02/29/2024
FINDING A P.A.D. DOCTOR
Once you are diagnosed with P.A.D., you will need a referral to a P.A.D. specialist. It's important to understand that not all vascular doctors are P.A.D. specialists and P.A.D. treatment is not limited to vascular surgeons. Different doctors have different tools, techniques, philosophies, and standard protocols that dictate treatment for P.A.D. That's why we urge all P.A.D. patients to get multiple opinions prior to any procedure.
Typically, when your primary care physician either diagnoses you with P.A.D. or writes a referral for a vascular specialist, you are at the mercy of the referral lottery. You end up with a referral to a general "vascular department" or a vascular specialist that has a referring relationship with your physician. It's likely your referring physician has never been to a vascular conference, doesn't read up on cutting-edge P.A.D. treatment tools and techniques, and has never personally observed a vascular doctor in practice, let alone others to compare available options and outcomes. They don't likely know that not all vascular specialists are equal in skillset. While all may treat P.A.D. in some form or fashion, they might not have the most advanced treatment options available in today's fast-moving cycle of innovation in P.A.D. treatment. P.A.D. treatments have advanced significantly in the past five years with only about 10% of vascular specialists trained in newer minimally invasive techniques from groin to toe. So, it's important for you as the patient to do some due diligence to ensure you are in fact seeing the best vascular specialist for your presentation of disease.
Who is a P.A.D. specialist?
Four main practices may treat P.A.D. Treatment options not only vary by practice but also between doctors within each practice:
Vascular Surgeon: May have the ability to treat P.A.D. and other vascular issues using endovascular (minimally invasive tools & techniques), bypass, and amputation.
Interventional Cardiologist: May have the ability to treat P.A.D. and Coronary Artery Disease (C.A.D.) using endovascular tools & techniques.
Interventional Radiologist: May have the ability to treat P.A.D. using minimally invasive tools & techniques as well as provide other image guided diagnostics and therapy such as cancer treatments
Vascular Medicine: Always treat P.A.D. patients who do not require surgery, but instead only medical therapy, which may include walking program. A patient may have a vascular medicine doctor along with a vascular surgeon, Interventional Cardiologist, or Interventional Radiologist for long-term disease management.
How to choose a P.A.D. specialist?
This depends on individual presentation of disease. Since the stage at which someone is diagnosed varies, each case must be considered independently. Also, you may not end up with the same practice or physician treating you during your life-long journey. Early stage P.A.D. when you are in the 'claudicant' stage, may only require a Vascular Medicine doctor to discuss medical therapy and lifestyle modifications. But having a vascular surgeon, interventional radiologist, or interventional cardiologist who specializes in P.A.D. treatments review your ABI Test, ultrasound, and/or CT Angiogram is highly suggested for even early stage diagnosis to begin to understand future treatment options if disease progresses.
When selecting a vascular surgeon, interventional radiologist, or interventional cardiologist, a good rule of thumb is to ensure you have what's considered a "CLI Fighter" from the start. What is a "CLI Fighter?" CLI stands for Critical Limb Ischemia, the most advanced stage of P.A.D. A "CLI Fighter" understands what treatment is appropriate, whether bypass or endovascular, but is fully trained in, or can refer you to someone who specializes in advanced minimally invasive tools and techniques to treat complex blockages found in advanced stages of P.A.D. when medically appropriate to ensure all efforts are exhausted prior to amputation. Typically "CLI Fighters" have a higher volume of complex P.A.D. cases with a high limb salvage success rate.
What criteria are not relevant when selecting a P.A.D. specialist, specifically a CLI Fighter?
Don't simply choose a vascular specialist based on general prestige of a facility, type of facility, pedigree, title (including department rank), speaking engagements, or number of publications. None of those will indicate treatment outcomes. It's an antiquated way of selecting a doctor. Today's selection process must be led by proven skillset of an individual doctor.
What questions should I ask when choosing a P.A.D. specialist, specifically a CLI Fighter?
When do they decide to perform a procedure?
Do they offer a procedure with any sign or symptom of P.A.D., including leg cramps and/or neuropathy? Walking, pharmaceutical therapy, and lifestyle modifications are frontline treatment for P.A.D. unless you have a wound and/or rest pain at night. Always get a second opinion before any procedure to ensure it's what's right for you.
Do they offer a procedure when a patient presents with lifestyle limiting claudication? A physician may offer a procedure for lifestyle-limiting claudication if a regular walking regimen isn't improving symptoms.
Do they only offer a procedure with rest pain or a non-healing ulcer present? Some doctors may treat too soon and some may wait until there's permanent nerve damage before treating. Lifestyle limiting claudication is standard for treatment but must be weighed risks/benefits based on individual presentation.
What is the volume of endovascular P.A.D. procedures performed not just by the facility, but by the specific doctor? Typically a "CLI Fighter" will average 4-6 endovascular procedures daily. Some only perform procedures two to three days a week, others have procedures daily.
What is the success rate of crossing the most complex blockages known as Chronic Total Occlusions (CTO), or 100% blockages?
What is the amputation rate, or percentage of patients that are referred for amputation?
What is the most complex type of blockage they treat using minimally invasive tools and techniques before referring a patient for bypass or amputation?
Do they treat below the knee vessels including the foot using minimally invasive tools and techniques? If so, what is their criteria for treating these vessels? Some believe treating below-the-knee and into the foot are ineffective. Some will only treat below-the-knee and foot vessels if a non-healing toe ulcer is present, with what they consider tissue loss. You want someone who will weigh your individual presentation, symptoms and potential for relief, versus risk of complications.
Do they use multiple entry points depending on the accessibility of the blockage Most doctors access the leg arteries through a puncture in the groin area. But if they aren't able to get through the blockage coming down from the groin, a CLI Fighter will have the ability and willingness to attempt through a puncture in the foot or calf.?
If all endovascular options are proven ineffective, does this physician use advanced techniques for endarterectomy and bypass or have a relationship with a physician whom he/she would trust for themselves or family for those invasive procedures?
Where are P.A.D. specialists treating patients?
Advanced P.A.D. specialists are located within hospitals and office-based labs (OBL). But don't be blinded by the shiny lights of a big name and facility. Location is secondary to proven skillset when selecting a vascular specialist. Since minimally invasive treatment options can be performed outpatient (meaning the patient can come and go same-day), some advanced vascular specialists prefer to operate independently in OBLs versus inside a hospital. Some advanced vascular specialists perform procedures in both OBLs and hospital settings depending on the needs of a patient. For you as a patient, it's an individual decision whether you prefer to be treated inside a hospital or office-based setting. Hospital or office name should not be a factor in that decision, mainly proven skillset. If you don't have a support system at home following a procedure, you may prefer to find an advanced skill vascular specialist who is in a hospital or who has an office-based lab with hospital privileges. If you desire consistent staff and require more immediate care, an OBL may be preferred.
Do you need help finding a P.A.D. Specialist?
The Way To My Heart will work with you to explore options in your area. We will connect you with vascular specialists deemed as having advanced skills for treating P.A.D. based on standards set for each practice by medical societies and with relationships we have developed through them and through advanced CLI fighters on The Way To My Heart's medical advisory board. PAD Navigators work with you to understand where you are in your journey, your symptoms, comorbidities, your insurance limitations, geographical limitations, financial ability, and your facility preference, coupled with the accessibility of a PAD specialty team (can you be seen in a timely manner).
