When peripheral arterial disease (PAD) reaches its worst stage of critical limb ischemia (CLI), patients are faced with possible amputation, increased heart problems and a shorter lifespan.
Currently, 8–10 million people in the United States—mostly adults 65 and older—have PAD, resulting in approximately 150,000 leg amputations every year.
And yet few Americans are aware of PAD, let alone ways to prevent and treat it before it reaches the CLI stage. A lack of public and health care provider awareness, access to care and knowledge about potential interventional radiology treatments can contribute to late diagnoses and unnecessary amputations, severely hindering patient quality of life, experts say.
Furthermore, PAD numbers are expected to skyrocket as the U.S. population ages, with an estimated 19 million people having PAD by 2050, according to the American Heart Association (AHA). There are also significant disparities, with higher rates of PAD in rural, Black and Native American communities and among those with low socioeconomic status. Hispanic men and women have similar disease rates as non-Hispanic white people but present at later stages.
One of the challenges is that PAD doesn’t always gain the same attention in the medical community as a condition that is as life-threatening as a stroke or heart attack, said SIR President Parag J. Patel, MD, FSIR.
In addition to the aging population, more Americans suffer from chronic medical diseases that increase PAD risk, such as chronic kidney disease, diabetes and obesity, Dr. Patel pointed out.
“Kidney failure and diabetes have their own effects on worsening peripheral vascular disease. So, patients who have lived long with those chronic diseases tend to have these types of problems in their blood vessels,” he said. “We’re just seeing a growing number of patients.”
In response, 25 organizations, including SIR, came together to develop a PAD National Action Plan, which was announced in 2022. The plan aims to decrease the spread of PAD and raise public awareness.
Public awareness and professional education go hand in hand: Sometimes neither patients nor health care professionals are aware that a patient’s symptoms are pointing to PAD, leading to missed or delayed screening and diagnosis.
The U.S. Preventive Services Task Force (USPSTF) recommendations say there is insufficient evidence to screen for PAD in asymptomatic patients. But what is considered a symptom? That’s the question Yolanda Bryce, MD, an IR at Memorial Sloan Kettering Cancer Center, wants more people to consider and to research.
“What people normally equate to a symptom is what we call claudication—which is pain with walking in the buttocks, hips or legs that goes away with rest—but a lot of people don’t present with those exact symptoms,” Dr. Bryce said. “For example, women disproportionately present with atypical exertional leg pain that starts at rest or keeps going even after rest. That might not be considered a PAD symptom, so you may not screen for PAD even though you should.”
In addition, Dr. Bryce said, Black patients disproportionately present with decreased activity, not pain. “So, if you don’t screen for that, which you’re likely not going to do, you will miss that person and then they’ll later present with advanced disease.”
Even with claudication, patients and health care providers might assume other causes such as arthritis or a muscle injury, not understanding the severity, said Sanjay Misra, MD, FAHA, FSIR, who represented SIR in the group that developed the national plan.
“A lot of patients go to these different providers first—nephrologist, diabetologist, endocrinologist, podiatrist—so raising awareness of guidelines is important,” Dr. Misra said. “Guidelines are meant to help physician providers, but you actually need to suspect PAD before the guidelines can even help you.”
Patients with coronary artery disease (CAD) are also at risk for PAD, since the same problems are at play. And yet, according to the AHA, even patients with clinically diagnosed PAD are not treated as frequently with guideline-directed medical therapy, such as statins or antiplatelet agents, as those with clinically diagnosed CAD are.
Limb amputations increase in United States
A critical concern is that lack of screening, diagnosis and treatment leads to unnecessary limb amputations. A 2019 study in Diabetes Care showed that after a 2-decade decline, rates of nontraumatic lower extremity amputations in individuals with diabetes was surging. Between 2009 and 2015, such amputations increased by 50% among these patients and were most pronounced among those ages 18 to 64.
“Patients are getting amputations and don’t even get an angiogram or a procedure done to assess for peripheral arterial disease first,” Dr. Misra said. “So, one of the things that this plan is pushing for is lowering amputation rates; public reporting of amputations, especially by hospitals; and really advocating for appropriate workup of patients before they get an amputation.” Health care professionals need to make sure they have “exhausted all interventional medical surgical techniques before a patient loses a limb,” he said.
If a patient is diagnosed early, cholesterol- and blood pressure-lowering medications and lifestyle changes, such as tobacco cessation, exercise and a healthy diet, may halt or reverse PAD. Beyond that, IRs can play a critical role in treating and managing patients, striving to prevent patients from reaching the CLI stage and limb amputation.
Raising awareness about IR treatments that restore blood flow in limbs—including angioplasty, stents, stent-grafts and thrombolytic therapy—could reduce the rate of limb amputations.
In addition, IRs can become a valued part of a health care team, helping to manage patients long after their treatment. Dr. Bryce considers her PAD patients to be patients for life, as an interventional treatment does not cure PAD but rather manages it. In her vascular lab, she has developed a regimented system of follow-up care.
“After I do the procedure, I see them, depending on a wound or not a wound, in 2 weeks vs. 4 weeks, and I follow them. If the wound is healed, I still follow them every 6 months to make sure they’re doing well, and I image them and make sure I catch a problem early—rather than say ‘OK, I fixed you; go on with your life,’” she said. “They are my patients forever—for as long as they’re alive.”
Dr. Bryce recommends that IRs who treat PAD patients consider longitudinal follow-up, dedicated clinic space and how to work with a multidisciplinary team to manage a patient’s risk factors.
Getting involved in research is also important. “The USPSTF has said that there’s insufficient data to screen for PAD. Therefore, we need research in this area to show that screening for PAD in a high-risk population is worthwhile,” she said.
She also pointed out the historical mistrust of doctors and research projects among some in the Black community because of racist medical treatment and experiments such as the Tuskegee syphilis study. This makes it ever more important for nonwhite IRs to become involved in research, she said.
“Studies have shown that increased involvement of principal investigators or members of the investigating team who are minorities increases enrollment of minority patients,” she said.
While many factors are connected to the increase in PAD and limb amputations in the United States, IRs play an important role in preventing amputations and improving patients’ lives, experts say.
“I think it’s part of our duty to help all of our patients, and we shouldn’t have a disproportionate number of patients who get to a point where they need an amputation or were never offered limb-sparing treatment,” Dr. Patel said.
References
- Six steps to reducing PAD. SIR Today, June 2022. bit.ly/3MJWp4z.
- PAD National Action plan. American Heart Association. professional.heart.org/-/media/PHD-Files-2/Science-News/p/PAD-National-Action-Plan.pdf.
- Final recommendation statement: Peripheral Artery Disease and Cardiovascular Disease: Screening and Risk Assessment with the Ankle-Brachial Index. U.S. Preventative Services Taskforce. spreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/peripheral-artery-disease-in-adults-screening-with-the-ankle-brachial-index.
- Geiss LS, Li Y, Hora I, Albright A, Rolka D, Gregg EW. Resurgence of diabetes-related nontraumatic lower-extremity amputation in the young and middle-aged adult U.S. population. Diabetes Care.2019;42(1):50–54. doi.org/10.2337/dc18-1380.
