In our fight against unnecessary amputations through the Global PAD Association, one of our most powerful tools is connecting patients with doctors who go the extra mile. Our weekly “What’s Up, Doc” series recently featured Dr. Marc Salhanick of Complex Vein and Vascular in Dallas, a vascular surgeon whose personal connection to peripheral artery disease (PAD) drives his extraordinary commitment to limb salvage.
Dr. Salhanick’s approach challenges the all-too-common narrative that amputation is inevitable for many PAD patients. His insights offer hope and practical guidance for both patients and healthcare providers navigating this complex disease.
((Watch the full interview below))
Dr. Salhanick’s path to specializing in PAD wasn’t purely academic—it was deeply personal. While training in general surgery at Parkland Hospital, his father developed complications from diabetes and hypertension that would change both their lives.
“He’d say, ‘Oh, well, you know, I’m on dialysis. What’s the worst that could happen?’” Dr. Salhanick recalled. “I was a medical student at the time. I was like, ‘Well, you know, all these other things could happen.’ He said, ‘That’s not going to happen to me.’”
But it did. His father developed a toe wound that rapidly progressed to a below-knee amputation. Six months later, he developed a wound on the other foot, and within a year, he had become a double amputee.
This experience revealed to Dr. Salhanick not just the medical progression of the disease, but the emotional landscape patients navigate. “I started to understand a lot better the fear and the anxiety and the stress and all the other things that went into what had led him to that point,” he explained.
Working with vascular patients at Parkland during his third year of residency, he began sharing his father’s story. “It wasn’t everybody who necessarily was ready to hear that story, but there were people who were ready to hear that story. And we were able to work together and, to be frank, save some limbs because of it.”
When Is Amputation Actually Necessary?
One of the most valuable insights from our conversation was Dr. Salhanick’s clarity on when amputation is truly the only option. According to him, there are only two legitimate reasons for major amputation:
- When pain cannot be controlled through revascularization or medication
- When the infection is life-threatening (specifically when the patient is in septic shock)
“It is exceedingly small, the number of patients that we have that have those issues,” he emphasized. “It’s maybe two or three in the year.”
This perspective stands in stark contrast to the experience of many patients in our network who are told amputation is their only option for far less severe conditions. Dr. Salhanick shared a troubling conversation with another doctor who told him to “stop doing interventions below the knee because they don’t work.” His response: “Why don’t you even look?”
Revolutionary Technologies Changing the Game
When it comes to treating below-knee arterial disease, new technologies are changing what’s possible. Dr. Salhanick highlighted the Spur retractable stent by Reflow Medical, a device he’s used in approximately 10 cases since its FDA clearance in May 2025.
“It’s a new retractable stent,” I explained during our discussion. “It’s for below the knee issues that you may have. And it’s changing that durability comment.”
The Spur stent system is designed with radially expandable spikes that penetrate arterial lesions to increase luminal diameter and modify lesion morphology. Unlike traditional stents that remain in place, this stent is retrieved after treating the vessel, reducing the risk of long-term complications.
Clinical trials have shown impressive results, with the DEEPER REVEAL study demonstrating a 99.2% technical success rate and 97% freedom from major adverse limb events at 30 days.
Dr. Salhanick’s willingness to embrace innovative technologies illustrates an important point for patients: the options available to you depend greatly on your doctor’s commitment to staying at the forefront of the field.
The Second Opinion Imperative
Throughout our conversation, Dr. Salhanick emphasized a message that aligns perfectly with our work at the Global PAD Association: the critical importance of second opinions.
“Asking for a second opinion doesn’t mean that you don’t trust your doctor,” he clarified. “You trust that they’re giving you the best advice that they can. And they are presenting you with the best option that they have.”
I shared a story about a patient who continued to agree to amputations simply because she liked and trusted her doctor, despite alternatives being available elsewhere. Dr. Salhanick acknowledged the emotional complexity of this situation.
“It’s kind of like you have a relationship with a significant other. And then suddenly you realize it’s like, well, they may not have really had all the answers… You know, have I been lying to myself? Have I been lied to? That feeling as well of like, how could I have been so blind to not see this?”
He pointed out that medicine is a practice, and innovation rolls out differently across facilities. Some doctors may have access to devices like the Spur stent while others don’t. “That may be legit,” he acknowledged. “They don’t have the option.”
The Plavix Question: How Long Is Long Enough?
One of our live viewers, Heinz, asked a question many PAD patients struggle with: Is Plavix (clopidogrel) a lifelong requirement after receiving stents?
