Vascular Education Evening – Ballina

North Coast Vascular, Medtronic and BARD hosted another valuable Vascular Education Evening in Ballina on Thursday, 27th July 2017 for GPs and Practice Nurses at The Point Restaurant (Ramada, Ballina).

An amazing dinner, catch up and valuable education was enjoyed by all attendees. Information sessions were conducted by Dr Deepak Williams, Christine Kemp, Alex Rosewarne (Medtronic) and Annie McKenzie (BARD).  

Attendees received educational tools for vascular health for their patients and also what to look for in chronic wound patients. GPs and Practice Nurses were able to get a good understanding and hands on approach of what their vascular intervention devices can do in the treatment of patients with vascular disease. Many of these products are used by Dr Williams on our patients for angiograms and angioplasties and GPs were also able to see and hear about the latest devices for AAAs repairs.

Feedback from attendees has been extremely positive and the valuable education session is well received with many of the ideas and solutions that can be put into place to assist patients with their Vascular health.

We thank those that attended and it was great to meet you all and share a little of what Vascular health can do for our patients.

A special “Thank you” to Alex (Medtronic) and Annie (BARD) as their companies sponsored the evening.

We look forward to putting together another evening of Vascular Education in the next little while.

 

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Vascular Education Evening – Kingscliff

On Thursday, 6th October North Coast Vascular hosted an evening of Vascular Education for GPs and Practice Nurses in the Tweed region. The beautiful setting of Babalou at Kingscliff enabled all to enjoy an amazing dinner, catch up and worthwhile education provided to GPs and Practice Nurses by Dr Williams, Christine, Alex (Medtronic) and Annie (BARD).

Attendees received educational tools for vascular health for their patients and also what to look for in chronic wound patients.

Feedback from attendees has been extremely positive and that an event like this had not been held before and many would definitely attend again.

We thank those that attended and it was great to meet you all and share a little of what Vascular health can do for our patients.

A special “Thank you” to Alex (Medtronic) and Annie (BARD) as their companies sponsored the evening. The GPs and Practice Nurses were able to get a good understanding and hands on approach of what their vascular intervention devices can do in the treatment of patients with vascular disease.

We look forward to putting together another evening of Vascular Education in the next little while.

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Haemodialysis Vascular Access

By Chanelle Osborne- Renal Vascular Access Nurse

Between 1950 and early 1960, techniques and devices were developed that allowed repeated access to the circulation for haemodialysis. Some of these concepts were simple, like the cannulation of the iliac veins and vena cava by a double lumen plastic catheter while others were quite ingenious, such as the indwelling permanent vein Teflon cannulae. It wasn’t until 1965 that the first arteriovenous fistula was undertaken by Dr Appel in the USA.

The provision of adequate haemodialysis is dependent on repeated and reliable access to the central circulation. This access to the circulation is best provided by a primary arteriovenous fistula (AVF) and to a lesser extent arteriovenous grafts (AVG) and central venous catheters. (CVC)

The radiocephalic AVF is the most common fistula as it provides the best option for cannulation. The depth of the cephalic vein in the forearm is usually more shallow so easier to cannulate, has a longer length of vein allowing for better rotation of cannulation sites and allows for the option of a future fistula in the upper arm if another fistula is required. If the radiocephalic fistula is unable to be created due to calcified arteries and small fragile vessels then the brachiocephalic fistula is an excellent alternative.

An AVG can be made if there are issues with integrity of the native vessel, obesity (fistula too deep within the arm for cannula to reach) or a failed AVF. The most common AVG is the forearm loop; however there are many potential sites for AVG placements including the upper arm, thigh and chest wall.

If a fistula cannot be created or vascular access is required urgently then a CVC insertion can be done. The right internal jugular vein is the preferred insertion site for a CVC with respect to ease of access, shorter pathway through the vessel and it carries less risk of causing stenosis of the outflow veins of the arm.

The AVF is the ‘gold standard’ for haemodialysis vascular access as it remains the most reliable access due to its history of longer patency rates, less thrombotic events and much less infection rates. Currently in the Richmond and Clarence Health Service Group there is a ratio of 86 % AVF’S to 13% of AVG’S and 1% of CVC’S.

