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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. 

Physicians must give the patient up to other high skilled limb salvage specialists to try and prevent amputation.

Amputation is NOT treatment. 

Amputation is failure. 

Amputation is a death-sentence for many patients with PAD. The post-amputation mortality rate is equated to advanced stage cancer! 

I know that failure can be avoided. Sometimes it takes multiple endovascular attempts by highly skilled interventionalists. I was in a procedure in the Netherlands where a previously placed stent didn’t cover the entire treatment area, so a stenosis formed that stopped the flow and clotted all the way up the stent. The blockage material was likened to tire rubber. One doctor was ready to amputate. But a different physician with another set of tools and techniques was able to restore flow. 

In France, a patient’s treatment had been attempted multiple times without success. The patient’s disease had progressed to the point where the physician couldn’t identify the start of the blockage using an antegrade approach. A visiting expert explained a different type of procedure, retrograde, and that was successful, avoiding an amputation. 

In the U.S., I observed a patient getting treated in Phoenix, Arizona to clear a long, calcified occlusion from the popliteal all the way to the iliac that had been attempted multiple times. After seven minutes of atherectomy, she had fantastic flow restored. The doctor bent down to the patient and said, “We saved your leg.” When she stood up, I noticed tears in her eyes. Had this failed, amputation was imminent. This physician exhausted all efforts to save her patient’s leg. When faced with a complex case where failure wasn’t an option, she tapped industry connections for new tools and techniques that proved successful. When in the right hands, different tools and techniques can make the different in life and limb.

Aside from the most prevalent practices, IC, IR, and vascular surgeons, cardiothoracic surgeons, general surgeons, orthopedic surgeons, and podiatric surgeons also provide surgical treatment for PAD. Each generally follows their own practice guidelines, and each has their own threshold for amputation. While some specialists do transcend beyond old textbook methods defined by their practice, many fail to adopt new advanced endovascular limb salvage techniques. 

The differences in treatment vary based upon:

  • Training Location 
  • (University, Fellowship, Advanced Continuing Medical Education (CME) credits) 

and the physician’s willingness to learn new techniques

  • Standard Practice Guidelines
  • Standard Facility Protocols, Standard Teaching Protocols
  • Philosophy based on chosen evidence-based medicine
  • Whether a procedure is initiated and performed in a hospital versus OBL.
  • Reimbursement, who pays for the procedure and how much 
  • Access to medical tools, especially advanced wires, balloons, stents, thrombectomy, and atherectomy devices

But while physicians are taking these into consideration in determining whether a conservative approach, intervention, bypass, or amputation are appropriate, at what point is the patient’s best interest considered? Each is unique. Where in this process does the patient have a voice? If a patient knew there was a minimally invasive option by a highly skilled limb salvage specialist, how many patients would prefer a shoulder to groin graft protruding from their chest re-routing flow (axillobifemorial bypass) or amputation? Many advanced stage PAD patients experience excruciating pain, and they will agree to whatever the physician tells them will bring relief without question because they “like” and “trust” their physician.

We have a patient in Michigan who was told amputation was the best option, she asked for a referral to a limb salvage specialist nearby for a second opinion. The physician told her the other specialist was a hack and that she could die without removing the limb due to infection. We tried to convince her otherwise, but she went through with the below-the-knee amputation. She said the pain was so bad that she couldn't imagine any treatment would give her relief. Two months later she came back to us saying her second leg was on deck with the same explanation by her surgeon. This time she was open to a second opinion. Turns out, she didn't even have PAD. Her non-healing ulcers were caused by chronic venous insufficiency. A minimally invasive ablation zapped the troublesome flaps, and no amputation was necessary. 

Invasive procedures are not always necessary. But it's the traditional standard versus the newer regime of physicians treating PAD in a minimally invasive way, that has created a large gap in treatment and contentious behavior. It's so prevalent, that when I attended a recent industry conference, an IR fellow monopolized time with a medical device maker’s atherectomy simulation. A company representative asked him why he was spending so much time with the demo. To which the IR responded, “The VS won’t share PAD cases with our department. So, I don’t get the experience and I really want more experience saving legs percutaneously.” His university is not unique in that territorial nature. I was approached by a patient who was told by her VS that she had no-option but a fem-fem bypass, which has few options if it fails. She came to The Way To My Heart in search of a second opinion. We knew of an IR at the same university who’s told me he gets few PAD patients referred despite his advanced limb salvage skills. The PAD patients who find him are by chance. Most of the time he is referred cancer and fibroid interventions. In this case he was concerned about politics impacting his position if a VS got upset with his treatment. He asked us to go back to the VS and specifically ask permission to prevent conflict. It should not be this way. Patients should have a right to choose what’s right for them. And there are a variety of options.

