By Kym McNicholas, Chairman & CEO of the Global PAD Association
In the realm of complex peripheral arterial disease, certain cases defy conventional intervention strategies. It’s in these challenging scenarios that Dr. Carlos Bechara of Rush Hospital in Chicago has distinguished himself through his innovative hybrid techniques and refusal to accept amputation as an inevitable outcome.
The Global PAD Association recently recognized Dr. Bechara with the 2025 PAD MacGyver Award, honoring his exceptional resourcefulness in limb salvage cases that others deemed beyond intervention.
Hybrid Technique Innovation
Dr. Bechara’s approach to complex cases centers on thoughtfully combining open surgical techniques with endovascular interventions—a methodology he’s refined through years of challenging cases.
“My creativity comes when I’m able to combine open surgical techniques with endovascular techniques to try to save a leg,” Dr. Bechara explained. “This hybrid approach has served me well.”
One particularly illustrative case involved a patient with multiple high-risk factors: morbid obesity, end-stage renal disease, diabetes, and a digital ulceration. The patient had been referred specifically for below-knee amputation after other interventionalists determined limb salvage was not feasible.
Rather than proceeding with amputation, Dr. Bechara developed an unconventional solution: “I made an incision just above the knee where I exposed the popliteal artery. I cleaned it out, put a patch on top of it, and then worked both retrograde and antegrade. I opened up all the vessels—the iliac, the common femoral—ballooned them using lithoplasty for the calcified segments, and then proceeded distally to revascularize the tibials.”
The intervention proved successful, not only salvaging the limb but catalyzing significant life changes for the patient. “He eventually healed his toe and avoided the amputation,” Dr. Bechara noted. “A year later, he returned to my clinic after losing significant weight. He was back on the transplant list because of his weight loss. It was transformative—this patient was initially sent for bilateral amputation, and now his trajectory had completely changed.”
Technical Approaches to Occlusive Disease
Dr. Bechara has developed several innovative techniques for addressing complex occlusions, including a “wire-first” approach for completely occluded aortoiliac segments.
“When faced with a completely occluded aorta and iliacs in a high-surgical-risk patient, I developed a technique where I was able to pass the wire subintimally,” he explained. “By making a small incision in the groin and extracting that wire, cleaning the vessel around it, I created a landing zone in the groin and was able to place stents in a retrograde fashion.”
His approach to flush occlusions, published in the Journal of Vascular Surgery, demonstrates similar ingenuity: “I developed a technique where I come from the arm and block the path of resistance with a balloon. That allows me to navigate wires and catheters into areas where I can’t visualize but can predict where the vessel originates.”
While newer technologies like steerable sheaths have somewhat reduced the need for such techniques, they represent the creative problem-solving that has allowed Dr. Bechara to treat patients previously deemed unsuitable for intervention.
Diagnostic and Intervention Thresholds
Dr. Bechara’s clinical decision-making reveals a nuanced approach to intervention timing. He emphasizes appropriate patient selection while maintaining a lower threshold for diagnostic angiography in certain presentations.
“I’ve been taught and I teach my trainees to treat patients, not numbers, not imaging,” he stated. “For patients with iliac occlusions, I personally have no threshold in treating because we can make a significant difference in their quality of life, and the results are durable.”
For patients with tissue loss, his approach is particularly proactive: “I usually go straight for angiogram because it’s going to tell me exactly what’s going on, where the problem is, and whether I can do something at the time of the diagnostic study.”
He notes the limitations of non-invasive studies, particularly in diabetic patients with calcified vessels: “Ultrasound is not 100% accurate, especially in patients with calcified vessels. It can be misleading.”
Recognizing the Diagnostic Gap
A concerning pattern in PAD care is the frequency of delayed or missed diagnoses. Dr. Bechara recounted a case emblematic of this issue—a nurse referred after multiple back interventions failed to address her leg symptoms.
“No one bothered to check for a femoral pulse, which she had none,” he noted. “Physical exam is a lost art. We rely so much on diagnostic testing that basic vascular assessment gets overlooked.”
This gap in early diagnosis directly impacts the potential effectiveness of both conservative and interventional approaches, often resulting in more complex presentations requiring advanced techniques.
Exercise Therapy: Implementation and Limitations
While advocating for appropriate intervention in advanced disease, Dr. Bechara remains a proponent of supervised exercise therapy in selected patients, particularly non-smokers with femoral-popliteal disease.
“I do believe walking programs help in the right claudicants,” he explained. “With smoking, the collateral pathways don’t develop as robustly as in non-smokers.”
His approach to patient education on collateral development is notably effective: “We have vascular system images in the clinic. When you stand with a patient and show them where the blockage is and point to where collaterals are, they understand what you’re talking about and how those get better over time.”
This visualization helps patients conceptualize their vascular pathophysiology and increases engagement with exercise therapy.
Collaborative Practice and Future Directions
Dr. Bechara emphasizes the importance of subspecialization and collaboration in advancing PAD care. “I’m lucky to work with talented interventional radiology colleagues. If I’m stuck on something, I have no problem reaching out because the outcome for the patient is what matters, not who performs the procedure.”
Looking toward the future of PAD intervention, he expressed enthusiasm for continued innovation in minimally invasive bypasses, bioabsorbable stents, and advances in antiplatelet therapy. He also advocates for greater subspecialization within vascular surgery: “We need people to specialize in certain areas and be part of the development of technology to take this to the next level.”
The MacGyver Philosophy in Practice
The essence of Dr. Bechara’s approach is perhaps best captured in advice he received from Dr. Hazem Safi: “If someone has done it before and it didn’t work, don’t ignore it. Maybe they didn’t do it well or maybe it can be done differently.”
This philosophy—challenging conventional limitations while maintaining rigorous clinical judgment—has allowed him to expand intervention options for patients previously considered beyond help.
“These patients are looking for someone who’s going to say, ‘I can help you,’” Dr. Bechara reflected. “And while sometimes we can’t, we owe it to our patients to explore all possibilities.”
Professional Resources
The Global PAD Association offers consultation services for complex cases through our physician network at 1-833-PAD-LEGS (1-833-723-5347). We also facilitate collaboration between specialists for challenging presentations.
Our professional education programs and patient resources can be accessed at padsupportgroup.org, including supervised exercise therapy protocols and smoking cessation support materials.
The Global PAD Impact Awards recognize innovation in PAD care based on peer and patient nominations. This recognition does not constitute a formal endorsement of specific clinical practices. Clinical judgment should always guide individual patient management decisions.