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 year1 2 3, 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 — hospitals, ambulatory surgical centers (ASC), or office-based labs (OBL). At the center of this debate is who or what is leading 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 the 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). Different physicians have different approaches, tools, techniques, skills, and even philosophies to treat blocked arteries, particularly in the legs of patients with 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.