Some specialists who treat patients with PAD:

  • Support walking and medicine to the point of ‘lifestyle limiting claudication.”
  • Support walking as medicine until disease advances past the body’s ability to effectively dilate collateral vessels so few surgical options are available besides amputation.
  • Only perform bypass. 
  • Only use high trauma-causing techniques during an endovascular approach.
  • Use various advanced limb salvage techniques, including multiple access points, and have the ability to revascularize vessels gently below-the-knee and into the foot. 
  • Refuse to treat below-the-knee, amputating the legs of most Diabetics who present with advanced stages of PAD, specifically “Diabetic Ulcers.” 
  • Amputate as frontline treatment prior to angiogram. Some patients don't get a vascular evaluation when presenting with advanced stage symptoms including non-healing ulcers and gangrene. For example, A Primary Care Physician may send them to a podiatric surgeon who amputates as frontline treatment for gangrene without proper revascularization of flow to the point of amputation.

The difference between success and failure can depend largely on the physician. But whether a patient ends up with the appropriate vascular specialist for them is primarily up to the referring physician, who may not be aware of available treatment options and that they vary, not necessarily based on practice, but on the individual vascular specialist. 

This leaves patient outcomes at the mercy of a "referral lottery." 

A 92-year-old woman was referred by her primary care physician (PCP) to a local VS and podiatric surgeon. After a failed angioplasty by the trusted VS, he and the podiatric surgeon told her that a transmetatarsal amputation was her only option to rid of the pain caused by non-healing ulcers on two toes. She didn’t question them because she ‘liked’ and ‘trusted’ them because they came highly recommended from her PCP. Her son, on the otherhand, was skeptical. A quick Google search led her son to uncover a more advanced limb saving approach called, “pedal loop revascularization.” He reached out to The Way To My Heart, and we connected them to an endovascular specialist who was able to use that technique and other minimally invasive advanced approaches to clear multiple artery blockages and restore critical blood flow and oxygen to help heal the wounds and relieve the debilitating pain. Amputation was prevented. 

Each practice and approach does have value. 

Each has limitations. 

It is the responsibility of each physician to know their value and limitations and communicate that to patients. 

For example, we had a patient at a large well-known hospital in California, who had two failed interventional procedures, which resulted in a dissection at the TP trunk, an important vessel below-the-knee. Two vascular surgeons at the hospital told him it was a “clot” that couldn’t be removed and his vessels below the knee were unsalvageable, that the only way he would save his leg from amputation was if he would “grow new arteries”. He found our organization and we directed him to a nearby interventional cardiologist who used low trauma techniques including low barometric pressure angioplasty and an atherectomy device to restore flow restored flow. Within a week he went from hobbling with a cane to playing tennis with me. Months later he won a regional tennis championship. A year later, a national doubles championship with his son. And still, four years later he continues to compete in tennis and plays 18 holes of golf without the assist of a cart.

Why didn’t that patient’s physicians tell him that while they might not be able to restore flow, another physician might have the skills? Sometimes physicians, while well-intentioned, don’t know what they don’t know and remain limited by their own practice guidelines - they’re uninformed. I had lunch with an Orthopedic Surgeon and during our discussion I shared new limb salvage options using advanced tools and techniques. He told me he didn’t know “Diabetic Foot” could be treated other than by amputation. He assumed that when physicians refer a patient to him they know his approach to treatment. He didn’t offer other options because he never looked beyond what his practice guidelines dictate as the method of treatment for blocked arteries and gangrenous toes, which is to amputate. 

Surgeons who offer only bypass or amputation must encourage patients to seek a second opinion from a highly skilled endovascular specialist. Endovascular specialists who only treat above-the-knee and/or only use limited high-trauma causing techniques that require stents for bailout, need to take steps to learn more advanced limb salvage skills. Until advanced skills are obtained, they must encourage patients to get a second opinion as well.

