Published:
February 1, 2024
There was nothing Vincent Scarpari and his wife enjoyed more than dancing. But a health condition affecting more than eight million Americans was making that increasingly difficult. Scarpari had severe peripheral artery disease (PAD)—a narrowing or blockage of arteries in the arms or legs causing poor blood flow. His disease had progressed to the point of near complete loss of circulation beyond his ankle. Tissue was dying and he had suffered with gangrene and intense pain in his toes for almost a year.
Despite multiple rounds of hyperbaric oxygen therapy to stimulate healing and his diligent efforts to manage the gangrene, nothing was working. The 74-year-old Lancaster County man was facing below-the-knee amputation.
That is when Scarpari was referred to Ruhani Nanavati, MD, RPVI, a vascular surgeon with the Lancaster General Health Heart & Vascular Institute. He underwent venous arterialization (VA), a new, advanced surgical procedure available for select patients like Scarpari who have the most severe cases of PAD. In the past, amputation would have been their only option.
"My goal was always to be able to dance with my wife again," said Scarpari. "I was willing to try anything to save my leg and was excited about the procedure Dr. Nanavati offers."
"For people with PAD, the risk of needing to have a limb amputated is always a concern," explained Dr. Nanavati. "While there are many effective ways to slow the progression of PAD and reduce this risk, sometimes surgery is needed to improve blood flow to preserve the limb."
What causes peripheral artery disease?
PAD is usually caused by plaque buildup on the inside of the arteries. People like Scarpari who have diabetes, as well as people who smoke or have high blood pressure or high cholesterol, have a greater risk of plaque buildup and developing PAD.
Commonly found in the arteries of the legs, this buildup leads to poor blood flow. Although many people don't have symptoms, others may experience leg pain and trouble walking. As the disease gets worse, some may notice their feet and toes becoming increasingly cold and painful, and may start to develop sores. And as Scarpari experienced, in worst case scenarios, this can lead to gangrene (tissue death).
How to know if you have PAD
To diagnose PAD, your doctor will perform a thorough exam and check your pulse and blood pressure at different areas of your body. They may also order ultrasound tests or CT scans to gain specific information.
Taking this PAD Risk Profiler can be helpful in estimating your personal risk of developing peripheral artery disease and steps you can take to stay healthy.
PAD treatment options
Depending on how advanced the PAD is, your doctor will suggest a variety of treatment options. This could include a heart-healthy diet, exercise, managing conditions like diabetes and high blood pressure, stopping tobacco use, and medication. When indicated, you may be recommended an intervention.
Procedures and surgeries for PAD
Vascular surgeons at Penn Medicine Lancaster General Health offer a wide range of advanced and highly effective procedures to treat patients with PAD. This includes everything from minimally invasive interventions such as angiograms to major surgeries.
"For patients with blockages in the large blood vessels of the leg, the most common interventions are balloons and stents, or in severe cases, some type of bypass operation," said Dr. Nanavati. "However, if a patient is not a good candidate for a major surgery and they have suitable anatomy, we can offer advanced attempts at minimally invasive intervention by accessing the small vessels directly in the leg beyond a blockage, and then try to work through the blockage backwards."
She explained that patients like Scarpari with severe small blood vessel disease resulting in complete loss of the arteries in the foot—also known as "desert foot"—sometimes a major limb amputation appears to be only option. This is especially true if there is tissue loss or gangrene. However for the right patient, venous arterialization is offering hope to save the limb.
Venous arterialization
Venous arterialization takes a patient's own vein and slowly trains it to function like an artery. This restores blood flow to the foot, helping prevent limb loss.
Arteries are vessels that carry fresh blood flow from the heart out to the leg. Veins are a separate vessel system that return the blood back toward the heart. VA connects the vein system of the leg to the healthiest part of the arteries, and over time, with multiple interventions, trains the veins in the foot to carry arterial blood flow where it was once lost.
Surgeons decide on the type of VA to perform based on the patient and their specific anatomy. They must have a strong heart and healthy veins in order to be a good candidate. They will order a complete workup to determine if this is viable option.
Why Scarpari was a great candidate for VA
"Vincent was a great candidate for VA," explained Dr. Nanavati. "He had good arteries leading down to the calf, healthy veins with no history of blood clots, and he was extremely motivated to follow through on the surgical process."
She and Scarpari had a long conversation about expectations of the surgery. She shared with him that the probability of achieving his goal of healing and avoiding a major amputation was about 50 to 60 percent. It requires multiple planned surgical re-interventions to train the veins to arterialize and carry blood flow into the foot. Scarpari agreed to this five-to-six-month process, understanding that he could still lose his leg if his body did not take the VA.
VA surgery and post-operative expectations
"The surgical process and training your body to change how it functions takes many months," explained Dr. Nanavati. "Managing leg swelling afterwards and keeping wounds clean and dry to prevent infection is critical. There is close follow-up and frequent procedures are required as patients work toward healing, which is not guaranteed. You have to be dedicated and mentally prepared for the challenge ahead. However, for the opportunity to save a leg from amputation and maintain long term quality of life, it can certainly be worth it."
Hitting the dance floor
After undergoing surgery and follow-up therapies, Scarpari and his wife have slowly started dancing again and look forward to enjoying one of their favorite activities on an upcoming cruise.
"Beyond the technical aspects of the surgery, the key to Vincent's success was his diligence in following post-operative guidelines and his determination to persevere through this long and challenging process," said Dr. Nanavati.
"There is no doubt that this has been difficult to get through, but my faith in the Lord was my strength, and Dr. Nanavati is not an ordinary surgeon. She is a gifted human being—so empathetic and caring. I highly recommend that people who may be facing an amputation look at all of their options," said Scarpari.
Learn more about innovative treatments for peripheral artery disease and other heart and vascular conditions available at Penn Medicine Lancaster General Health.