Dr. Salhanick acknowledged the lack of definitive evidence on this question. “The bottom line is that there’s not great evidence,” he explained. While coronary stents typically require Plavix for six months, peripheral arteries present different challenges.
His approach is generally to recommend three months of Plavix for interventions from the superficial femoral artery down, and six months for bare metal stents. However, he emphasized that if the stent has failed, continuing Plavix serves no purpose.
I also mentioned Dr. Anahita Dua’s research showing that Plavix isn’t effective in many patients, particularly those taking certain statins, highlighting the importance of Plavix sensitivity testing when treatments aren’t working as expected.
Investigating Pain: Beyond PAD
Another viewer, Allison, asked about managing PAD-related foot discomfort when she wasn’t yet a candidate for intervention—a common scenario among patients in our support community.
Dr. Salhanick emphasized that pain might have causes beyond PAD, including:
- Chronic foot injuries (which is why he works closely with podiatrists)
- Venous dysfunction
- Nerve entrapment syndromes
- Spinal stenosis
He shared a case where a patient with severe pain was referred by a spine surgeon who suspected PAD. While the anterior tibial artery did show abnormalities, Dr. Salhanick determined this wasn’t causing the excruciating pain. The patient ultimately had spine surgery, which resolved the pain completely.
“I could also see,” he noted, “that other vascular providers would have tried to do something on that AT [anterior tibial artery]. And I don’t think that was the answer.”
For PAD-specific pain management, we discussed three key strategies:
- Getting diabetes under control (aim for A1c under 6%)
- Stopping smoking to prevent arterial spasm
- Using prescription B vitamins like Metanix for neuropathic pain
I’ve seen remarkable results with Metanix in patients, including my own father, though I noted it’s often not covered by insurance.
Complex Cases: Learning from Lorna’s Journey
One of the most valuable segments of our conversation came from Lorna, a viewer with both PAD and chronic venous insufficiency (CVI) who shared her complicated medical journey.
Lorna had undergone multiple procedures, including stenting of her iliac, femoral, and aorta, followed by an emergency femoral-femoral bypass when her left iliac stent failed. She was experiencing excruciating pain and difficulty walking.
Dr. Salhanick identified several issues with her case:
- Her femoral-femoral bypass was an “extra-anatomic” bypass that doesn’t replicate normal blood flow. “I don’t do too good on physics, but that just don’t make no sense,” he explained, describing how blood has to flow unnaturally up and over from one side to the other.
- He suggested her pain might be coming from ischemic neuropathy resulting from the acute limb ischemia she suffered. “The unfortunate thing with this is that that nerve damage is irrevocable,” he explained.
- He recommended she might benefit from an electromyogram (EMG) to help diagnose the neuropathy, though he acknowledged it’s “not a fun experience.”
Following his assessment, I mentioned that Dr. Ankur Thapar, one of our Global PAD Association luminaries, works with a team that performs sympathetic nerve injections for pain management in similar cases. I also noted that interventional radiologists sometimes have additional pain management options for patients with nerve damage from ischemia.
Dr. Salhanick agreed with this approach, highlighting the importance of creating “a whole team around you” for complex cases.
The Outflow Concept: A Highway Analogy
Perhaps the most valuable educational moment came when Dr. Salhanick explained the concept of “outflow”—a critical factor in the success of any vascular intervention that patients rarely understand.
He used a brilliant highway analogy: “Imagine that you’re on the highway and you get into an accident. And then you are able to get off early… And you come down and you get to a part of the highway that’s open only to find there’s another accident. And then what ends up happening is the people behind you keep coming and keep coming… And before you know it, everything’s just backed up.”
Similarly, if there’s no place for blood to go beyond a treated artery, the intervention will fail regardless of how well it’s performed.
He also compared poor outflow to “a highway with no exits”—even if the main road is open, it’s functionally useless without ways for blood to reach surrounding tissue.
This concept is so fundamental that every patient should ask their vascular specialist about outflow before any procedure. If the doctor can’t explain their approach to ensuring adequate outflow, it might be time for another opinion.
Mike’s Miracle: The Power of Walking
The most inspiring segment of our discussion featured Mike, a member of our Global PAD Association community who transformed his PAD through lifestyle changes alone.
Diagnosed with 75% narrowing in his superficial femoral artery six months earlier, Mike initially fell into depression. His mother had lost her leg to PAD following a failed bypass, and he feared the same fate.
