Peripheral vascular disease

[NDcienporciento100]

Hi
I am a physician with a strong interest in peripheral vascular disease. I am curious about your training because you care for patient with both arterial disease and venous disease wounds. What are you taught regarding when you should refer a patient for venous disease work-up or for arterial disease work-up? Do they teach you to work it up yourself and if so how? Do they teach how a patient should be treated procedurally for vascular disease? Do they tell you who you should refer to?

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[Retrograde_Nail]

Hi
I am a physician with a strong interest in peripheral vascular disease. I am curious about your training because you care for patient with both arterial disease and venous disease wounds. What are you taught regarding when you should refer a patient for venous disease work-up or for arterial disease work-up? Do they teach you to work it up yourself and if so how? Do they teach how a patient should be treated procedurally for vascular disease? Do they tell you who you should refer to?

Are you an interventional radiologist?

 

[Retrograde_Nail]

Hi
I am a physician with a strong interest in peripheral vascular disease. I am curious about your training because you care for patient with both arterial disease and venous disease wounds. What are you taught regarding when you should refer a patient for venous disease work-up or for arterial disease work-up? Do they teach you to work it up yourself and if so how? Do they teach how a patient should be treated procedurally for vascular disease? Do they tell you who you should refer to?

Podiatrists are trained to interpret arterial studies just like anyone else who is interested enough to learn how to read them.

Non palpable or weakly palpable pulses are always abnormal. My threshold for ordering non invasive vascular studies is incredibly low. Especially in patients with DM2, CKD, ESRD, Smoker, etc. There always some component of tibial vessel disease present in these patients. When I order my arterial studies I get segmental pressures, ABIs, toe pressures.

Whether I refer to IR or vascular surgery depends on which doctor is on call. We have good IR docs and some bad ones. We have some good vascular docs and others who are really not helpful at all.

Venous work is variable. If someone comes to me with a venous ulcer we treat with local wound care, dressing and unna boot for several weeks. Once venous ulcer is healed I transition to compression stockings indefinitely. If the wound is not healing at expected rate then I will refer to vascular surgery for evaluation for need for vein ablation. I don't order any preliminary studies to determine if there is venous insufficiency as for me this is a CLEAR clinical diagnosis. Doesn't take a genius to identify whether the patient has venous disease. But again treatment of venous disease depends on who your vascular doc is and how motivated they are to do this kind of work.

 

[Feli]

I typically refer to vascular surgeons when indicated... even if they're an hour away. I don't mid saying that.

I will run ABI for them when I refer if it's arterial, usually just clinical concern for venous. As said, DPMs know how do vasc exam and order tests or interpret. Sometimes, we get stuck with having to do an amputation or I&D for source control and then send/consult to vascular after.

IR and ICard can get good results, and I've seen a few who do, but I just see many more of them who do cath, cath, testing, cath and play courtesy consults games and basically do cashectomy on the patients. Modern Vascular obviously didn't help the cause in my neck of the woods, and those same docs are still around in private practice or even working for podiatry supergroups now.

Mainly, the cath IR/IC docs seem to job-hop more, whereas the vascular surgeons are generally facility employed and stay a long time... and they can do everything the cath docs can, as well as BKA, bypass, etc etc.

 

[Retrograde_Nail]

I should also note there have been times where I referred to the good IR doc for an inpatient case and the patient had severe vascular disease and they could not get me hardly any flow and would be like "we tried". In these cases I have gotten second opinion vascular surgery consult which would most likely end up with patient getting a bypass.

And then there have been times where I've been blown off by both the crappy IR doc and the crappy vascular surgeon who happened to be both on call the same week I was on call. Both were not helpful or aggressive enough. Fortunately there is a competing vascular group who has privileges at the hospital and I would just consult them for a third opinion.

Podiatry owns IR/vascular. We feed them so many cases it is not even funny. We need their help but we put food on their table with all our patients. It is really the only relationship I have in medicine where we stand on even ground.

