Wixon says patients still slip through the cracks. “The most frequent gap I encounter involves the “hidden” smoking history — patients who haven't picked up a cigarette in 30 years, whose providers assume they are low risk. Female family members also are frequently overlooked.”

Referrals and imaging for AAA and aortic dilation/ectasia

For cases of incidentally discovered aortic dilation/ectasia, Dr. Wixon the absolute safest next step is to route that patient to a vascular surgeon. “We can assume the responsibility of long-term ultrasound tracking, keeping the patient safe and removing the administrative tracking burden from your primary care team.”

When an AAA is found incidentally, he says the referral process is straightforward: “We only need imaging results.”

For routine referrals, a simple ultrasound is all that is required. When managing an AAA, he suggests following this simple rule regarding imaging:

• Ultrasound – use to safely monitor and track the aneurysm over time
• CTA – reserve for mapping and planning an endovascular intervention

Deep vein thrombosis (DVT) / venous disease

DVT red flags prompting escalation to vascular evaluation

Standard anticoagulation remains the bedrock of DVT care, but it does not actively dissolve a clot; it relies on the body to naturally clear it over time. In cases of massive iliofemoral DVT, that delay can lead to permanent venous valve damage and severe post-thrombotic syndrome (PTS), leaving patients with chronic pain, swelling and ulceration.

Dr. Wixon urges primary care partners to escalate cases to vascular specialists if any of the following present:

• Clot burden is highly proximal
• Patient has a history of recurrent clots despite therapy
• Signs of phlegmasia (severe pain, dusky discoloration or coldness)

“Escalating these patients to our office allows us to consider early mechanical clot removal or address underlying anatomical issues like May-Thurner syndrome, ensuring the patient doesn't just survive the DVT, but maintains their quality of life afterward,” adds Dr. Wixon.