By Julian J. Javier, MD, FSCAI, FACC, FACP and Leandro Perez, MD, FACC, FSCAI, RPVI
Individuals with peripheral arterial disease (PAD) have blood flow disruptions due to narrowed or damaged blood vessels. Peripheral artery disease is a growing condition that puts patients at high risk for heart attacks and other cardiovascular events due to atherosclerosis (buildup of plaque), and the risk of plaque sloughing off and creating clots.
Advanced PAD often Leads to CLI
In the early stages of PAD, patients may show no symptoms, or they are often ignored. PAD is progressive; symptomatic disease progression and cardiovascular morbidity are high as it evolves. The advanced stages of PAD, which occludes blood flow, especially in the tibia and foot arteries, causing ulcerations, gangrene, and tissue loss, is known as Chronic Limb Ischemia (CLI).
Approximately 2 million people in the U.S. have CLI, but that number is probably much higher as it often goes undiagnosed until the disease is severely advanced. CLI is an occlusive disease state that doesn’t provide adequate perfusion to complete the body’s metabolic demands. CLI is increasingly escalating. Few other diseases have as high of a mortality rate as CLI.
Numerous Amputations Should be Prevented
In south Florida, we are seeing record numbers of people that were recommended amputation. In most of these cases, it is unfounded. Many physicians resort to amputation to try and save their patients’ lives, but it’s unfortunately often performed unnecessarily, and it puts patients at a higher risk of death. Amputation severely reduces a person’s survival rate. Because CLI is increasing in record numbers, patients’ survival rates are much worse than that of many deadly cancers, yet there is no clear strategic protocol in place by the government to help patients survive and better prepare and mandate their physician’s treatment plans.
In-Depth Imaging in Crucial to Avoid Unnecessary Amputation
Patients with CLI almost always have comorbidities such as diabetes, hypertension, high cholesterol, kidney disease, and extensive atherosclerosis throughout their bodies. Angiography is a critical tool to understand the patient’s vascular health overall. Sadly, many patients with CLI are never offered any in-depth imaging studies. With the proper testing, physicians can decide how to best treat the patient and avoid amputation through revascularization procedures. Patients who undergo amputation have double the risk within the year of death.
Many physicians see gangrene as a clear sign for amputation, yet amputation doubles the death rate in patients. Vascular and surgical revascularization treatment as opposed to amputation, are the optimal treatment options to provide better outcomes and survival rates.
It’s unfair to not educate patients on their options. And it’s unethical to not properly diagnose and offer advanced treatment options.
Angiography lowers a patient’s risk of amputation by 90% compared to those who do not receive it. However, only one in four patients are offered an angiography.1 Managing the numerous comorbidities that coincide with CLI is essential. Unfortunately, less than one third of patients are prescribed medications to manage disease states such as diabetes, lipid disorders or hypertension.2
Symptoms of PAD
• Claudication (leg and calf pain while walking)
• Weak pulse on ankle or foot
• Hair loss on legs and feet
• Leg pain while standing or sitting, which subsides after resting for an extended period of time
• A sensation of tightness & burning may occur in the leg or foot
• Swelling of the calves, which dissipates after elevation
• Dark veins
• Dry, itchy skin
• Ulcers can occur near the ankle and are often painless, but may have a dark rim
• Shortness of breath
Symptoms of Advanced PAD/CLI
• Ischemic rest pain
• Non-healing wounds
• Gangrene
• Multiple systemic comorbidities
Diagnosis and Advanced Treatment Options
Once diagnosis is confirmed, there are multiple treatment options that range from conservative to invasive; it all depends on the severity of the condition. For more advanced conditions, invasive treatment is needed. Until recently, invasive treatments were mostly surgical, very traumatic with days of recovery in hospital post-surgery; however, in the last decade, the introduction of percutaneous non-surgical techniques procedures has shifted the treatments from surgery to catheter-based interventions that do not require blades or general anesthesia. The same techniques used to open arteries of the heart without surgeries using catheter-based therapy are now the method of choice for the treatment of venous or arterial disease of the legs. The introduction of catheter-based techniques has now caused a shift from a surgical technique to a percutaneous technique that can be done in the comfort of an office without the need of hospitalization, all done under local anesthesia as an outpatient procedure.
Our goal is to educated patient and improve legislation on imperative CLI protocols and treatment to help individuals avoid unnecessary amputation.
Julian Javier, MD | Leandro Perez, MD
Dr. Julian J Javier and Dr. Leandro Perez are Cardiac and Vascular specialists with a special emphasis on limb preservation and venous disorder. Dr. Javier and Dr. Perez are board certified in cardiovascular disease and are well known nationally and internationally, authors of multiple articles in prestige peer review journals and book chapters on venous and arterial disease. They are affiliated with Physicians Regional Medical Center and Collier Regional and are accepting new patients.
To Schedule your appointment with Dr. Javier or Dr. Perez, please call (239) 300-0586.
Naples Cardiac and Endovascular Center
www.heartvein.com
1168 Goodlette-Frank Rd N Naples, FL 34102
(239) 300-0586
References:
1. Henry AJ, Hevelone ND, Belkin M, Nguyen LL. Socioeconomic and hospital-related predictors of amputation for critical limb ischemia. J Vasc Surg. 2011;53:330-339.e1.
2. Chung J, Timaran DA, Modrall JG, et al. Optimal medical therapy predicts amputation-free survival in chronic critical limb ischemia. J Vasc Surg. 2013;58:972-980.