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Amputation Prevention Center

ProVascularMD has four amputation prevention centers in Southern California. We’ve made it our mission to do everything we can to prevent all but the most necessary amputations.
Amputation prevention by Vascular Specialist in Los Angeles, California
Amputation is a critical juncture in the natural progression of diabetes and vascular disease. It is associated with high mortality rates, high healthcare costs, and an irreversible reduction in quality of life. No matter the circumstance, the decision to amputate should not be made lightly and care providers should seek every viable alternative for their patients. Amputation prevention has emerged as a specialty area offered by an elite class of Vascular Specialists that can effectively re-establish flow throughout the lower extremity. ProVascularMD has four amputation prevention centers in Southern California, and we’ve made it our mission to do everything we can to prevent all but the most necessary of amputations.

In the rest of this article, we dive deep into the current state of vascular-related amputation in the United States, and the prominent role that vascular care plays in amputation prevention. Read on to learn more.

Amputation prevention specialist Dr. Michael Lalezarian in Los Angeles, California

Your Partner in
Amputation Prevention

Dr. Michael Lalezarian

Timely, accessible care is paramount in the effort against peripheral artery disease, critical limb ischemia, and their complications.

Dr. Michael Lalezarian is a double-board certified Vascular Interventional Radiologist specializing in minimally invasive endovascular arterial revascularization. He is a committed partner in the battle against the devastating consequences of advanced vascular disease.

5-Star Arterial Ulcer and Venous Ulcer care in Los Angeles
“He is truly dedicated, and an extraordinary physician who’s really concerned with his patients!”

Adrianne S, October 2018

Complications of Amputation

Rates of amputation have declined over the past two decades, but amputation is still a prevalent problem today. In fact, there are still over 50,000 incidents of vascular-related amputations in the United States annually. From our view, there’s still work to be done to bring this number down to include only the most necessary of cases.

The challenges of amputation extend beyond the obvious quality-of-life implications of immediate limb loss. Amputation brings with it a high likelihood of surgical and post-operative complications (20% to 37%), including wound infection (10% to 30%), deep vein thrombosis (13% to 26%), cardiac complications (9% to 10%), sepsis (9%), bleeding (8%), and renal failure (2% to 3%). In comparison, surgical care sees a 16% to 17% complication rate, while endovascular approaches only see a 5% to 9% complication rate [1].

Over 55% of patients who undergo amputation as a result of diabetes or PAD end up permanently disabled, and approximately the same amount never return to ambulatory status. Mortality is also strikingly high following amputation. In a recent US Medicare study, 1-year mortality following amputation for CLI was 40%, which was 10% higher than the subpopulation that did not undergo amputation [2]. From these data points it’s clear that the majority of patients are better off if they can avoid amputation altogether

Understanding Amputation Risk

The vast majority of lower limb amputation cases are the result of longstanding peripheral artery disease (PAD) secondary to diabetes, smoking, and cardiovascular disease. The decision to amputate is often made in the face of large infected wounds or persistent gangrene, and while much of routine care is focused on diabetes management and wound care for this reason, the underlying vascular component must be dealt with to effectively promote healing.
More than 8.5 million individuals in the United States have PAD [3]. In its early stages, PAD is asymptomatic and only detectable on imaging, rendering it ‘silent’ for much of the patient’s life. When individuals with PAD do become symptomatic, they present with intermittent claudication, a sort of cramping pain in the affected limb that flares up when exercising or walking great distances. Even this can be difficult to detect in primary care as the vessels in the leg remodel and collateralize, providing patients with interim symptomatic relief for long periods of time as their disease actually continues to worsen. Importantly, only a fraction of individuals with PAD on imaging exhibit symptoms. Equally important is the fact that the telling symptoms of PAD are easily confused with equally viable differentials that present with leg pain.

In its later stages, PAD becomes critical limb ischemia (CLI). CLI represents an advanced clinical presentation of PAD in which disease causes rest pain, ulceration, and gangrene. Around 1% of all PAD patients progress to CLI, representing about 10% to 15% of those with claudication. Without intervention, individuals with CLI have a 25% mortality rate and a 25% amputation rate at one year following diagnosis. At 5 years, mortality jumps up to 55% [2].

Amputation appears to be more prevalent in specific demographics, including in African Americans and Native Americans where the amputation rate is nearly double that of non-Hispanic white individuals [3,4].