Physicians who are confident in their skillset should not be concerned about their patients seeking a second opinion. If they are concerned, it’s time to revisit that skillset and learn something new, not arguing for their own limitations, which is what is happening. Some physicians and organizations are trying to discourage patients from exploring a second opinion by diminishing the value of other options and berating the competition through media campaigns, publications, and even on social media. Let’s take a closer look at a few points of contention being discussed in an effort to not just sway patients, but also policy makers.

Overtreatment vs. lack of early intervention

Some say overtreatment is leading to amputation, specifically too many unnecessary interventions. The widely adopted standard practice for intervention is at the onset of lifestyle limiting claudication or rest pain. It’s rare that insurance companies will cover an intervention without symptoms. I think there are three greater issues: 

  • Overtreatment using bypass and amputation without prior appropriate intervention,
  • Too many interventions performed by poorly trained interventionalists who use high trauma techniques, resulting in the overuse of stents, and 
  • Too few interventions by highly skilled interventionalists using appropriate advanced interventional techniques. Waiting until the patient is facing imminent tissue loss, guarantees a complex, higher rate of failure, and possibly permanent nerve damage. A procedure in late stage doesn’t always relieve debilitating pain and may not be durable because of advanced progression of disease. Even more, a short focal lesion is much easier to treat with less trauma than a long, diffused lesion. Few low trauma options are available once the disease advances past the body’s ability to effectively dilate collateral vessels enough to re-establish adequate flow.

One of our patients was told ten years ago that she had a small 100% blockage in her SFA. Her Vascular Surgeon said frontline treatment was walking to grow collateral vessels (a natural bypass), which is true. As I mentioned above, the standard threshold for intervention is "lifestyle limiting claudication." Not for this surgeon. Despite complaints throughout the years that it was getting tougher and tougher for her to push through the pain, her surgeon refused to treat, saying, "It would only lead to a revolving door of treatments," ultimately resulting in amputation. Now, she can barely walk a block and her surgeon is saying that her disease has advanced past her body's ability to grow collaterals. While he could bypass, she now only has one severely diseased vessel carrying flow into her foot, so it won't be durable. He claims her best is to see how long she can tolerate the pain, then he will amputate. 

We have a similar patient also given two initial options upon diagnosis of a CTO in his left SFA one decade ago: Bypass or walk. It was a short, focal lesion at the time. He was told intervention is ineffective and will only lead to a revolving door and amputation. Not wanting an invasive procedure, he chose to walk through the pain and dilate his collateral vessels. While the onset of pain gradually decreased in frequency over the first five years, as his disease advanced the frequency of leg cramping increased. The latest CT angiogram shows the short, focal lesion is now a long, calcified occlusion extending upwards to the profunda and downward to the TP trunk. His tibial vessels are now also significantly diseased. At age 70 with overall deteriorating health, his VS says bypass is no longer an option and he should just continue to walk until he’s ready for an amputation. Lack of early intervention is like waiting for the house to burn down before calling the fire department.

The best place to treat: OBLS, ASCs, or Hospitals?

Competition for treating PAD patients has increased with additional reimbursement and approval of interventions in an outpatient setting at ASCs and OBLs. It’s created more options for patients, the way it should. Some patients are more suited for treatment in a hospital setting with the ability for overnight stay, especially ones at high-risk of complications. Others are better treated in an ASC or OBL, especially ones requiring more procedure time, a familiar care team, and less chance of exposure to drug resistant bacteria. But some physicians and organizations don’t agree. They want ALL of the patients for themselves: More patients equate to more money. They don’t consider that there are plenty of patients for everyone. 

Lack of diagnosis is a big problem leading to patients presenting at later stages with fewer less trauma, durable options available to prevent amputation. Diabetes is rampant and a leading complication is PAD. Instead of competing, physicians and organizations should be collaborating to inspire more patients to get tested and treated sooner. But they’re not, and some are resorting to public smear campaigns to destroy the competition. It includes the use of media as well as direct-to-patients, speaking poorly of competitors to prevent patients from seeking a second opinion elsewhere. In Tucson, Ariz., physicians are even reporting competitors to the state medical board by proxy. Ironically, one of their patients reached out to me from his hospital bed after they failed to restore flow percutaneously, then failed again with a bypass that included the removal of four inches of his fibula. The competitors they were trying to thwart, saved this man’s leg from amputation. Physicians should be more focused on improving their skillset versus trying to bring down competitors with a different set of advanced limb salvage skills. 

