Amputation Prevention Center
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.
Your Partner in Amputation Prevention
Dr. Michael Lalezarian
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.
Adrianne S, October 2018
Complications of Amputation
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 .
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 . From these data points it’s clear that the majority of patients are better off if they can avoid amputation altogether
Understanding Amputation Risk
More than 8.5 million individuals in the United States have PAD . 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% .
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].
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.
The Role of Revascularization in Amputation Prevention
Despite these positive findings, amputation is still the first-line treatment offered for approximately half of all CLI cases that end in amputation . 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
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 . 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.
Lower Extremity Arterial Disease
 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.
 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
 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.
 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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