 

[GreenHousePub]

When I was a student, there was an intern on gen-surg (on her second attempt at matching) who came up to me on my first day and told me "All podiatrists don't understand the vascular system, you guys just don't know anything about healing and blood flow."

It was with great satisfaction that I found out later that she wasn't able to match gen surg, and ended up doing family medicine at one of the worst family medicine residencies in my area.

This question reminds me of her.

 

[Retrograde_Nail]

When I was a student, there was an intern on gen-surg (on her second attempt at matching) who came up to me on my first day and told me "All podiatrists don't understand the vascular system, you guys just don't know anything about healing and blood flow."

It was with great satisfaction that I found out later that she wasn't able to match gen surg, and ended up doing family medicine at one of the worst family medicine residencies in my area.

This question reminds me of her.

I mean I am not surprised by these comments. There is so much blatant disrespect for our education and training. Nobody cares. Nobody cares to learn about our educational standards. There is really no answer for this either other than doing good work and displaying competency.

 

[msion]

Everybody loves veins. It's not even funny that my office has frequent visits from IC/IR groups for vein business.
A bunch of PAD referrals I sent somehow end up with venous ablations.

My go-to referral is always vascular surgery. For a lot of patients endovascular is just not feasible, and open bypass still has its value. But vascular surgeons are pretty rare, so if that's not possible then the next goes to interventional cardiology. Then maybe IR. The biggest problem I have with IR is lack of clinic follow-up. Most of IR docs are hospital based and clinic is almost nonexistent. Cases were cut and run. Outpatient follow-ups are almost impossible.
IC and vascular groups at least have outpatient clinics that patients can follow-up with if they need further intervention or repeat intervention.

But PAD isn't hard. I have an arterial doppler that I frequently use on patients. That combined with history you get get a pretty good idea. I have had many cases of heel pain that turned out to be SFA stenoses. And venous ulcers speak for themselves in terms of location and appearances. I'd love to have a specialty that can treat lymphedema though... not sure what to do with them.

 

[Retrograde_Nail]

Everybody loves veins. It's not even funny that my office has frequent visits from IC/IR groups for vein business.
A bunch of PAD referrals I sent somehow end up with venous ablations.

My go-to referral is always vascular surgery. For a lot of patients endovascular is just not feasible, and open bypass still has its value. But vascular surgeons are pretty rare, so if that's not possible then the next goes to interventional cardiology. Then maybe IR. The biggest problem I have with IR is lack of clinic follow-up. Most of IR docs are hospital based and clinic is almost nonexistent. Cases were cut and run. Outpatient follow-ups are almost impossible.
IC and vascular groups at least have outpatient clinics that patients can follow-up with if they need further intervention or repeat intervention.

But PAD isn't hard. I have an arterial doppler that I frequently use on patients. That combined with history you get get a pretty good idea. I have had many cases of heel pain that turned out to be SFA stenoses. And venous ulcers speak for themselves in terms of location and appearances. I'd love to have a specialty that can treat lymphedema though... not sure what to do with them.

Great points. Our IR docs have terrible outpatient follow up with their inpatient cases. I mean terrible. It is the only reason I am hesitant to deal with them in the first place. It is frustrating.

Lymphedema...send it to a designated clinic that handles it. If you don't have those resources then find a physical therapist who likes doing wraps and send all your lymphedema to this person. Physical therapists most commonly deal with this but it is usually a PT with special certification in lymphedema management.

 

[NDcienporciento100]

So my next question; what do you like to see from a vascular provider when you send them a patient? If I am hearing you correctly you want a prompt revascularization (no screwing around with a bunch of diagnostic angiograms). And you want patients to have good clinical follow-up after their intervention with that provider. Anything else?

 

[Feli]

So my next question; what do you like to see from a vascular provider when you send them a patient? If I am hearing you correctly you want a prompt revascularization (no screwing around with a bunch of diagnostic angiograms). And you want patients to have good clinical follow-up after their intervention with that provider. Anything else?

Yeah, the reason they are sent in the first place is usually due to symptoms (pain, ulcer, etc), need for upcoming non-elective foot procedure, or they've already had an urgent/emergent amp or infection control procedure.

