When Do You Refer A Patient For Vascular Intervention?

Desmond Bell, DPM, CWS

   Any patient falling into a Rutherford-Becker Category 4 through 6 should get a referral to a vascular interventionalist without hesitation. An interventionalist can be a vascular surgeon, cardiologist or interventional radiologist, who can perform procedures to open occluded arteries. In a number of instances, vascular surgeons perform both traditional bypass surgeries as well as the minimally invasive endovascular procedures, such as angioplasty, atherectomy, stenting and laser procedures, which many skilled cardiologists and interventional radiologists also embrace.

Understanding The Strong Socioeconomic Impact Of PAD

In July, I interviewed Mary Yost, MBA, who is the President of the Sage Group, LLC, for the Save A Leg, Save A Life radio program. The Sage Group is a for-profit research and consulting company specializing in vascular disease of the lower limbs including PAD, intermittent claudication, CLI, acute limb ischemia and diabetic foot ulcers (DFU).

   During this program, I asked Yost about the economic burden of PAD on the U.S. healthcare system. She noted that in 2010, the total cost of PAD (inpatient and outpatient) ranged between $164 and $300 billion. The $164 billion represents annual costs per patient in the U.S. REACH Registry.10 Patient costs in 2010 dollars were multiplied by the 17.6 million people with PAD.

   As Yost noted, the $300 billion estimate is more accurate because it includes all-cause hospitalizations.10 Even so, it understates the real cost because it does not include nursing home care, home healthcare, lost wages and other factors related to long-term care of patients who have had amputations to CLI.10

   Seventy-five percent of those with PAD are asymptomatic. While they do not have leg symptoms, 70 percent most likely have coronary and/or cerebrovascular disease.10

   It is estimated that between 5 and 10 percent of patients requiring below-knee amputations die in the hospital. Approximately 15 to 20 percent of patients who require above-knee amputations die while hospitalized.10 One in-hospital death from PAD or CLI can cost $12,000.10

   Additionally, there is a high rate of revision amputations. The revision amputation rate is 20 percent in patients requiring below-knee amputations and 12 percent in patients who require above-knee amputations.10

   Each of these statistics adds to the total national bill for amputation. This is before you consider the adverse patient outcomes such as the 60 to 80 percent of patients who are unable to walk, those suffering from depression, hospital re-admissions for amputation-related problems, the necessity for long-term care, etc.10

   The cost in dollars varies, depending on a number of factors. That being said, the socioeconomic impact of PAD is extensive.

What Medicolegal Liability Can Podiatrists Face For PAD?

In my travels, I have had the opportunity to visit many communities and colleagues who are seeking better ways to apply the team approach to limb preservation.

   Intuitively, we know that the team approach is preferred, if for no other reason than knowing that the patient population that is at the greatest risk for PAD and CLI has multiple comorbidities that make them among the sickest of the sick. While the team approach makes sense in terms of achieving better outcomes and reducing amputations, there is another important reason that podiatrists should know when to refer to a vascular specialist.


Being in home health definitely puts us in the frontlines. Thank you for your article.

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