Multidisciplinary limb preservation clinics have been shown to decrease amputations by 86%. Collaborating across multiple specialties, Duke’s Threatened Limb Clinic (TLC) offers the latest treatments to patients with diabetes, peripheral artery disease (PAD), chronic limb-threatening ischemia (CLTI), and other risk factors to restore circulation to at-risk limbs, possibly avoiding amputation altogether.

“We offer the highest level of technology to patients in our clinic,” says vascular surgeon Samantha D. Minc, MD, MPH, clinic director. “We focus on addressing the needs of the whole patient with podiatrists and vascular surgeons and work collaboratively with providers who send patients to us.”

“We have such a diverse skillset as a faculty, there is nothing in vascular surgery that we can’t handle,” agrees vascular surgeon Kevin W. Southerland, MD, who works with the clinic.

For 10% of patients with PAD, the condition progresses to CLTI, characterized by significant rest pain. Patients with foot wounds that have not healed after two weeks are also at risk of limb loss. The clinic gives patients with CLTI access to specialists in not only vascular surgery but also podiatry, interventional radiology, and psychiatry.

“We serve the unique needs of this patient population, including managing their comorbidities,” says Minc. If amputation becomes necessary, the TLC also offers specialized nurses, physical and occupational therapists, counselors, and past patients to help current patients make the adjustment. “The sooner these patients are referred to us, the more options they have,” Minc adds.

Treatment options include the latest innovations, such as bioabsorbable tibial scaffolding and endovascular deep vein arterialization, as well as cutting-edge skin substitutes.

For patients with severe disease in the tibial arteries, balloon angioplasty may not be sufficient to reestablish circulation. “The issue is that tibial arteries will often recoil very quickly,” says Minc. A newly FDA-approved drug-eluting bioabsorbable scaffold now allows vascular surgeons to place a scaffold to keep the artery open and restore circulation.

“The scaffold absorbs over time so you don’t have to leave a stent in that might prevent a future tibial bypass,” says Minc. “These scaffolds have been shown in studies to prevent the recurrence of disease.” Research shows that restenosis rates are low and wound status improved in patients receiving the tibial scaffolds.

For patients with occlusions in all the main arteries to the foot, no effective medical therapies exist. Endovascular deep vein arterialization (DVA) has recently been shown to offer a possible method of restoring circulation even for patients with “no-option desert foot.” With a percutaneous approach, a multidisciplinary team forms a fistula to connect a vein and an artery in the foot. The venous valves are removed, and the direction of blood flow is reversed in the vein, allowing nutrient-rich blood to circulate to the foot tissues again.

“Only a couple of places in North Carolina perform this procedure,” says Southerland. At Duke, DVA works for more than 90% of patients and preserves the threatened limb approximately 40% of the time. “It’s not a guarantee, but without an intervention, there’s nearly a 100% chance of limb loss,” Southerland continues.

“If there’s a possibility of a foot or toe amputation, the best thing for the patient is to refer them to us, because we can exhaust the entire treatment algorithm,” Southerland concludes.