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How To Prevent PAD Amputations

Knowing treatment options and who offers them could save life and limb.

· The Way To My Heart

A female patient experiencing Critical Limb Ischemia, a form of advanced peripheral artery disease (PAD), was kept awake at night due to the debilitating pain. She now lays on the table in the cath lab at a large university hospital awaiting treatment. The anesthesiologist injected a sleeping dose as the interventional cardiologist approached her side. The endovascular procedure then began with a small puncture in the groin and a pump of contrast fluid. Quickly the pain-causing problem was clear: Complex disease with a blocked common femoral artery (CFA) and superficial femoral artery (SFA). The Interventionalist sent her to the operating room for a surgery consultation for amputation evaluation and she lost her leg. To observers he said, “Standard teaching protocols dictate that if we can’t stent an artery, we can’t treat it.” The patient had signed a document prior to this procedure giving physicians permission to amputate if they couldn’t restore flow. She didn’t know that just two hours away, a physician in a small office-based lab (OBL) had cleared the same type of blockage in the same location and that patient walked out on both legs just hours following the procedure.

How is it that some patients lose a limb and others don’t?

Every patient presents differently and at different stages. That is true. But other modifiable factors are contributing to the nearly 150,000 PAD-related amputations each year, most of which are preventable. Early diagnosis, early treatment, and lifestyle modifications help. But the greatest contributing factor for unnecessary amputations is in the hands of physicians.

The “right” way to treat is highly contested among key physicians treating PAD: Vascular surgeons (VS), interventional cardiologists (IC), and interventional radiologists (IR), along with the “right” place to treat -- hospital, ambulatory surgical center (ASC), or office-based lab (OBL). At the center of this debate is who or what is leading to the majority of needless PAD-related amputations? Everyone thinks their way is the best and only way. It’s always their competition that’s leading to poor patient outcomes, not them. 

What is the right treatment, and isn’t there a standard treatment protocol that works for everyone with PAD? Yes and no. Frontline treatment, if PAD is diagnosed, is lifestyle modifications, including smoking cessation, diet, and exercise. It also may include medication such as blood thinners and statins to increase flow and reduce cholesterol. Most insurance requires three months of this conservative approach to see if claudication improves. Many believe the next step is intervention, then surgical bypass, and amputation as a last resort. The question is when to switch to the next level and how to perform it. Some skip steps, even performing amputation as frontline treatment

It’s difficult to standardize when physicians should switch treatment levels because many patients are poorly diagnosed or not diagnosed at all until advanced stages. At that point lifestyle modification and medication are not going to be effective. If someone is in advanced stages of PAD, called critical limb ischemia (CLI), has a non-healing ulcer or gangrene, then the first step for these patients is intervention or surgery. It is imperative that these patients are appropriately evaluated to save their limbs.

Some physicians stick with conservative treatment too long, withholding interventional or surgical treatment. Lifestyle modifications are important, especially walking. Withholding angioplasty to restore just enough flow to relieve some debilitating pain for a patient who complains of lifestyle limiting claudication, happens much too often. But also waiting to treat a chronic total occlusion (CTO) can lead to a situation where it is much more difficult to resolve.

And then there are those physicians who go straight to performing bypass or extremely invasive bypass. This shouldn’t be frontline treatment and blockages should first be addressed percutaneously (intervention). 

Many physicians tell patients their steps in the treatment process are the right ones. And sometimes physicians won’t send patients for a second opinion. They might say, “I know what I’m doing.” “No one else can help you,” Don’t go to the physician across town because he’s a hack.” "I have to fix all of his patients." And many times they convince the patient to undergo some form of amputation that might have been avoided. Physicians MUST stop telling patients their way is the best and only way to treat PAD. It’s not necessarily true. Yet patients believe them because they trust their physicians.

Different physicians have different approaches, tools, techniques, skills and even philosophies to treat blocked arteries, particularly in the legs for patients with PAD. 

I’ve observed treatments across practices during a five-year journey around the world. As a journalist, I visited catheterization labs (cath labs) in hospitals, ASCs, and OBLs. I participated in thousands of hours of procedures wearing scrubs, lead, and a mask in nearly a dozen countries and two dozen states. My knowledge and experience isn’t from a text book. I was on the frontlines watching hundreds of physicians treating blocked arteries in the legs percutaneously, using bypass, and amputation. What I learned is that the treatment standards are outdated, not consistent, and are often not in the patient’s best interest. Each patient is different. No location, length, degree of calcification, and percent stenosis is ever the same. A multi-practice approach is critical to improve patient outcomes. A one-size fits all modality or algorithm will never work. Yet, there’s a conflict between practitioners treating PAD.

I founded The Way To My Heart, a 501(c)(3) nonprofit, to help these PAD patients. It is a network of nearly eight thousand patients around the world, which provides high touch advocacy for patients with PAD. We help patients explore and understand all options available to them so they can make an informed decision as to what treatment will help them to live a better quality of life. What I have found is that some physicians strongly discourage patients from seeking second opinions. Some refuse to acknowledge their limited skillset or suggest another option may be available elsewhere. I know this because I’ve single-handedly saved more than 500 “no-option” patients from amputation. Each was told amputation was imminent, but they were saved by a highly skilled limb salvage expert. I was shocked that none of their physicians would entertain the possibility of other available options. 

In one case in South Carolina, an IC not trained in below-the-knee revascularization amputated one leg and told the patient his other leg was on deck. His wife reached out to us, and we referred him to a limb saver who used a wire and “low and slow’ angioplasty to open up the iliac and tibial vessels. The procedure took less than 90 minutes. Months later flow remains along with continued pain relief. No amputation was necessary. In another case, I was advocating for a patient in a large California hospital chain with a VS who said that her leg must come off because treatment for disease below-the-knee is “ineffective.” He refused to give her a referral for a second opinion. We found her a limb salvage expert in the same system, different hospital who was able to save the leg – fully revascularizing her below-the-knee vessels. Before, she couldn’t walk a block. Now she walks more than a mile daily just weeks later. In each case, the first physician should’ve acknowledged to the patient that he won’t treat disease below-the-knee and that they should find a vascular specialist who does. Instead, both physicians told their patients they had no option but to walk until they were ready to amputate.