Some claim OBLs are preying upon vulnerable communities and performing unnecessary procedures. 

The most vulnerable communities are underserved by skilled physicians. These communities have the highest rates of amputation because patients don’t get diagnosed and treated in early stages. This is true in Arizona, which has a high rate of Native Americans. It’s also the case, particularly in the south, which has some of the highest amputation rates in African American communities. OBLs have made extra effort with direct outreach to these patients to perform endovascular approaches sooner and prevent amputation. This should be applauded.

Some claim OBLs are only in it only for the money and perform interventions for maximum reimbursement. 

That might be true in some cases. I’ve observed physicians with questionable practices. For example, I’ve been in an OBL where the physician performed atherectomy on every patient. Physicians get additional reimbursement for use of atherectomy devices. Some would argue, that’s not warranted in every case. I’ve been in other OBLs, where they maximize reimbursement opportunities with truncated procedures. As many as 20 patients are shuttled in for a maximum procedure time of 45 minutes, start to finish. In some of these practices, physicians work fast using high trauma techniques and excessive stenting. I’ve even seen cases where the tech performs most of the intervention while physician barely does more than just ‘touch’ the patient so that multiple labs can be operational at once. The CMS data reveals the practices which may have exceedingly high daily volume. Two of our patients treated by the same physician in this manner were told their disease was too advanced to treat percutaneously and that amputation was next. He referred them for a vascular surgery consult. Each reach out separately to The Way To My Heart, and we found them another nearby interventionalist, who restored flow with ease in under two hours for each patient. A little extra time made all of the difference between life & limb. While the aforementioned practice behavior is unacceptable, and should be addressed, it’s not typical. 

What is typical, is the overuse of costly invasive procedures prior to appropriate intervention by a highly skilled specialist. I’ve seen amputations and unconscionable “Hail Mary” procedures at hospitals without a prior angiogram to attempt a minimally invasive intervention. One patient came to us after a fem-fem bypass where blood flow from one leg was shared with the other. The surgeon never tried to intervene. Weeks later the patient’s strong leg was getting weaker, and within three months, rest pain in both legs kept him awake at night. The vascular surgeon admitted the patient for a double above-the-knee amputation. The patient’s wife franticly searched online alongside him hours before the procedure. She found The Way To My Heart, and we were able to connect them to an IR in the same hospital, who happened to be doing his rounds. While I was on the phone, he walked up to the patient’s room, accessed his records, and offered a second opinion, which was to perform an intervention. The patient told me that the VS followed up with a scathing review of this IR and further tried to convince him amputation was his only hope. The patient decided to take his chances with the IR, and now more than a year later, the patient walks without pain up to three miles daily. 

Another patient I advocated for was admitted through the emergency room at a large university hospital where physicians were telling her an axillobifemoral bypass was necessary without prior angiogram. It wasn’t until I provided critical questions for this patient to ask her physician, that that he backed down and agreed that a basic angioplasty would suffice. Months later, she is continuing to walk two to three miles daily. Her hospital roommate wasn’t as fortunate to have our guidance and ended up with that costly procedure. 

Two other patients in our network, one in Illinois, another in Texas, came to us after receiving an axillobifemoral bypass, sealing their fate. Both are young men in their 50’s. Neither was offered a prior angiogram, One of the patients had a failed aortic bypass with no prior intervention. In each case, second opinions secured by The Way To My Heart revealed hope to revascularize the original vessels. It’s not an easy process to reverse such an extreme surgery, and highly skilled interventionalists are working against the clock with a long-term action plan that could potentially result in the removal of the unnecessary graft that is now depleting critical organs of blood flow to feed the legs. Why are physicians resorting to high-cost invasive procedures without first attempting less expensive, minimally invasive ones first? Is it the money or is it simply that these physicians are poorly trained? Where’s the accountability?

