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Limb Preservation
for the Vascular
Specialist
From Wound Care to
Wound Closure
Sreekumar Madassery
Editor
Aesha Patel
Assistant Editor
123
Limb Preservation for the Vascular
Specialist
Sreekumar Madassery • Aesha Patel
Editors
Limb Preservation for
the Vascular Specialist
From Wound Care toWound Closure
Editor
Sreekumar Madassery
Rush University Medical Center
Chicago, IL, USA
Assistant Editor
Aesha Patel
Rush University Medical Center
Chicago, IL, USA
ISBN 978-3-031-36479-2 ISBN 978-3-031-36480-8 (eBook)
https://doi.org/10.1007/978-3-031-36480-8
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
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Preface
I have dedicated much of my career to CLTI limb salvage/limb preservation,
and as those involved know, it is an immense effort to manage and effectively
help these patients. Nothing brings more personal satisfaction than helping a
patient continue to walk on their own limbs, especially when they were told
the only option is to have a major amputation. This is not always possible for
many reasons, rightfully or wrongfully.
The contributing comorbidities, patient access to care, disparities in management and collaboration, as well as the lack of complete understanding of
how to properly treat these patients, all make this a herculean effort.
In my training, and still to this day, what I have found most disheartening
in this space is the vast piecemeal nature of resources and information, disagreements and politics between specialties for patient ownership and management, and the lack of standards in revascularization outcomes. We are a
far cry away from having a proper system in place with global guidelines and
standards to give all patients the right to a safe and good outcome, and to be
armed with all the right information. While we are slowly seeing changes
with a few large-scale trails, we are still left with many unanswered questions, with many people utilizing them to claim ownership of disease processes; nonetheless there is hope. I also realized that when I tell a trainee to
look up a topic regarding an upcoming case or clinic patient, there is no sound
starting point to get an overall global perspective of the topic and disease
process, after which then they can further go onto exploring the minutia when
desired.
So, with all this in mind, I envisioned this book as a single source of pearls,
examples, and explanations of everything from A to Z related to limb preservation in CLTI, from global experts that I have had the pleasure of meeting
and interacting with, as a jump off point for anyone interested. By including
endovascular and surgical revascularization specialists from all disciplines,
as well as experts in podiatry, vascular medicine, infectious disease, and plastic surgery, I intended to demonstrate the collaborative nature that must exist
if we intend to give our best to all patients. In the end, no one person or specialty can help all patients dealing with PAD and CLTI, but together, we can
impact a much larger population.
My sincerest thanks to my mentors and friends that have supported me in
the past and on this endeavor. This also would not have been possible without
the impressive work by Dr. Aesha Patel, who as a current resident managed to
organize, edit, and help facilitate its formulation. It is truly inspiring to see
v
vi
that there is a bright future ahead with trainees that can carry the torch that we
all hopefully have, and still preserve what is pure and innocent about healthcare. To my family, my biggest cheerleaders in life and trusted source of
motivation, hopefully always know my undying love and thanks.
Chicago, IL, USA SreekumarMadassery
Chicago, IL, USA AeshaPatel
Preface
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Sreekumar Madassery and Aesha Patel
2 Seeing a Patient with a Wound . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Nicholas Alianello, David G. Armstrong, Amir Dorafshar,
J. Karim Ead, David Kurlander, Sreekumar Madassery,
Hannah K. Park, and Idanis Perez-Alvarez
3 Determining the Appropriate Workup . . . . . . . . . . . . . . . . . . . . . 31
Mary Costantino, Faris Galambo, Ryan Lutz,
Sreekumar Madassery, Nicholas Petruzzi, Jill Sommerset,
David M. Tabriz, Desarom Teso, and Ulku C. Turba
4 Beginning and Managing Underlying Comorbidities . . . . . . . . . 49
Zaeem Billah, Zachary Chadnick, Kartik Kansagra,
Ali Kimyaghalam, Sreekumar Madassery, Austin Shinagawa,
Kuldeep Singh, and Geogy Vatakencherry
