COMMENTARY

Limb Salvage: What's Needed to Get It Right?

Frank J. Veith, MD

Disclosures

November 02, 2015

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Editor's Note:
Revascularization of threatened ischemic limbs is an area of interest for many specialties, but the skill set and specialist teams required for these procedures can be daunting. Revascularization will be a featured topic at the upcoming VEITHsymposium, which will be held November 17-21 in New York City. As a preview, Dr Frank Veith provides his views on the various skills needed to achieve excellent outcomes for salvaged limbs.

Hi. I am Frank Veith, professor of surgery at New York University and the Cleveland Clinic.

Today, I am going to talk about saving lower limbs threatened by ischemic gangrene, ulceration, or severe ischemic rest pain. This is a subject that has recently gained increasing attention as an area of opportunity for many specialties. I will give a little history on the subject and make the point that these procedures may not be so easy.

In the late 1970s, amputation for such patients was the standard of care. My colleagues and I pioneered an aggressive approach[1,2] to saving such threatened limbs by introducing better angiography and a variety of very distal bypasses to leg, ankle, and foot arteries. We also introduced adjunctive or stand-alone balloon angioplasty or stenting to save limbs as these methods became available,[2] and we showed the value of redo or repeat interventions when a primary procedure failed—which they often did over time.[2,3,4] Finally, we showed that most threatened ischemic limbs could be saved by this aggressive approach.[2,4,5]

Our first presentations and articles on such aggressive limb salvage were greeted with skepticism, disbelief, and often disdain. Some said these aggressive approaches were too expensive – until we showed that a major amputation was even more expensive, and resulted in greater disability.[6]

Despite this early skepticism, our methods for saving limbs became widely adopted at many vascular centers throughout the world. Still, many patients—even in the United States—were subjected to unnecessary amputations because the limb-saving procedures were difficult, time-consuming, and required specialized expertise and commitment.

More recently, other specialties, such as interventional cardiology and interventional radiology, as well as vascular surgeons, have developed remarkably better endovascular technologies and skill in dealing with occlusive disease of the smaller arteries in the leg. These specialists have used these techniques to treat threatened limbs and salvage them. It is one of the hot new areas in vascular treatment, and there are abundant numbers of patients, many of them diabetic. These patients have limbs threatened because of arterial occlusive disease. Mostly, these patients have multisegmental disease that involves distal arteries in the leg and foot.[2,4]

Because of this very distal artery involvement and because of the extent of the gangrene or necrosis in their feet, these patients are difficult to treat. These procedures are also complicated by the comorbidities that many of these patients often have. Special skills and commitment, often from many specialties, are required to get optimal results in patients with threatened limbs.

 
Special skills and commitment, often from many specialties, are required to get optimal results.
 

Expertise in endovascular techniques, open vascular operations, excisional therapy of gangrenous foot or heel lesions, skin grafting, medical and intensive care unit (ICU) management, specialized anesthesia, and rehabilitation are often needed.[5]

Just because vascular specialists can place a stent in larger arteries or treat the aorta or coronary arteries does not qualify them as expert in all the techniques needed to save threatened lower limbs. Patients and referring physicians should realize that specialized skills and commitment are required to achieve optimal outcomes in patients with ischemic gangrene or necrosis.

Moreover, the individual or center that takes on the care of such patients must be prepared to follow the patients closely and to deal with the recurrent problems that will frequently develop.

Although the first operations will usually be successful, many will fail or develop threatening lesions that require treatment.[4,5] Often, the redo treatment will be more difficult than the original procedure. Some failed endovascular treatments can be salvaged by an open procedure and vice versa—reemphasizing the need for open and endovascular specialized expertise.

The recent renewed interest in saving critically ischemic lower extremities is justified by the excellent outcomes that can be achieved.[7] However, such outcomes cannot be achieved by every vascular surgeon or vascular specialist. Therefore, the enthusiasm for limb-saving procedures must be tempered by certain realizations.

First, such procedures can be difficult and require special expertise in their performance. Second, after a limb salvage procedure, careful follow-up is obligatory, and the treating doctor must have a willingness to perform even more difficult secondary procedures when the initial procedure is threatened or fails.

I am Frank Veith. Thanks for watching.

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