Lack of accountability for physicians and organizations

Some argue that hospitals have plenty of oversight with their own peer review boards and that OBLs don’t have enough. Obviously, based on the aforementioned procedures, there is not enough oversight in hospitals. If there was proper oversight in hospitals, the above examples would never have occurred. We wouldn’t have the high rates of amputations and unnecessary invasive procedures if that was true. I think both need to be held accountable through an independent audit committee made up of multi-practice medical experts who review patient outcomes, including consideration of the patient’s disease complexity. 

So, what are the solutions?

The Way To My Heart’s belief is that all physicians treating PAD, whether by intervention, bypass, or amputation, should be required to:

  • Obtain continuing education credits across multiple practices to learn all available options, including new advanced tools and techniques. Referring physicians should also fulfill this requirement.
  • Present all available options for PAD treatment to patients prior to any procedure.
  • Encourage them to get a second opinion from multiple practices who may treat differently.
  • Participate in a multi-disciplinary team with patients to ensure holistic care, but not limiting patients to their select team  

(i.e. Vascular Specialist, Wound Care Specialist, Endocrinologist, Dietitian, Physical Therapy, Primary Care). 

  • Get an independent review of failed attempts to restore flow prior to performing amputation.

Organizations where PAD is treated, especially by multiple practices, should require:

  • Every Primary Care Physician to screen for PAD during annual exams for all patients over age 50, especially with high risk factors, for early PAD diagnosis.
  • An intervention before any invasive procedure by a highly skilled specialist.
  • All interventionalists to learn and use advanced limb salvage tools and techniques or refer to an interventionalist that does for limb salvage.
  • Development of multi-disciplinary teams for holistic care, but discourage exclusive ‘cliques’ that limit a patient’s choice within each discipline, or puts pressure on a patient to remain with a specific team.
  • Implement a multi-practice review of failed attempts to restore flow prior to amputation.

(In fact, insurance companies shouldn’t reimburse without it.)

  • Make it easier and faster for patients to obtain and share full records including images and cases notes from diagnostics and procedures.

Patients deserve better than what they’re getting in terms of treatment for PAD. They describe PAD pain as that of having tourniquets wrapped around your legs 24/7. Their tissue and nerves are screaming for oxygen! It's inexcusable that patients are being left for days, weeks, months, and years in pain awaiting appropriate treatment aside from lifestyle modifications. One of our patients has waited 18 months for intervention to clear a 100% blocked iliac and short focal lesion in her distal aorta because her first surgeon didn’t have the skill and marked her as palliative. No one else would touch her because of that. They left her to slowly die in pain, wheelchair-bound. It took paying for her own additional CT Angiogram to pursue second and third opinions outside of her hospital, that she finally got on the schedule for intervention with a highly skilled specialist. 

My biggest issue is with those physicians who refuse to give up their patients and allow them the best chance of life and limb salvage. Some physicians are too conservative saying walk, walk, walk until the disease advances beyond the patient’s ability to dilate collaterals to supply critical nutrients to the lower extremities. Others go straight to amputation without proper vascular evaluation. Two extremes – too little treatment, and overtreatment. There must be a happy medium. Standard protocols aren’t the answer. Learning advanced skills, sharing all options, allowing multiple opinions, and empowering patients to take their health into their own hands is critical to saving life and limb. 

This article is not to be taken as criticism to any one practice or organization. It's to promote awareness that it’s the lack of early treatment coupled with lack of appropriate treatment that’s leading to a large number of unnecessary amputations. The rate of amputation in this country as primary treatment is horrifying. We have the power to change that. Physicians have a responsibility to exhaust all efforts to 'do no harm,' and that includes limb preservation. Body dysmorphia is debilitating both physically and mentally. If amputation is imminent, the patient has nothing to lose. So, physicians who don't have the skill for advanced limb salvage, should send patients to someone who does. Give the patients the best chance of limb survival. The ultimate goal of all physicians and organizations should be to give patients a better quality of life. 

#PeripheralArteryDisease #PeripheralArteryDiseaseAwareness #AmputationPrevention #InterventionalCardiology #interventionalcardiologist #interventionalradiology #interventionalradiologist #vascularsurgery #vascularsurgeon #Whydolegsgetamputated

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