“I was struggling to even walk up the hill outside the house. I was getting cramp in my left calf really, really bad,” Mike recalled.
Instead of intervention, Mike committed to walking regularly, quit smoking, and completely changed his diet. His results were extraordinary: his ankle-brachial index improved from 0.68 to 1.05 in his affected leg, and he recently completed a 13-kilometer walk across the Confederation Bridge for the Terry Fox run.
Dr. Salhanick explained that walking helps the body develop collateral vessels—natural bypasses around blockages. “The body is a lot smarter than we are,” he noted, adding that controlling diabetes and quitting smoking are essential to allowing these natural bypasses to develop and stay open.
Medical Misadventures: Tales from the Trenches
Toward the end of our conversation, Dr. Salhanick shared some memorable patient stories that illustrate important lessons:
The Toothbrush Tale
Dr. Salhanick typically advises patients with surgical incisions to simply let warm, soapy water run over the wound during showers. One patient called in distress because they “couldn’t get the red off” their incision and had started scrubbing it with a toothbrush.
The redness was normal skin pulling against staples—not something to be removed! “I now have to tell patients to not scrub their incisions with a toothbrush as a result of this,” he explained with a chuckle.
The Moving Wound
In another case, Dr. Salhanick performed an angiogram on a patient whose bypass appeared perfectly functional, despite reports of a deteriorating wound. As they were finishing the procedure, he noticed something alarming: the wound appeared to be moving.
“My initial thought was, ‘Oh no,’” he recalled, fearing a dangerous pseudoaneurysm. Upon closer inspection, he discovered the movement came from maggots that had infested the wound.
The patient was diagnosed with calciflaxis, a rare condition involving calcium deposits in the skin that Dr. Salhanick successfully treated with sodium thiosulfate. “It’s bizarre and no one talks about it,” he noted, highlighting the importance of recognizing this uncommon condition.
The Doctor’s Mediocre Superpower
I wrapped up our conversation with my favorite interview question: “If you could have any mediocre superpower, what would it be?”
Dr. Salhanick’s answer revealed his dedication to patients: “I wish that I could end a patient encounter on time, politely.” He explained that he often runs behind in clinic because he takes time to talk with patients and make them feel cared for. “I think patients, they come to the doctor because they want to feel cared for. They want to be fixed, but I also think that it’s an important aspect of it that your patients feel that you really care for them.”
His practice motto—“treat patients like you would want your family members to be treated”—sometimes means running late, but clearly results in the kind of compassionate care that makes a difference for PAD patients.
The Path Forward
Dr. Salhanick’s insights reinforce several key messages we emphasize at the Global PAD Association:
- Understand that PAD is a disease of the arteries, not veins (a common confusion)
- Know that there are almost always options before major amputation
- Be prepared to seek second opinions when amputation is recommended
- Ask specifically about outflow before any procedure
- Commit to lifestyle changes, particularly walking, even when it’s difficult
- Control diabetes and stop smoking to improve outcomes
His compassionate approach, informed by both personal experience and clinical expertise, offers hope to the millions suffering from PAD. With the right information, the right team, and the right commitment to lifestyle changes, many limbs can be saved that might otherwise be lost.
Disclaimer
The "What's Up, Doc" series and this article should not be considered an endorsement of any participating physician. Every patient's presentation of peripheral artery disease is unique, and finding the right doctor requires careful consideration of multiple factors including your specific symptoms, disease progression, geographic location, insurance coverage, and even personality compatibility.
When selecting a vascular specialist, consider:
- Their experience with your specific type of arterial disease
- Their familiarity with the latest technologies and techniques
- Their track record with limb salvage procedures
- Their willingness to collaborate with other specialists
- Their communication style and how comfortable you feel asking questions
For personalized guidance in finding the right doctor for your situation, we encourage you to contact the Global PAD Association's Leg Saver Hotline at 1-833-PAD-LEGS (1-833-723-5347). Our PAD Navigators can help assess your needs and connect you with appropriate specialists in your area.
For additional resources and information, visit padhelp.org.
We also invite you to join our supportive community of PAD patients and caregivers in our Facebook group at padsupportgroup.org, where you can connect with others on similar journeys and access educational content about living with PAD.
Remember: Being your own advocate is crucial in the fight against PAD. Don't hesitate to seek second opinions and ask questions about all available treatment options.
Kym McNicholas is an award-winning journalist and the founder of the Global PAD Association. She moderates “What’s Up, Doc,” a weekly series featuring conversations with leading vascular specialists.