A functioning vascular access is paramount to the adequacy of each haemodialysis session. Establishing a good vascular access starts very early in the spectrum of care of the chronic kidney disease patient, often with education and vein preservation at stage 3 kidney disease and continuing throughout their life.

In patients with kidney disease both arms should be protected anticipating possible use for vascular access, particularly the non-dominant arm. Cannulation of the cephalic and basilic veins of both arms should be avoided. Appropriate sites for short term peripheral cannulation are the dorsum of the hands and flexor aspects of the wrists and forearms. Ideally, avoid the anticubital fossa. Venepuncture or cannulation of veins that are typically used by the vascular surgeon to form a fistula may render veins unsuitable for construction of an AVF.

The intent is to promote a culture of vein preservation in order to maximise the chance of patients with kidney disease to successfully maintain haemodialysis in the future.

Once a fistula has been constructed;

  • bloods are not to be taken from the fistula
  • cannulas are not be inserted into the fistula arm,
  • blood pressures are not to be taken on the fistula arm
  • pressure bandages are not to be applied to the fistula arm (unless advised by the vascular surgeon)

Once a fistula is created assessment of the fistula is preformed to detect the functionality of the patient’s access. The techniques of visual inspection, palpation and auscultation as the process of assessing takes a very short period of time, but is in fact the most important aspect of a patient’s care.

The thrill (a buzzing feeling created as arterialised blood is shunted into the vein) at the anastomosis is continuous and very prominent. The pulse should be soft and the fistula easy to compress. In the presence of anastomotic stenosis the thrill, which is normally continuous, is only felt during systole and a “water hammer pulse” is present at the anastomosis, as opposed to a thrill. Above the point in the fistula where a stenosis or narrowing of the vein is present, the thrill is typically weak and the vein is poorly developed.

Other complications of fistulas to be aware when assessing a fistula include steal syndrome, infection, aneurysm formation and thrombosis.

Assessment by the vascular surgeon is done at least 6 monthly. If a patient hasn’t seen their surgeon for some time a referral should be made. When making referrals if “indefinite referral” is indicated then the referral is ongoing.

Assessment of the fistula by health care workers is done from creation and throughout the patient’s dialysis life. Assessment becomes even more important in the pre dialysis population as patients are not always compliant with checking their access so early issues are not detected which can then result in a non-functioning fistula.

“Effective patient management is a critically important component of vessel management and is the responsibility of all health care providers.”

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Focus on Deep Vein Thrombosis (DVT)

by Dr Deepak Williams (North Coast Vascular)

DVT is a common condition that is increasing with the aging population. It usually occurs in the deep veins of the lower limb and occasionally in the deep veins of the upper limb. DVT has a significant effect on the patient’s life if not treated properly.

The causes of DVT can be classed according to the Virchow’s Triad Immobility this can be due to prolonged travel by air, road or rail, hospitalisation, surgery, fracture requiring a cast and post-partum.

Hyper coagulator ability is the coagulation of blood faster than usual caused by medication such as birth control pills which contain estrogens, smoking and a genetic predisposition eg Factor 5 Leiden positive, polycythaemia or cancer.

Trauma to the Vein is usually due to fracture to the leg, bruising or compilations after invasive procedures on the veins eg varicose veins surgery, placements of catheters or lines through the veins. The symptoms of DVT include pain, swelling, warmth and redness of the limb. Symptoms may mimic infection or cellulitis. Chest pain and breathlessness would indicate pulmonary embolism.

Diagnosis is made with ultrasound scanning which locates the site, position of the thrombosis and can occasionally differentiate between fresh and old thrombosis. D-dimer test used to determine if a blood clot exists. D-dimer is a chemical that is produced when a clot actually dissolves. If the test is negative then no blood clot exists; it may give a false/positive. The other tests include direct venography or CT venograms.

Treatment of DVT the mainstay of treatment of DVT is still anticoagulants and compression. DVT in the tibial veins can be treated with Aspirin and compression; however thrombus requires anticoagulation unless there is a contraindication such as recent surgery or haemorrhagic stroke etc. Anticoagulants commonly used are Warfarin, Apixaban, Rivaroxaban, Xarelto and Dabigatran.