For the vasc docs I feel are worth referring to, I usually send the pts with a basic ABI... the vasc might do an exam or another flow test, but then they are having a procedure within a week to a month... depending on severity and scheduling. A communication/procedure report is appreciated as to how it went and which vessels of the trifrucation are now viable.

The vasc places where pts with little or no symptoms just get a bunch of diagnositic tests and caths are typically your refer-for-profit places (often owned or doing kickback with the refer pod group or groups), and they very seldom benefit patients too much. Some obviously end up with the train wrecks as I linked above.

 

[Hybrocure]

My residency worked very closely with vascular surgeons and we would always scrub with them, communicate with them often, etc. This helped a lot in how I practice now, which is essentially having a very low threshold when it comes to vascular consultations or ordering studies.

Non palp or weakly palpable with obvious skin changes or wounds and/or pain will get vasc studies either in house or sent out depending on insurance. Then depending on the results I refer to a vascular surgeon or IR.


At the end of the day even if you play low and loose with ordering these studies it is very rarely a bad thing. So much dangerous pathology gets missed because docs don’t think their vasc disease is bad enough or they don’t want to be bothered to order studies.

 

[msion]

The vasc places where pts with little or no symptoms just get a bunch of diagnositic tests and caths are typically your refer-for-profit places (often owned or doing kickback with the refer pod group or groups), and they very seldom benefit patients too much. Some obviously end up with the train wrecks as I linked above.

A lot of IC/IR groups have extensive PE involvement so likely that's the cause. I think the doctors may be fine, but the upper management definitely push them to do certain tests to meet the milestone goals.

I once had a lunch with a regional director of a major interventional group about potential ancillary opportunities. She was just so condescending to the physicians even in that group and was very pushy with me as well to sign some intent forms. Just reminded me of the ADT salesperson so I backed out. She later moved on to another position with a nephrology group. So I imagine these MBAs just hop from place to place, collect their shares and then ruin another specialty.

Of course we are seeing that in our specialty as well, so...

 

[GreenHousePub]

All I'd wanna see from Vascular is a fat-ass kick-back check from all my referrals but thanks to the Government and laws that's not happening unless I wanna end up in prison.

 

[DYK343]

Hi
I am a physician with a strong interest in peripheral vascular disease. I am curious about your training because you care for patient with both arterial disease and venous disease wounds. What are you taught regarding when you should refer a patient for venous disease work-up or for arterial disease work-up? Do they teach you to work it up yourself and if so how? Do they teach how a patient should be treated procedurally for vascular disease? Do they tell you who you should refer to?

Vascular workups are half of most podiatrists physical exam.
We treat a lot of diabetics and therefore have repetitive exposure to PVD.
Most of us treat arterial insufficiency and stasis ulcers daily.
I would say podiatrists are probably some of the best providers at recognizing PVD (outside of a vascular surgeon).
I have found that many PCPs are very poor at recognizing PVD.

I spent 4 months on vascular surgery during residency and as a student.
I spent 2 months on interventional radiology. 1 as a resident and 1 as a student.
I spent 1 month on cardiology (which included some IR lower extremity).
Everyone's experience will be slightly different - but that was my experience.

We know which vascular providers in town provide actual results and which just collect a paycheck.
That could be cards/IR/vasc surgery. Whoever gets me good results gets my referrals.
I would say in my area 70% of the interventionalists dont do anything for my patients. Only stent the SFA and thats it.
The 30% that actually do good work get all my referrals because the patients come back for the amputation and bleed/heal.

 

[msion]

The 30% that actually do good work get all my referrals because the patients come back for the amputation and bleed/heal.

Yup.
I hate when some IR/IC told patients that now they can heal a gangrenous toe after the angio, or only needs a toe amp when in reality there was minimal distal flow. Most of these cases I had to revise them to TMAs. But patients always were like "but the other doctor said my circulation is much better now and I can heal."
So now I don't even argue with these patients anymore. Fine, wound care and abx only, maybe HBO as well, and see you later for another amputation.

