Medical Innovation And The Fight Against Amputation

Many specialists unite with one goal: preventing amputation. When podiatrists encounter patients that may lose a leg from peripheral arterial disease (PAD), vascular treatment is an urgent need. But, the question may arise: “Why doesn’t the vascular community seem to agree on how to best intervene?”

A July 2015 research paper compared the primary and secondary outcomes of angioplasty versus open vascular surgery.¹ The research found both treatments equally effective in amputation prevention, improving the quality of life and life expectancy of patients with critical limb ischemia (CLI), but that endovascular treatment offered additional benefits of lower cost, lower complication rates, and easier recoveries. The study also showed a lower 30-day mortality rate for angioplasty.  The article summary stated, “Based on these results it is suggested that angioplasty should be considered as the first choice for feasible CLI patients.”¹

And in our experience, that is what patients are doing. More patients with vascular complications from PAD and diabetes seek early intervention using endovascular, outpatient procedures in an office-based setting, rather than waiting to have more invasive, hospital-based surgeries after disease progression.

Some vascular surgeons have been receptive to this pivot. In a September 2021 article, Juan Carlos Correa, MD, a seasoned vascular surgeon trained extensively in endovascular procedures, explained his choice to leave his traditional vascular surgery practice in Overland Park, Kansas and specialize in endovascular treatment and pedal loop revascularization: "I wanted to be part of the future of PAD treatment, not the past. I saw what they were doing in the clinics and wanted to be part of it.”²

Not every vascular surgeon has been this forward thinking. Along with any medical innovation will come those hesitant to evolve from the traditional methods. Increasing this tension further is the notion that vascular surgeons who are not embracing endovascular treatment are most likely losing patients. Since endovascular procedures can be done more safely and earlier in the PAD disease progression, as well as without a hospital stay, patients are drawn to that option. For that reason, it is likely that vascular surgeons who are not embracing endovascular treatments are losing patients - and therefore profits - to practices that are. Certainly, peripheral bypass surgery has an important role in peripheral artery disease (PAD) treatment as well. If less invasive methods are, for any reason, not maintaining patency of an artery, it may be time to utilize an open surgery approach. Open surgery is also very effective and remains an excellent next option for peripheral artery disease treatment if the noninvasive methods that the patient is a candidate for have been exhausted. Because it is a more invasive surgery, it is in the patient and vascular surgeon’s best interest to consider both options and proceed according to the patient’s needs.

Instead of using this as incentive to learn and implement advanced endovascular techniques, some physicians have taken to publically speaking negatively about their competition with a different skillset to recapture patients. Kym McNicholas, Executive Director at The Way to My Heart, an international patient advocacy group for PAD patients, warns the public about just relying on media and marketing campaigns to choose a physician and treatment option in her article titled, “The Truth Behind PAD Amputations.”³ She states, “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.”³ She advocates for patients to always get a second opinion to understand all available options in order to make a more informed decision on the right treatment plan for them, as different physicians have different tools, techniques, philosophies, and limitations when it comes to the treatment of blocked arteries in the legs.³

During my discussion with him on the topic, Scott Brannan, MD, Modern Vascular’s Chief of Endovascular Surgery, warned, “You can find all sorts of misinformation out there, misguided reporters from publications with no medical credentials are putting out false accusations of unnecessary treatments and negative outcomes. It just shows at best a general misunderstanding of the medical innovation and at worst an outright abuse of the facts. It’s a shame, these articles and infighting are a distraction from what really matters, doing what’s right for the patient.”  

The concern, shared by Kym and others, is that patients will go into procedures – sometimes amputation - without knowing about alternatives that might be better suited for them.  A recent article by LA McKeown published in October of this year titled, “Vascular Care falls Short Before Amputation for CLI: Medicare Analysis” suggests that a large group of patients did not exhaust revascularization options before amputation: “A look back at the care patients with critical limb ischemia (CLI) received in the year prior to amputation suggests that most received minimal vascular care, with 69% not undergoing a revascularization attempt that might have saved the limb or improved overall survival.”⁴ This indicates that the journey of educating and advocating for patients is not done. Thus, it is paramount that vascular surgeons, interventional radiologists, podiatrists, wound care specialists, and other specialists who regularly work with those at risk for nontraumatic amputations are united in preventing amputations in the safest and most effective ways possible.

Dr. Berkowitz currently holds the title of Chief Medical Officer at Modern Vascular. Previously, he served as Medical Director of Specialty Performance Improvement for Banner Health in Phoenix, Arizona. Prior to that position, he was the Chief Physician Executive and medical group president for Northern Light Health, a nine-hospital system in Maine. He's also held the title of Chief Medical Officer at St. David's Healthcare, a six-hospital system in Austin, Texas and at the Central and West Texas Division of HCA, which was awarded the Texas Award for Performance Excellence and the prestigious Malcolm Baldrige National Quality award.

References

1. Fu X, Zhang Z, Liang K, et al. Angioplasty versus bypass surgery in patients with critical limb ischemia – a meta-analysis. Int J Clin Exp Med. 2015;8(7):10595-10602.

2. Yahoo Finance. Vascular surgeons are embracing the future of peripheral arterial disease (PAD) treatment by transitioning to outpatient procedures. Available at: https://tinyurl.com/26wx3744 . Published September 23, 2021. Accessed January 4, 2022.

3. McNicholas K. The truth behind PAD amputations. LinkedIN. Available at: https://www.linkedin.com/pulse/truth-behind-pad-amputations-kym-mcnicholas/?trackingId=Tas0gUF%2F19BExdpuTgffag%3D%3D . Published August 5, 2021. Accessed January 4, 2022.

4. McKeown LA. Vascular care falls short before amputation for CLI: Medicare analysis. tctMD website. Available at: https://www.tctmd.com/news/vascular-care-falls-short-amputation-cli-medicare-analysis . Published October 6, 2021. Accessed January 4, 2022.