In This Article
- Diabetes can deteriorate blood vessels, causing peripheral artery disease (PAD), where plaque build-up in the arteries results in reduced blood flow to the legs and feet
- Traditionally, many patients would have no option other than amputation to treat PAD
- Massachusetts General Hospital researchers are implementing a cutting-edge, innovative procedure to reduce the need for amputation, called deep venous arterialization (DVA)
- DVA redirects blood from the artery to the veins in the foot by placing a stent below the knee, returning oxygenated blood to the limb via the venous outflow. This can be done surgically or via minimally invasive techniques
- More research is underway to comprehensively treat the patient beyond improving limb flow, including effective wound care and getting the patient back to functionality after the procedure
There has been an increase in diabetes across the U.S., which can lead to many other complications. This includes peripheral artery disease (PAD), where plaque build-up in the arteries reduces blood flow to the legs and feet. Amputation is often the only option for patients with PAD. Still, Anahita Dua, MBChB, MBA, MSc, director of the Vascular Lab and co-director of the Peripheral Artery Disease Center at the Fireman Vascular Center at Massachusetts General Hospital, is seeking to change that.
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Dr. Dua uses an innovative procedure that redirects blood flow to the foot and increases the likelihood of avoiding amputation. In this Q&A, Dr. Dua explains the impact of the procedure and how further research could transform PAD patient care.
Q: When would a patient need surgery for PAD?
Dua: With people living longer in this day and age, there are more people who develop conditions such as chronic kidney disease and diabetes. Unfortunately, diabetes eats away at the small blood vessels located at the ends of organs, which can cause blindness or kidney failure and can require leg amputation. This is known as peripheral artery disease (PAD), where atherosclerosis occurs, and plaque builds up inside the damaged artery. Over time, with multiple blockages in the arterial tree, blood cannot make it from the heart to the foot, and the patient experiences a lot of pain and difficulty walking. These patients often need surgery to either amputate their limb or preserve it.
Q: What is the new innovative PAD procedure, and how is it done?
Dua: Patients with chronic, limb-threatening ischemia can be considered "no option" patients, where there are no outflow distal targets in the foot. So amputation is considered the only option. We are using a technique called deep venous arterialization (DVA), published in the Journal of Vascular Surgery, which is an innovative procedure offered at Mass General that attempts to save the limb.
Because the arteries are not delivering blood to the veins in the foot, the venous system isn't doing anything to deliver blood back to the heart and is sitting like an empty boat. We essentially hijack the venous system to deliver oxygenated blood by connecting it to the artery at knee level. We come down from the patient's artery and up from the vein of their foot, and we fire a needle from the artery into the vein at knee level to oxygenate the arterial blood. Over time, new blood vessels will sprout off of this connection and deliver nutrients to the foot tissue, allowing the patient to avoid amputation.
We've started the Limb Evaluation and Preservation Program (LEAPP) at Mass General, which is a centralized program that understands we need to take measures after surgery to ensure the patient is functional again. We need to heal the wound, get them walking and back into society, and a hundred other things. With LEAPP you get this comprehensive package in a timely fashion. For example, you can see an endocrinologist soon after your surgery rather than waiting months to the point that treatment becomes obsolete.
Q: How is this an improvement over the standard of care?
Dua: This procedure increases the likelihood of salvaging the limb of a "no option" patient. However, limb flow is just one piece of a 10-piece puzzle. Our program offers comprehensive care that takes into account the rest of those pieces, like effective wound care to prevent sepsis after the procedure and achieving functionality by getting the patient walking again.
Q: Are there ongoing trials for this procedure?
Dua: We recently completed a PROMISE II study with a limb salvage technology for this procedure that did exceptionally well. It's being sent to the FDA and will enter the third phase soon. We also have other things coming down the pike, such as dissolvable stents below the knee and new technologies that will prevent patients from needing amputation.
We are at the forefront of amputation research by investigating if we are correctly selecting patients for amputation and determining which patients would benefit from DVA. We follow the outcomes of our patients in a large database to better treat them.
Q: How will this innovation improve the future care for PAD overall?
Dua: The way I present it to people is to have them think of cancer; if you have one doctor who tells you there's nothing they can do for you, you could go to another doctor that will try to give you another five years. That's the psychology that needs to be presented to people, that while I may not be able to keep your leg on your body forever, maybe I can give you another five or ten years with your leg. It's a huge deal if a patient who was going to be amputated gets to keep their foot. At the end of the day, if we couldn't save the limb because it's too far gone or impossible, we have the next realm of things where we can do the amputation and get the patient a prosthetic and back to functionality as soon as possible.
Learn about the Limb Evaluation and Preservation Program
Refer a patient to the Fireman Vascular Center