5 Infectious Disease Evaluation and Management . . . . . . . . . . . . . 65
Nipun Atri, Nawar Hude, Sreekumar Madassery,
and Joseph L. Mills Sr
6 Arterial Revascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Ibrahim Ali, Bulent Arslan, Robert Beasley, Carlos Bechara,
Pauline Berens, Venita Chandra, Omar Chohan, Claudia Cote,
Farnaz Dadrass, Sabeen Dhand, Anahita Dua, Fakhir Elmasri,
Bryan Fischer, Ahmad Omar Hallak, Daniel K. Han,
Carmen Heaney, Kevin Herman, Uman Jaffer, Samuel Jessula,
Ahmed Kayssi, Nicole Keefe, Neal Khurana, Maureen Kohi,
Ricki A. Korff, Prakash Krishnan, Abhishek Kumar,
Chad Laurich, Robert A. Lookstein, Sreekumar Madassery,
Alison Maringo, Jesse Martin, S. Jay Mathews,
Reuben Perez McCon, Ankit Mehta, Jim G. Melton,
Jorge Miranda, Abigail Mize, Miguel Montero Baker,
Jihad A. Mustapha, Mohamed Nagi, Zola N’Dandu,
Murat Osman, Blake P. Parsons, Raghuram Posham,
Aishwarya Raja, Rehan Riaz, Michele Richard,
John H. Rundback, Fadi A. Saab, Gloria Salazar,
Brian J. Schiro, Eric Secemsky, Jill Sommerset,
vii
viii
David M. Tabriz, Jordan Taylor, Anish Thomas,
Srini Tummala, Venkat Tummala, Omar M. Uddin,
Jos Van Den Berg, Micah Watts, Bret N. Wiechmann,
and August Ysa
7 Venous Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Syed Samaduddin Ahmed, Adam Said, Osman Ahmed,
Patrick Lee, Sreekumar Madassery, Ron Winokur,
Brian P. Holly, Mark Lessne, Shin Mei Chan, Kush R. Desai,
Jordan C. Tasse, Grifn Mcnamara, Jillian Drogin,
and Keith Pereira
8 Post-Revascularization Management . . . . . . . . . . . . . . . . . . . . . . 283
Timothy E. Yates and Sreekumar Madassery
9 When Is the Wound Closed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Timothy E. Yates and Sreekumar Madassery
10 Long-Term Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Philip T. Skummer, Matthew J. Scheidt, Parag J. Patel,
and Sreekumar Madassery
11 Long-Term Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . 307
Ian Del Conde and Sreekumar Madassery
Contents
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Introduction
SreekumarMadassery andAeshaPatel
1
Peripheral vascular disease (PVD) is a progressive circulation disorder caused by narrowing,
occlusion, or otherwise abnormal ow in the
peripheral blood vessels, most commonly affecting the legs and feet. The affected vessels include
the arteries, veins, and/or lymphatic system. In the
arterial system, the progression is part of the
Peripheral Arterial Disease (PAD) spectrum, and
in the Venous system, part of Venous Insufciency.
PVD presents with a multitude of symptoms,
often leading to poor quality of life, exacerbation
of a patient’s comorbidities such as coronary
artery disease and stroke, and unfortunately can
result in amputations.
PAD affects more than 200 million people
worldwide and has become increasingly
recognized as an important cause of cardiovascular
morbidity and mortality with rising prevalence
throughout the world [1]. It is a manifestation of
atherosclerotic disease, dened as plaque buildup
and loss of elasticity of the arterial walls, leading
to narrowing and stenosis of the vasculature.
Other etiologies can be from acute embolic
disease or vasculitis. The most common risk
factors include smoking, diabetes, hypertension,
hyperlipidemia, chronic kidney disease, obesity,
and age. There is a broad spectrum of clinical
presentation, ranging from asymptomatic to
S. Madassery (*) · A. Patel
Department of Vascular and Interventional Radiology,
Rush University Medical Center, Chicago, IL, USA
e-mail: aesha_d_patel@rush.edu
intermittent claudication, to rest pain and tissue
loss. The most severe presentation is Critical
Limb Ischemia (CLI) or Chronic Limb
Threatening Ischemia (CLTI), which is dened
as PAD with rest pain or tissue loss for greater
than 2 weeks. CLTI has a mortality risk of 24%
over the rst year and 60% over 5 years [2]. After
lung cancer, CLTI is responsible for the most
deaths over 5 years in the United States [3]. This
is why we, along with many operators refer to
this as “arterial cancer,” so as to raise the appropriate level of concern within the medical community and in the public. Historically, PAD has
been understated compared to coronary artery
disease and cerebrovascular disease. However,
with substantial evidence showing its direct links
to heart attack and stroke, its high morbidity and
mortality rates, as well as the signicant functional decline and disability of patients suffering
from CLI/CLTI, it has become of increasing
importance in recent years.
