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Limb Salvage Center

ProVascularMD has four limb salvage centers in Southern California. We’re committed to saving limbs and saving lives, and we’ve made it our mission to do everything we can to prevent all but the most necessary amputations.
Limb salvage by Vascular Specialist in Los Angeles, California

What is Limb Salvage?

In vascular medicine, limb salvage refers to the surgical approaches that are used to heal feet and legs that are at risk of amputation, including those affected by severe ulceration, gangrene, tissue loss, or pain from underlying vascular disease. While these symptoms are multifactorial, some form of severe vascular obstruction, either in the arterial system or the venous system, is often a root cause.

Many amputations are preventable with modern vascular approaches, so the possibility of limb salvage should always be evaluated before an amputation is prescribed. As vascular specialists, we play a critical role in treating the underlying occlusion and restoring blood flow, but this is one of many components of care that are needed to maximize the patient’s chances of healing, restoring function, and ultimately avoiding the need for amputation down the line. Successful limb salvage relies on aggressive care from wound specialists, podiatrists, infectious disease specialists, endocrinologists, and other medical disciplines that can actively manage exacerbating comorbidities throughout the healing process.

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

Your Partner in
Limb Salvage

Dr. Michael Lalezarian

Timely, accessible care is paramount in the effort against peripheral artery disease, critical limb ischemia, venous disease, 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

Limb Salvage Surgery Indications

Candidates for limb salvage surgery include anyone with underlying vascular disease being considered for amputation. This can include individuals with peripheral artery disease, critical limb ischemia, severe chronic venous insufficiency, deep venous obstruction, or a combination of these conditions. Often these patients will also have other comorbidities that contribute to tissue loss and compromise healing.

When evaluating ulcer patients, it’s common to focus on the visible manifestations of the disease and to overlook the underlying vascular phenomenon. An ultrasound exam is usually all that’s needed to determine if a vascular intervention could be of benefit, and can make all the difference when a patient is on the path to amputation.

Peripheral Artery Disease

Peripheral artery disease refers to atherosclerotic disease in the extremities, usually in the legs. While peripheral artery disease can progress silently (without symptoms) for several years and even decades, individuals will begin to experience claudication and visible changes to their leg as the disease worsens. More severe stages see a progressive decline in ambulation due to pain and the development of ulceration. Individuals with more severe peripheral artery disease are often diabetic and/or lifetime smokers.

Critical Limb Ischemia

Critical limb ischemia refers to the end-stage of peripheral artery disease. Patients at this stage of arterial obstruction have severe ulceration, gangrene, and/or severe leg pain at rest. If untreated, critical limb ischemia has a high mortality rate in the years that follow diagnosis (approximately 50% at 5 years).

Chronic Venous Insufficiency

Chronic venous insufficiency (CVI) is the consequence of venous hypertension and valve damage throughout the venous system in the leg. CVI is extremely common and immediately recognizable due to the manifestation of varicose veins. The vast majority of this population is not at risk of amputation, including many of those with venous leg ulceration (CEAP Score C5-C6). However, a subset of patients in this category will have a severe deep venous obstruction or mixed arterial and venous ulcer etiology, and should be considered for limb salvage surgery.

Deep Venous Obstruction

Deep venous obstruction can refer to a thrombotic occlusion (deep vein thrombosis), vein compression (e.g. May-Thurner Syndrome), and/or heighted venous pressure caused by valve damage in the deep veins. In either case, the consequence is venous stasis leading to ulcer formation and tissue loss.
Limb Salvage Specialist
in Los Angeles
Limb salvage patient being cared for at limb salvage center in Los Angeles, California

Limb Salvage Procedures

Limb salvage procedures can include arterial revascularization, venous revascularization, and venous ablation. Arterial revascularization may consist of balloon angioplasty, stenting, and/or atherectomy, while venous revascularization may consist of balloon angioplasty, stenting, thrombolysis, and/or thrombectomy. The goal of a limb salvage procedure is to eliminate vascular obstructions, open up occlusions, and restore healthy blood flow throughout the limb. In turn, healthy blood flow helps the limb and its extremities to heal.

A skilled vascular specialist utilizes a deep armemotorium of techniques and a variety of devices to address the unique needs of each individual patient. While open vascular surgery is practiced by some vascular surgeons and reserved for special situations, many vascular procedures today are done with minimally invasive, catheter-based techniques. These are also referred to as pinhole procedures or keyhole procedures, because a vascular specialist can treat the vascular disease through a single tiny puncture in the leg, the foot, or the arm by threading a small tube through the vascular system to the treatment site.

Arterial Revascularization

Arterial revascularization refers to any procedure that a vascular specialist uses to re-establish blood flow in the arteries of the lower extremities. Balloon angioplasty is a standard component in most arterial revascularization procedures, as it allows the operator to open stenotic lesions that aren’t completely occluded. In the case of total occlusion, atherectomy may be used to forge a path through tough occlusions, or atherectomy may be used to prep a hard lesion for angioplasty and reduce the risk of rupture. Finally, stent placement is quite common to reduce the risk of restenosis, and many stent devices have a drug eluting variant to help maintain patency for as long as possible. Depending on the complexity of disease, an arterial limb salvage procedure can be as simple as opening up a single atherosclerotic blockage using balloon angioplasty, or as complex as treating multiple lesions simultaneously with multiple procedural stages and devices.

Venous Revascularization

Catheters, balloons, and stents can be used to resolve obstructions and occlusions in the venous system as well. However, where arterial blockage is usually caused by severe atherosclerosis, venous blockages can be caused by thrombosis, compression (e.g. May-Thurner Syndrome), or excessive venous pressure. Therefore, venous revascularization can also involve thrombolysis and/or thrombectomy to clear out clot, and venous ablation to shut down high pressure superficial veins that are backing up flow into the deep system.

The exact treatment parameters, anatomy, devices, and techniques vary enough between arterial and venous treatment that specialized training and practice is required to specialize in one or the other. Dr. Lalezarian specializes in both arterial and venous revascularization and is able to provide comprehensive vascular treatment to patients in his care.

Your Partner in Limb Salvage
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] Tsai, S., Dubovoy, A., Wainess, R., Upchurch, G. R., Wakefield, T. W., Henke, P. K., & Arbor, A. (2000). Severe Chronic Venous Insufficiency : Magnitude of the Problem and Consequences, 705–711. http://doi.org/10.1007/s10016-005-5425-8
[4] BackTable, LLC (Producer). (2020, March 28). Ep. 60 – Building A Limb Salvage Program [Audio podcast]. Retrieved from https://www.backtable.com/podcast/60/building-a-limb-salvage-program

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