by Brandon Olivieri, R-3, Mt. Sinai Medical Center, Miami, FL, 2016
The next time you go running, play tennis, go for a hike, or even climb a set of stairs, think about something we often take for granted: our legs. Imagine if you experienced excruciating lower extremity pain during even the most mundane activities – how drastically would your life be altered? Interventional radiologists who specialize in treating peripheral artery disease (PAD) and critical limb ischemia (CLI) relieve pain like this every day, significantly improving the quality of life of their patients. While the number of IRs treating PAD/CLI has decreased since the 1980s, trainees should consider the option of having a successful and gratifying future practice treating these patients.
IRs pioneered the endovascular treatment of PAD/CLI. Charles Dotter performed the first percutaneous angioplasty on January 16th, 1964 when he dilated a focal superficial femoral artery stenosis in an 82 year-old women with critical limb ischemia who refused amputation, giving her two more years of amputation-free life before she eventually succumbed to pneumonia. This event was the transition of IR from a diagnostic specialty to a therapeutic one and drastically altered the field of medicine forever.
Multiple studies have since proven the effectiveness of percutaneous PAD/CLI therapy. The BASIL trial demonstrated equivalent rates of amputation free survival between those randomized to open surgery versus percutaneous revascularization, with decreased costs within the first year in the endovascular arm.1 A more recent study by Henry et al examining more than 1 million Medicare patients with critical limb ischemia found that the act of performing an angiogram decreased the odds of amputation by 90%.2 Trials such as these have helped build the endovascular PAD/CLI realm into a dynamic multimillion dollar industry with ground-breaking new technological advances always on the horizon.
However, as Dr. Barry Katzen noted in his 2008 Annual GEST Lecture, when “we have something valuable, other people are going to want it, and other people are going to be able to do it.”3 In the 1980s nearly 100% of angioplasty was performed by IR.3 In contrast, 2012 Medicare data reveals that 29% of peripheral procedures were performed by radiologists.3,4 Interventional Radiologists as a whole have gradually been relegated to a minority of the now multiple specialties who participate in PAD/CLI treatment. Many view this loss of vascular IR as directly related to the minimal longitudinal clinical care historically provided by IRs.
Now, with the widespread resurgence of the Dotter’s clinical IR physician, we stand poised to regain our place in providing the best therapy available for these complex patients. However, with vascular surgeons, interventional cardiologists, as well as some seasoned interventional radiologists already actively treating PAD/CLI, many new IRs wonder how they can compete when just entering the marketplace. These concerns can be addressed by 3 key points:
- With CDC estimates of approximately 8 million people affected by this disease, there is more than enough peripheral artery disease to go around.5 In addition, PAD is currently underdiagnosed and undertreated with the prevalence only expected to increase as the population ages. In the Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care (PARTNERS) study, 6979 primary care patients aged 70 years or older or aged 50 through 69 years with history of cigarette smoking or diabetes were screened for PAD.6 PAD was found in 29% of patients, with 457 patients (55%) patients newly diagnosed with PAD alone and 366 (35%) of patients newly diagnosed with both PAD and CAD.6 Based on this data alone, one could predict that the number of patients affected by PAD/CLI will continue to increase with current trends of the population aging and the growing prevalence of obesity-related medical conditions. Of patients in the PARTNERS study who had carried a diagnosis of PAD prior to study enrollment, 83% were unaware of their diagnosis.6 Furthermore 51% of primary care physicians were unaware of these prior PAD diagnoses.6 This raises the concern that PAD may be under-treated secondary to poor patient and physician awareness.
- Endovascular therapy for known PAD/CLI remains an underutilized therapy. Major amputation is the sixth most expensive surgical procedure performed in the US, and ranks among the top five procedures with the highest perioperative mortality.7-9 The previously mentioned study by Henry et al examining more than 1 million Medicare patients with CLI demonstrated that while angiography reduced the risk of amputation in hospitalized CLI patients by 90%, it was only performed in 27% of these patients.2 Another study performed in 2012 enrolling 20,464 Medicare patients with critical limb ischemia found that 54% of patients had no angiogram and 71% had no revascularization attempt prior to undergoing major amputation.10
- We do have data showing that IRs as a specialty provide high quality care for PAD patients with excellent immediate and long-term procedural outcomes. 9,11 However, regardless of specialty, the physician who truly deserves patients is the one who not only has the endovascular skillset to treat PAD, but who is also willing to go to battle side-by-side with their patients against disease. Therefore with emphasis during IR residency and fellowship now on clinical exposure, we have taken significant strides in the right direction.
