Limb Preservation for Patients with Non-Reconstructable Peripheral Arterial Disease May be Possible with New Techniques

Development of New Vascular Surgery Procedure and Coordinated Care Protocols Preserve Quality-of-Life for Patients with Extensive PAD Histories

The University of Maryland's Limb Preservation Program has developed a novel technique for lower extremity revascularization in patients with severe peripheral arterial disease (PAD). Open Proximal Endarterectomy with Retrograde Access and Stenting (OPERAS) successfully improves arterial blood flow in a chronically ischemic lower extremity. The combination of open endarterectomy and percutaneous stenting treatments used with this approach is thought to lead to higher rates of successful revascularization. Percutaneous retrograde access, fairly new in Maryland, is emerging as a treatment option for patients who have failed revascularization with the traditional antegrade access.

The efficacy of OPERAS was evaluated in a retrospective study of the program's patients with critical, limb-threatening ischemia, more than 60% of whom were offered above-the-knee amputation at referring facilities. Led by Khanjan H. Nagarsheth, MD, MBA, Assistant Professor of Surgery in the University of Maryland School of Medicine and co-director of the Limb Preservation Program at the University of Maryland Medical Center (UMMC), the study found that for chronic total occlusion of the arteries of the thigh and knee (n=12), OPERAS resulted in 100% technical success. At the one-year follow up, the limb preservation rate for the procedure remained high at 88.9%.

Meeting a Statewide Need for Improved Treatment Options for Peripheral Arterial Disease (PAD)

OPERAS was developed out of necessity of caring for a patient population in Maryland presenting with an extensive PAD history with multiple previous stenting, balloon angioplasty and bypass interventions. By the time they are referred, many patients' lower extremity vasculature is deemed non-reconstructable, and most face major amputation. UMMC's team of experts believes that limb preservation equates to life preservation for most patients, and so they are willing to try new treatments in attempts to save "unsalvageable" limbs. OPERAS, coupled with the Limb Preservation Program's aggressive, multidisciplinary approach to wound management, has resulted in improved limb preservation rates in the area.

Coordinated Care from the ED to the Maryland Vascular Center and Office-based Laboratory

Employing an emergency department (ED) limb pathway protocol to successfully evaluate and treat patients with stable ischemic rest pain, claudication, gangrene or wounds without signs of infection in outpatient settings has streamlined care for UMMC's limb preservation patients. Doing so helps prevent unnecessary hospitalizations and provides patients with appropriate care within 24 hours of presentation.

An example of the successful implementation of the ED limb pathway involved caring for a 50-year-old male who recently presented to the ED at the UMMC downtown campus with severe ischemic rest pain along with dry gangrene of the forefoot. The Limb Preservation team was notified via DocHalo, an app that facilitates care coordination, and the patient was scheduled for evaluation in the office within 12 hours. Within 24 hours, the patient underwent non-invasive testing and angiography and was scheduled for definitive revascularization and ongoing wound care. Following his revascularization procedure that employed novel retrograde access techniques, he was admitted to UMMC and subsequently received podiatric surgery to remove devitalized tissue. After discharge, the patient is being followed in the office setting and at the wound care center at UMMC's Midtown campus, where he receives hyperbaric oxygen therapy.

Because this patient was evaluated promptly and treated with a combination of outpatient and inpatient procedures, his limb was ultimately saved. By utilizing the University of Maryland's Limb Preservation Program's resources, the specialized team avoided the patient's extended hospitalization and improved his overall outcome. This particular case is just one example of how the multidisciplinary team and close coordination with outpatient services has changed the landscape of patient care for PAD and wounds, improving UMMC's rates of limb preservation and decreasing the need for major amputation.