 

[heybrother]

I may be the exception here but I'm very happy about the willingness of cardiology to intervene in my town. At my residency it was radiology + vascular surgery and they were massively overworked and always behind. In my current town I've seen cases with active ischemic disease get an intervention in under 24 hours. I actually had a patient who I sent for PVD have chest pain in the cardiologists office and get wheeled straight to a cath lab for PCI. Vascular surgeons, rare. Interventional cardiologists - not rare where I am. Sitting on an ischemic cases waiting and praying for intervention sucks. Props to the OP for his PVD interest.

 

[Hybrocure]

The #1 factor that determines who I sent my PAD/PVD patients to is whichever doc can get them in the soonest. I have found IR or interventional cardiologists the best to accommodate quick scheduling and they’ve done good work. Many can get patients in same or next day.

Whereas some of my area vascular surgeons it can take weeks unless you admit them into a hospital and consult

 

[dtrack22]

Yeah I send anyone I can to a local IR doc who is private practice. Has his own angio suite in office. He does good work, texts me post-revasc images so I can see distal runoff myself, is willing to go retro- through a pedal access point. He seems just as skilled with a wire/balloon/stent as the vascular docs. Vascular gets referrals when interventional angio has failed or something can’t be recannalized by the IR doc. They also get the Medicaid folks (even though the IR doc has figured out our states reimbursement system, he’s technically in a different state, and it is at least a wash for him). I just like the guy and don’t feel like dumping non-profitable patients on him when the regional hospital has vascular docs who get paid regardless.

 

[air bud]

Vascular workups are half of most podiatrists physical exam.
We treat a lot of diabetics and therefore have repetitive exposure to PVD.
Most of us treat arterial insufficiency and stasis ulcers daily.
I would say podiatrists are probably some of the best providers at recognizing PVD (outside of a vascular surgeon).
I have found that many PCPs are very poor at recognizing PVD.

I spent 4 months on vascular surgery during residency and as a student.
I spent 2 months on interventional radiology. 1 as a resident and 1 as a student.
I spent 1 month on cardiology (which included some IR lower extremity).
Everyone's experience will be slightly different - but that was my experience.

We know which vascular providers in town provide actual results and which just collect a paycheck.
That could be cards/IR/vasc surgery. Whoever gets me good results gets my referrals.
I would say in my area 70% of the interventionalists dont do anything for my patients. Only stent the SFA and thats it.
The 30% that actually do good work get all my referrals because the patients come back for the amputation and bleed/heal.

when vascular says they were poking around in the plantar arch and opening stuff up...that gets me going.

 

[Redsting]

Everybody loves veins. It's not even funny that my office has frequent visits from IC/IR groups for vein business.
A bunch of PAD referrals I sent somehow end up with venous ablations.

We just had some vascular start at my hospital. The clinical manager has thanked me several times for all the veins I've sent them.

I also have sent people for vascular after they presented with an ingrown nail or small wound who went on for heart Cath or a CABG. The most recent had the arteries to his heart occluded 85% and was asymptomatic.

 

[air bud]

I am continually amazed at how many people I diagnose (Well the arterial duplex says so) with significant PVD that cardiology sees consistently. Like diabetic smokers with 18 vessel cabg. I am like " and your cardiologist has never checked blood flow to your legs?".

Someone looks at me wrong and I order a arterial Doppler/duplex whatever you want to call it. I don't do segmental or ABI and my hospital doesn't do Toe pressures.

Have started getting more aggressive ordering CTA just because it speeds up vascular intervention when I refer them out (no vascular in town).

We are experts at this stuff. Nothing heels without blood flow. The foot is affected first. Anytime something is not going as planned....think about blood flow. I prescribe a crap ton of gabapentin. Gabapentin not working huh I wonder if there is some vascular stuff going on I am missing.

And level 4s all day long bros.

And we all know ABIs are a waste of time.

 

[msion]

We are experts at this stuff. Nothing heels without blood flow. The foot is affected first. Anytime something is not going as planned....think about blood flow. I prescribe a crap ton of gabapentin. Gabapentin not working huh I wonder if there is some vascular stuff going on I am missing.