Amputation Prevention

Preventative efforts should begin as early as possible in the course of PAD, but implementing them requires diligent care providers, aggressive screening programs, and the right network of specialists. PAD guidelines recommend screening every individual over 65, individuals over 50 if they have diabetes or history of smoking, and individuals under 50 if they have diabetes and at least one additional risk factor. As comprehensive as this approach should be, many patients still slip through and go undiagnosed until it’s too late. As physicians, we need to redouble our efforts to catch PAD in its early stages by looking out for telling risk factors and symptoms, and also in its later stages by shifting focus from the wound we can see to the vascular system beneath the wound.

Assuming a successful diagnosis, treatment poses its own hurdles. Lifestyle modifications are certainly an ongoing challenge in the PAD population where medical advice is seldom followed by patients. For this reason, PAD intervention is often reactive to emergent symptoms. To get ahead of amputation then, general practitioners, podiatrists, and wound care specialists must be proactive in involving their Vascular colleagues. Revascularization is recommended when symptoms cannot be addressed with conservative therapies, making it a viable option for late-stage PAD before CLI sets in. Even when the patient is in CLI and being considered for amputation, it’s not too late to save the limb. The right Vascular Specialist can re-establish flow and restore the limb to health in lieu of amputation.

Your Partner in Amputation Prevention
Vascular Specialist in Los Angeles
Amputation patient being cared for after failed amputation prevention

The Role of Revascularization in Amputation Prevention

Even as diabetes continues to become more prevalent throughout the Western world, amputation rates have actually declined markedly over the last two decades. This decline has correlated with a proportional increase in angiographic imaging and revascularization procedures. Over the same time period, we’ve seen advancements in medical and wound care therapies along with the establishment of integrated wound care centers [2]. While many would caution that correlation is not causation, these trends certainly suggest that more focus on PAD management has precipitated the decline in avoidable amputations, and that this success is owed in some part to more aggressive vascular care.

Despite these positive findings, amputation is still the first-line treatment offered for approximately half of all CLI cases that end in amputation [4]. This disparity is due in part to the simple fact that some patients are not viable candidates for revascularization, but some portion of this represents a gap in detection, diagnosis, and referral.

Success of Amputation Prevention Programs

Management of peripheral artery disease and its complications is complex and involves a diverse medical team to successfully prevent amputation. Dedicated amputation prevention programs, also called limb salvage programs, have been established by many Vascular Specialists around the country to more effectively manage the complexities of PAD care and maximize limb survival. At their core, amputation prevention centers focus on comprehensive vascular screening, imaging, and interventional services for PAD, while actively coordinating with complimentary care providers in wound care, podiatry, infectious disease, endocrinology, and other disciplines as needed.

As a relatively new and innovative development, evidence for amputation prevention programs is limited to single centers, but these centers have boasted tremendous success. One such amputation prevention center in Florida formally reported reducing amputation rates from 29% to 1% over the course of a 5-year period [1]. We’re happy to say that we’ve seen similar levels of success in our own practice at ProVascularMD amputation prevention centers in Southern California. Get in touch to learn more.

Your Partner in Amputation Prevention
Vascular Specialist in Los Angeles
More Resources
Peripheral Artery Disease Screening: Why Early Detection is Critical in PAD
Peripheral Artery Disease Screening: Why Early Detection is Critical in PAD
PAD signs, symptoms, risk factors, and screening methods.
Endovascular Treatment of Lower Extremity Arterial Disease
Endovascular Treatment of
Lower Extremity Arterial Disease
A brief 101 on the treatment options available for arterial disease.
Los Angeles Vascular Specialist Dr. Michael Lalezarian
Vascular Specialist in Los Angeles
Learn more about Los Angeles Vascular Specialist Dr. Michael Lalezarian.
References

[1] Sanguily J, Martinsen B, Igyarto Z, Pham M. Reducing amputation rates in critical limb ischemia patients via a limb salvage program: a retrospective analysis. Vasc Dis Manage. 2016; 13(5):E112‐E119.
[2] Barnes JA, Eid MA, Creager MA, Goodney PP. Epidemiology and Risk of Amputation in Patients With Diabetes Mellitus and Peripheral Artery Disease. Arterioscler Thromb Vasc Biol. 2020;40(8):1808-1817. doi:10.1161/ATVBAHA.120.314595
[3] Peripheral Arterial Disease (PAD) Fact Sheet. Centers for Disease Control and Prevention; 2016. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_pad.htm. Accessed November 25, 2019.
[4] Mcginigle, K. L., & Minc, S. D. (2021). Disparities in amputation in patients with peripheral arterial disease. Surgery, 169(6), 1290–1294. http://doi.org/10.1016/j.surg.2021.01.025

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