Treatment of uncomplicated DVT must continue until there is no evidence of a clot and that the clot has dissolved completely.

The role of surgery in DVT is increasing, the commonest indication for surgery is May–Thurner syndrome where the patient would benefit by having thrombolysis done in the first instance and then followed up with a venography and stenting of the left common iliac vein. There is increasing use of thrombolysis in acute DVT where it involves a short segment of the vein. Thrombectomy is rarely done.

Complications of DVT – Pulmonary Embolism (PE) is a major complication of DVT. It presents with chest pain and shortness of breath. Any patient who is at a high risk of PE should have an inferior vena cava filter placed in situ, especially patients undergoing thrombolysis, surgery or with a past history of embolism with new DVTs.

Post Phlebitic syndrome is when the affected leg becomes swollen, painful, skin changes and ulceration occurs.

Prevention is of prime importance. Continuous use of compression stockings and prophylactic anticoagulation after surgery or use of a filter with compression in patients that are undergoing long procedures has reduced the incidence of DVT in hospital patients. During long distance travel it is advisable to walk regularly and wear compression. Compression also helps to prevent future DVT, especially those with history of DVT or those who are immobile.

The whole idea is to prevent the clot from forming in the first place but if it does then to institute prompt therapies to prevent it increasing or travelling to other circulatory locations like the pulmonary circulation. Blood is a funny creature if it is not moving it clots; hence keep it circulating and take care of your vascular self.

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The Diabetic Foot

by Christine Kemp (Practice Nurse – North Coast Vascular)

People with diabetes are very prone to ulceration of the feet, this is due to multiple effects that diabetes has on the body.

  • Diabetes damages the peripheral nerves causing loss of sensation and inability to detect painful stimuli. Diabetes also damages the nerves to the sweat glands of the skin resulting in the skin being dry, cracked and ulcerated.
  • Diabetes damages blood vessels which reduces the blood flow to the feet making any wound slow to heal.
  • Diabetes reduces the body’s ability to fight infection which increases the risk and severity of wound infection.
  • Diabetes causes deformity of the feet which can lead to points of high pressure which can lead to callus, skin breakdown and ulceration.

50% of leg amputations are associated with diabetes

85% of leg amputations in diabetes are preceded by a foot ulcer

History and examination should include: x rays, ultrasounds, CT/MRI, angiogram/angioplasty.

Regular foot care can prevent ulceration

Diabetics must inspect their feet daily. Thorough washing and drying followed by moisturiser is essential.   Daily inspection of shoes for foreign objects is a high priority and shoes must be comfortable with good support and have no pressure points. Any podiatrist providing care must have excellent knowledge of vascular health.

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Care of your surgical wound at home

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In many cases surgical incisions heal quickly and should only require dressings for a short period of time; but some patients heal slower.  To reduce the risk of complications you will be given specific instructions for your wound care, you may also be referred to your GP or Community Nurse for wound care.

Hand Hygiene is extremely important if you are attending to your own dressings or your wounds are being attended to by Medical staff.  Wash hands with soap and water for at least 15 seconds, then rinse and dry hands thoroughly before commencing wound dressing.  The wound should be inspected for any redness, swelling, fluid and drainage of blood.  Any separation of the wound edges or odour from the wound is an indication that there may be an infection.  Some swelling can be normal and it usually settles within two weeks.  If any of these signs are present contact your GP or Surgeon for advice.

Antibiotics may be prescribed, if so the complete course should be taken.  Contact your Doctor if you have an allergic reaction to the medication and stop taking it immediately.  Severe allergic reactions occur within a short period of time after taking the medication or exposure to the allergen.  Common symptoms of an allergic reaction include: hives, itching, rash and watery eyes.  Symptoms of a moderate or severe reaction include: chest discomfort or tightness, cough, difficulty breathing, difficulty swallowing, redness/swelling of the face, eyes or tongue, nausea or vomiting, heart palpitations, wheezing and unconsciousness.

