Limb Preservation for Patients with Non-Reconstructable Peripheral Arterial Disease May be Possible with New Techniques
The University of Maryland's Limb Preservation Program has performed a retrospective study of their experience with a novel technique developed for lower extremity revascularization in patients with severe peripheral arterial disease (PAD).
The study, 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, evaluated the efficacy of a new revascularization technique pioneered at the University of Maryland. Open Proximal Endarterectomy with Retrograde Access and Stenting, or OPERAS for short, involves improving the arterial blood flow in a chronically ischemic lower extremity.
This study found 100% technical success in patients treated with the OPERAS technique for complete total occlusion of the arteries of the thigh and knee. All patients in the study suffered from critical, limb-threatening ischemia, and more than 60% were offered an above the knee amputation at referring facilities. The limb preservation rate for the procedure is 88.9% at 1 year follow up.
Need for Better Options in the Treatment of Peripheral Arterial Disease
The development of this technique occurred out of necessity for the patient population with PAD in Maryland. Since PAD is a progressive and chronic illness, many patients have multiple procedures involving stents, balloon angioplasty, and bypasses. By the time they are referred, their PAD is usually deemed non-reconstructable and most are facing a major amputation. The University of Maryland's Limb Preservation Program has succeeded in saving the limbs in those who are "unsavable" by creating new ways of treating old problems. The underlying belief is that limb preservation is also life preservation in the majority of cases. Developing and using new techniques for revascularization, along with the Program's aggressive, multi-disciplinary approach to wound management has resulted in improved limb preservation rates in the area.
Moving Care to the University of Maryland Vascular Center at Redwood and Office Based Laboratory
Successfully evaluating and treating patients with stable ischemic rest pain, claudication, gangrene, or wounds that do not have signs of infection in the office has helped streamline care for limb preservation patients. The limb team of experts has been able to prevent unnecessary hospitalizations and give patients prompt and appropriate care within 24 hours of presentation.
An example of the successful implementation of the Emergency Room (ER) Limb Pathway involved caring for a 50-year-old man who recently arrived to the ER of the UMMC downtown campus. He arrived with severe ischemic rest pain along with dry gangrene of the forefoot. The Limb Preservation team was notified via DocHalo, and the patient was scheduled for evaluation in the office within 12 hours. Within 24 hours, he underwent non-invasive testing and angiography and was scheduled for his definitive revascularization and ongoing wound care. He was admitted to UMMC following his revascularization, which employed novel retrograde access techniques and subsequently had his podiatric surgery removing the devitalized tissue. After discharge, he has been followed in the office setting and at the wound care center at UMMC's Midtown campus, where he is getting hyperbaric oxygen therapy.
This patient was evaluated promptly and treated with a combination of outpatient and inpatient procedures, which ultimately saved his limb. By utilizing the University of Maryland's Limb Preservation Program's resources, the patient avoided an extended hospitalization and experienced an improved overall outcome. This patient is just one example of how the multi-disciplinary team infrastructure and the use of outpatient services has helped to change the landscape of patient care for PAD and wounds, in addition to improving rates of limb preservation while decreasing the need for major amputation.