There is an urgent need for epidemiological studies to map out the prevalence of chronic limb-threatening ischemia (CLTI)—and peripheral arterial disease (PAD) in general—in South Asia, attendees of the International Chapter Education Session at VAM 2025 heard yesterday morning. That was the message from Prem Chand Gupta, MBBS, clinical director and head of vascular surgery at Care Hospital in Hyderabad, India, as he peeled back a curtain on the extent of amputation and limb preservation in Asia through his native country of India, highlighting how patients on the continent present with more advanced CLTI, are more likely to require urgent intervention, and have worse postoperative outcomes compared to patients in the West.
“Asia also has the highest prevalence of diabetes and CKD [chronic kidney disease], so this makes these patients more prone to develop the disease and also makes the disease more difficult to treat,” Gupta tells VS@VAM in an interview after his talk.
“In many of our countries, we do not know the prevalence of PAD and CLTI,” he says. “And how many of our patients are actually able to access proper care? We don’t know. Many patients end up with primary amputation as the first option.”
Gupta detailed for the VAM audience some of the reasons behind these statistics, among them a culture in rural areas where bare-foot walking remains common, and the fact the primary care physicians and general surgeons whom many patients visit for help don’t often appreciate the magnitude of the vascular problem with which they are confronted.
“We have had some attempt at studying the prevalence of disease in India but it’s grossly inadequate,” he explains to VS@VAM. Access to care varies across parts of the continent, with Southeast Asia, especially Thailand and Malaysia, technically better off, he continues, where healthcare is funded by taxes and government subsidy. In South Asian countries such as India and Bangladesh, on the other hand, public-private partnerships tend to predominate healthcare, with only pockets of excellence in the public system, Gupta continues.
“In India, nearly 50% of patients will pay out of pocket for medical care, so there is no insurance scheme they are covered under,” he says. “We have expertise and infrastructure, but the numbers are grossly inadequate. Vascular surgeons perform open and endovascular procedures and have all the latest tools available to them.”
But there are few multidisciplinary care teams, Gupta notes, “and we know that when they work together, they tend to improve outcomes.”
The gravity of the amputation and limb preservation problem in India is stark, he says. “India probably has the worst amputation epidemic in the world. The reasons? We have few vascular surgeons: it’s one per 3 million of the population. Most patients, even in the urban areas where we have a lot of vascular surgeons or specialists, they quite often end up with a primary care physician or a general surgeon or sometimes with a wound care surgeon or podiatric surgeon, and they often have minor amputations.”
In this crucible, in the absence of the vascular surgeon, the wrong approach often prevails, Gupta goes on. “There is patchy presence of specialists in the public sector and preventive care is very infrequently applied to these patients.” But there are positives to healthcare in South Asia, he adds. The pace of access to a specialist, if a patient can get in front of one, tends to be quick when compared to some countries in the West. Care can be dramatically cheaper. “For example, some of the bypasses that would cost $10–20,000 in high-income countries are $1,500–3000 in India,” says Gupta.
An attempt to unmask the extent of the CLTI burden in India through the prism of an epidemiological study is on Gupta’s radar for this calendar year. In the meantime, he says, “we need more vascular specialists, and we are working towards that. From the time when I trained in the late 90s, when we had one training program, we now have more than 50. So we are putting out more vascular surgeons every year. People are understanding the importance of multidisciplinary care teams and are tending to come together to work, and that will improve care and improve the chances of limb preservation in these patients with CLTI. We need to work on primary care physicians and general surgeons, and educate them.”