For a severe allergic reaction (Anaphylaxis) check the person’s airway, breathing and circulation. (Basic Life Support “BSL”).  A warning sign of severe allergic reaction is throat swelling, a very hoarse or whispered voice and coarse sounds when the person is breathing.  Seek urgent medical attention and call 000.

Showering and Bathing you will be given instructions after your procedure for showering/bathing normally, you may be required to keep your wound dry.  If you are unsure consult your Surgeon or Nurse for specific instructions.  After stitches, steri-strips or clips have been removed you can usually shower normally.

Medications you may be required to stop blood thinning medications prior to your operation.  If so the Doctor will instruct you when to cease the medication; also it is important to check with your Doctor when you should restart your normal medications/blood thinning medications.

Elevation and Compression you may be given instructions to elevate the limb.  This will assist in reducing the swelling and pain.  If you have an incision on your leg lie down with your leg above the level of your heart.  Your Doctor may give you instructions to wear compression stockings to control the swelling.  You may have to wear continuous compression or you may be able to remove compression at night.  Ask for instructions specific to you.

Nutrition A balanced diet is important for healing.

Constipation some painkilling medications may cause constipation so eat foods high in fibre, fresh fruit and drink plenty of water.  You may need laxatives, if so ask your Doctor for advice.

Smoking will lead to reduced blood supply and affect the healing of your wound.

Please contact North Coast Vascular if you have any of the following:

  • Fever above 38c
  • Heavy oozing or bleeding from the wound
  • Increased swelling or pain, foul odour
  • Any concerns about your surgery

 

For more information or advice, please contact Christine (Practice Nurse) on 6621 2200 or Christine@ncvascular.com.au

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Silver Surfers

Dr Williams sings the praises of TeleHeath

Dr Williams was asked by Feros Care to give his opinion on the use of Telehealth for their residents. Dr Williams could not sing the praises of Telehealth for Feros Nursing Home patients and also that Feros Care are so forward thinking in their approach to technology for the “Silver Surfers”.

North Coast Vascular value the use of Telehealth for our patients and the fast and reliable organisation and use Telehealth for all parties.
Dr Williams has a Team Care arrangement with all patients and GPs that participate in Telehealth, please feel free to contact North Coast Vascular if you have patients that would benefit from Telehealth.

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NCV at Crackin’ Cancer Karaoke Dinner 2016

North Coast Vascular was a proud supporter of the Crackin’ Cancer Karaoke Dinner on Saturday, 16th April 2016 at Lismore Workers Club.

A fun evening was had with many laughs and a bit of sing along.  All proceeds from the evening were going towards cancer patients who need help with everyday living costs while undergoing treatment at Lismore Base Hospital.

Well done to the team that organised the evening from Crackin’ Cancer Compassionate Fund.  A huge thank you to Patrick, Marshall, Mark and the rest of the team.

Crackin Cancer Karaoke Dinner 2016 Crackin Cancer Karaoke Dinner 2016b Crackin Cancer Karaoke Dinner 2016c

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Dr Deepak Williams second Surgeon in NSW to use a new Stent Graft system

website trivascular 03Dr Deepak Williams was the second Surgeon in NSW to use a new Stent Graft system for a patient that required a repair of their Abdominal Aortic Aneurysm on the 20th May 2015 at St Vincent’s Private Hospital (Lismore) in their new Hybrid Theatre. This patient was the fourth recipient in NSW to receive this new stent graft.   The benefits for the patient where that the procedure was all done using minimally invasive techniques, the Graft is customised for the patient and reduces the risk of the patient developing aortic neck dilation and Type 1 Endoleaks after 3 years.

Post operatively the patient was required to stay still for 4 hours and stay in bed overnight. A CT Angiogram scan was performed one day post-surgery which showed that there were no endoleaks and the stent graft was working very nicely. The patient was able to return home 2 days post operatively and was able to continue with normal life. It was an excellent result and Dr Williams looks forward treating more of his patient with this new technology that is less invasive.

To view this Stent Graft, please click on the link below http://www.trivascular.com/index.php?option=com_content&view=article&id=53&Itemid=170

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