To summarize the above points, PAD/CLI is an underdiagnosed, undertreated disease increasing in prevalence, with many patients having no endovascular workup. In addition, IRs provide high quality care just like other specialists who are committed to their patients. The question then raised is why do IRs comprise so little of the PAD/CLI market?
The reason is that IRs are not getting the training we need during residency to emerge from training and confidently and effectively treat this complex condition. As Dr. James Benenati mentioned in his 2014 Dotter Lecture, approximately 95% of IR trainees are interested in performing peripheral artery disease cases as part of their future practice but only 43% feel they are adequately trained to do so.4, 12 Crossing catheters, atherectomy devices, drug-eluting stents, re-entry devices, SAFARI, TAMI, pedal-loop, collateral-loop: these are just a handful of the multitude of unique techniques and technological advances used in the treatment of PAD that many trainees have no exposure to during residency. In addition and perhaps more importantly, trainees must gain a thorough understanding of the optimal conservative medical management of PAD/CLI.
The opportunity to have a successful and gratifying practice treating PAD/CLI is at our fingertips. As the future of our specialty, we must take it upon ourselves to change the current training atmosphere. This can start as with steps as simple as making your training program aware of your desire to receive exposure to PAD/CLI patients. If you are currently in residency and there are no interventional radiologists treating PAD/CLI at your institution, potential options for increased exposure include rotating with interventional cardiologists or vascular surgeons or even performing an externship. Attend one of the many PAD/CLI specific multidisciplinary conferences that occur throughout the year, some of which even offer scholarships. If there is an open conference/lecture slot at your institution, consider presenting one of the pre-recorded PAD-specific webinars put on by the SIR RFS Vascular Disease Service Line (VDSL). If you are a medical student currently applying to training programs around the country, ask what exposure trainees get to PAD/CLI patients during your interviews.
To learn more about establishing a PAD/CLI practice from some of the IRs who have led the path, please click the following link: Opportunity Knocks: Starting a Peripheral Artery Disease Program.13
For more information on PAD/CLI specific conferences, see the tabs under the SIR RFS VDSL website under the Clinical Education tab. If interested in our webinars, check out the SIR RFS YouTube channel. Please feel free to contact me at firstname.lastname@example.org with any questions.
- Adam DJ et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005 Dec 3;366(9501):1925-34.
- Henry AJ et al. Socioeconomic and hospital-related predictors of amputation for critical limb ischemia. J Vasc Surg. 2011;53:330-9.e1.
- Katzen B (June 2008). 2nd annual GEST Lecture. Is Interventional Oncology Doomed from the Start? How to Learn from Lessons of the Past. GEST – Global Embolization Symposium and Technologies. Conducted from Barcelona, Spain.
- Benenati J. (March 2014). 30th Annual Charles T. Dotter Lecture: Thirty Miles East of Samar. SIR 2014. Conducted from San Diego, CA.
- Peripheral Arterial Disease (PAD) Fact Sheet. CDC: Center for Disease Control and Prevention. Division for Heart Disease and Stroke Prevention. July 2014. www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_pad.htm.
- Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA2001;286(11):1317-1324.
- Yost ML. Cost-Benefit analysis of critical limb Ischemia in the Era of the affordable care act: Is it fiscally responsible to perform primary amputation as treatment? Endovascular Today. May 2014.
- Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361:1368-1375.
- Egorova N, Guillerme S, Gelijns A, et al. An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety. J Vasc Surg. 2010;51:878-885.
- Goodney PP, Travis LL, Nallamothu BK, et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Cardiovasc Qual Outcomes. 2012;5:94-102.
- Zafar et al. Lower-extremity endovascular interventions for Medicare beneficiaries: comparative effectiveness as a function of provider specialty. 2012 Jan;23(1):3-9.e1-14.
- Bhatt A, Khaja M. (March 2014). PAD Training in Interventional Radiology. SIR 2014. Conducted from San Diego, CA.
- Fratt, L. Opportunity Knocks: Starting a Peripheral Artery Disease Program. Cardiovascular Business. Jun 30, 2014. www.cardiovascularbusiness.com/topics/vascular-endovascular/opportunity-knocks-starting-peripheral-artery-disease-program?page=0%2C0