Similarly, chronic venous disease, referred to
as Venous Insufciency, and Lymphedema have
long-term deleterious effects on the lower
extremities of patients. They are some of the biggest contributors to healthcare costs due to the
prolonged and progressively debilitating nature
of their processes, which relies often on continuous wound care. Pain, numerous surgeries, hospitalizations due to recurrent
VenoThromboembolism (VTE) and infections
also plague this population. Additionally, many
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Madassery, A. Patel (eds.), Limb Preservation for the Vascular Specialist,
https://doi.org/10.1007/978-3-031-36480-8_1
1
2
S. Madassery and A. Patel
patients with non-healing wounds of the lower
extremities may have a mixed disease pattern of
PAD and Venous Insufciency with or without
lymphedema, which can make management
incredibly difcult for providers, as well as for
patients and their families.
To succeed, Limb Preservation requires a multidisciplinary approach, that can direct patient
treatment with a combination of wound care,
reconstructive surgery, medical optimization, and
revascularization. In recent years, with rising
awareness, limb preservation programs have
been increasing across the country. These programs offer a multidisciplinary approach to care
for patients at risk for amputation with the combined goal of limb salvage. This is still few and
far between to make a signicant impact as of
yet. Many reasons exist for this, including institutional, nancial, political, specialty-based societal and other external factors, which detract
from the main goal we should all be pursuing,
which is to improve the quality of life of our
patients. Additionally, the vast quantity of topics
related to managing PVD patients and Limb
Preservation can be daunting for anyone, particularly for trainees of all specialties involved in or
interested in this space to learn. It has been difcult to nd credible sources of information in one
place, in order to jump start their understanding
of the vital topics that need to be grasped. This is
one of the main reasons this book was formulated, to bring together many of the leading
experts in Limb Preservation, particularly those
who actually perform the types of cases they
speak of, which carry the highest merit, and
develop an abbreviated, up-to-date source of
guidance for all involved.
In this handbook, we discuss all aspects of
peripheral vascular disease and limb preservation. With a diverse authors list from across the
globe, consisting of endovascular specialists, surgeons, podiatrists, vascular medicine, and infectious disease specialists, this handbook will serve
as a guideline to the comprehensive care and
management of limb preservation for all disciplines. We begin with understanding the different
wound types and evaluating the underlying
causes that have been typically underdiagnosed
and undermanaged in these patients, as well as
the management of those underlying causes. We
then further elaborate on wound care management as well as proper diagnosis with various
non-invasive imaging modalities. From there, we
dive deep into the treatment of arterial, venous,
and lymphatic therapies. This includes treatment
algorithms, unique and complex approaches,
technique tips and tricks, possible complications
and how to manage them, as well as cutting-edge
options. We conclude by covering how to continue evaluating the wounds post-procedurally
and in long-term follow-up, when reintervention
or surgery is needed, and how to tackle the highly
involved medication management of these
patients.
All these aspects will play a signicant role in
saving these patients’ limbs. It has been well demonstrated that succeeding in limb preservation and
keeping these patients alive longer requires a multidisciplinary effort, and long-term management
of these complex patients. Not all major amputations can be prevented, and some are needed to
save a patient’s life (such as grossly infected/wet
gangrene), however far too many limbs are lost
due to inadequate prevention, management, and
intervention. By providing a multidisciplinary
comprehensive review of the evaluation, management, and treatment of peripheral vascular disease
for limb preservation, we hope to empower the
physician with the knowledge and tools needed to
treat this important disease.
We hope this can be the essential go-to handbook for all those involved in limb preservation,
from wound care to wound closure.
References
1. Adaw AW, Matsushita K. Epidemiology of periph-
eral artery disease and polyvascular disease. Circ
Res. 2021;128(12):1818–32. https://doi.org/10.1161/
circresaha.121.318535.
2. Mustapha JA, Katzen BT, Neville RF, Loostein RA,
Zeller T, Miller LE, Jaff MR. Disease burden and
clinical outcomes following initial diagnosis of criti-
cal limb ischemia in the Medicare population. JACC
Cardiovasc Interv. 2018;11:1011–2.
3. Armstrong DG, Swerdlow MA, Armstrong AA, Conte
MS, Pdula WV, Bus SA.Five year mortality and direct
costs of care for people with diabetic foot complica-
tions are comparable to cancer. J Foot Ankle Res.
2020;13:16.
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