Lessons in PAD care from VA vascular surgeons

The care of patients with peripheral arterial disease (PAD) is challenging and costly. Every practicing vascular surgeon knows that when patients present with ulcerations, infection, ischemia and comorbidities, we can accomplish amazing things. In an ideal world, our approaches universally entail (1) treatment of ischemia with reperfusion, (2) management of infection with debridement and antibiotics, and (3) treatment of the entire patient with patient-centered care, from comorbidities to family support to mobility and pain management.

However, we know that this idealized description often fails to materialize in the real world. There is controversy about the types and methods of revascularization we will offer. Managing the non-vascular aspects of chronic limb-threatening ischemia (CLTI), especially in regions of the United States where wound care experts are unavailable, can be challenging. Finally, getting the best treatments—both medical and surgical—can be costly and limited by a patient’s insurance and access to care.

We can learn much from healthcare systems that regularly care for large numbers of patients with CLTI, even in cost-efficient healthcare settings with significant regulation. More than 180,000 veterans receive care for PAD in Department of Veterans Affairs (VA) hospitals, and many of these patients are more aged with more comorbidities than similar populations outside of the VA. Yet, despite these challenges, lessons in PAD care abound in VA vascular surgery care.¹

First, VA vascular surgeons offer veterans participation in the latest studies to guide effective, evidence-based care. Of the 117 U.S. sites in the BEST-CLI (Best endovascular versus best surgical therapy in patients with critical limb ischemia) trial, 18 are VA hospitals.² VA facilities had half the number of investigators per site but enrolled the same number of patients per month as non-VA vascular centers, as Matthew Koopmann, MD, of the Portland VA Medical Center shared at the Pacific Northwest Vascular Society meeting in 2019.

Second, the teamwork available for veterans in a multidisciplinary setting offers significant benefits when treating PAD. Katherine Reitz, MD, and Edith Tzeng, MD, and colleagues at the Pittsburgh VA have studied more than 2,500 patients across the country, in a quality improvement project aimed at optimizing medical management of every veteran with PAD using a simple checklist.

Other multidisciplinary measures include the Prevention of Amputation in Veterans Everywhere (PAVE) program led by Jesse Jean-Claudee, MD, and colleagues nationwide; this has focused on providing systematic approaches to wound care and amputation prevention for more than 20 years.³ Limiting variation and encouraging systematic and proven approaches are key foundations underlying each of these efforts, as demonstrated by the overall consistency in amputation rates over the past 21 years (Figure 1).

Finally, advanced technology and new approaches abound when veterans present with severe CLTI. Teams from vascular surgery groups from across the country perform advanced limb salvage procedures. This is not a unique occurrence, and teams across the country provide similar treatments in a veteran-focused manner aimed towards optimizing limb- and patient-centered outcomes. For instance, radial-to-peripheral interventions, which offer expanded endovascular options for patients with complex peripheral vascular history, have become more widely used within VA vascular practices. This puts VA vascular surgeons at the forefront of these less morbid techniques for high-risk patients.

Additionally, the employment of telehealth technologies, long before COVID-19 made this popular, has allowed the delivery of specialized vascular care to veterans who often live in remote locations.

In summary, few will argue that systematic approaches to the care of patients with PAD are not challenging, but important, pursuits. As surgeons who care for patients with PAD in both VA and non- VA hospitals, we believe lessons through clinical trials, teamwork and technology can help us improve the care for patients with PAD nationwide.

References

1. Willey J., Mentias A., Vaughan-Sarrazin M., et al. Epidemiology of lower extremity peripheral artery disease in veterans. J Vasc Surg. 2018;68(2):527–535 e525.
2. Menard M.T., Farber A., Assmann S.F., et al. Design and Rationale of the Best Endovascular Versus Best Surgical Therapy for Patients With Critical Limb Ischemia (BEST-CLI) Trial. J Am Heart Assoc. 2016;5(7).
3. Gabel J., Bianchi C., Possagnoli I., et al. Multidisciplinary approach achieves limb salvage without revascularization in patients with mild to moderate ischemia and tissue loss. J Vasc Surg. 2020;71(6):2073–2080.e2071.

Mark Eid, MD, is a graduate research fellow and Philip P. Goodney, MD, is co-director of the VA Outcomes Group at White River Junction VA Medical Center in Vermont. Goodney is a member of the SVS VA Vascular Surgeons Committee.