Always amazing when someone couldn’t understand blood flow. One time I got a call from a wound care center about my heel ulcer patient somehow enrolled in their program. The wound care MD accused me of not trying hard enough with these heel gangrenes and they have good wound care products and HBO for amputation prevention.
Patient had pretty significant tibial disease that vascular gave up on. Refused BKA. Diabetic and of course ESRD.
After that I refer all heel gangrenes to that wound clinic. They all ended up with some kinds of amps.

That wound care MD never called me again though.

 

[NDcienporciento100]

Always amazing when someone couldn’t understand blood flow. One time I got a call from a wound care center about my heel ulcer patient somehow enrolled in their program. The wound care MD accused me of not trying hard enough with these heel gangrenes and they have good wound care products and HBO for amputation prevention.
Patient had pretty significant tibial disease that vascular gave up on. Refused BKA. Diabetic and of course ESRD.
After that I refer all heel gangrenes to that wound clinic. They all ended up with some kinds of amps.

That wound care MD never called me again though.

Tibial disease is very technically challenging. It’s what separates vascular specialists apart. Very operator dependent as the tools to treat are not as great. In my personal opinion no one should get an amp for sfa pop disease in todays world. Our tools are just too good there. But people still do get amps with SFA predominant disease. Operators performing high level tibial interventions are rare and unfortunately the ones that usually don’t can’t admit it to themselves at the detriment of the patient.

 

[Feli]

Tibial disease is very technically challenging. It’s what separates vascular specialists apart. Very operator dependent as the tools to treat are not as great. In my personal opinion no one should get an amp for sfa pop disease in todays world. Our tools are just too good there. But people still do get amps with SFA predominant disease. Operators performing high level tibial interventions are rare and unfortunately the ones that usually don’t can’t admit it to themselves at the detriment of the patient.

Yes, good info.

It's important to communicate back to the podiatrist that the PT is smoked ("unable to revascularize"), and they can plan accordingly. That is obviously the supply we need for nearly all amp flaps to have a good chance at healing/durability.

 

[Retrograde_Nail]

Tibial disease is very technically challenging. It’s what separates vascular specialists apart. Very operator dependent as the tools to treat are not as great. In my personal opinion no one should get an amp for sfa pop disease in todays world. Our tools are just too good there. But people still do get amps with SFA predominant disease. Operators performing high level tibial interventions are rare and unfortunately the ones that usually don’t can’t admit it to themselves at the detriment of the patient.

There needs to be better communication to patients that they still have microvascular disease even after the revascularization. I find IR and vascular surgeons are not truthful after they have done a revasc and this gives the patient false expectations leading to frustration towards podiatry because they can’t understand why their toe amp didn’t heal which resulted in a ray amp which sometimes turns into a TMA. I’m pretty adamant about documenting this in the chart myself even if vascular or IR will not acknowledge it. There should be more lawsuits over this because there is a pretty consistent lack of communication and misinformation in the charts that sets podiatrists up for failure.

The vascular surgeons who are the worst at doing endovascular work for tibial vessel disease are the biggest offenders. There are certain vascular surgeons I refuse to utilize if they are on call when I am on call. Ill either consult IR or a competing vascular surgery group.

 

[Weirdy]

Are any of you getting push back from vascular when you send a patient that has relevant clinical findings, needs intervention for wound healing/surgical intervention, but due to TBI= 0.5 -they are not getting intervention?

 

[Retrograde_Nail]

Are any of you getting push back from vascular when you send a patient that has relevant clinical findings, needs intervention for wound healing/surgical intervention, but due to TBI= 0.5 -they are not getting intervention?

If they are that’s a medical liability. I would bring to the chief of surgery or medicine or just consult a rival vascular group with privileges to the hospital.

 

[DYK343]

Are any of you getting push back from vascular when you send a patient that has relevant clinical findings, needs intervention for wound healing/surgical intervention, but due to TBI= 0.5 -they are not getting intervention?

Yes all the time. If its not a quick SFA stent/angioplasty they wont touch it.