Indian Journal of Vascular and Endovascular Surgery

: 2022  |  Volume : 9  |  Issue : 4  |  Page : 273--276

Pandemic of PAD/CLTI across the globe
“A surgeon's skills are measured by the way he handles blood vessels” Sir William Halstead

Kalkunte R Suresh 
 Editor in Chief, IJVES, Director, JIVAS, Bengaluru, Karnataka, India

Correspondence Address:
Kalkunte R Suresh
Editor in Chief, IJVES, Director, JIVAS, Bengaluru, Karnataka

How to cite this article:
Suresh KR. Pandemic of PAD/CLTI across the globe
“A surgeon's skills are measured by the way he handles blood vessels” Sir William Halstead
.Indian J Vasc Endovasc Surg 2022;9:273-276

How to cite this URL:
Suresh KR. Pandemic of PAD/CLTI across the globe
“A surgeon's skills are measured by the way he handles blood vessels” Sir William Halstead
. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Dec 7 ];9:273-276
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Full Text

This issue of IJVES contains an Editorial written by our members Dr. Sunil Rajendran and Dr. Natarajan Sekar titled “Vascular Awareness in India: What more needs to be done,”[1] where they have meticulously outlined the essentials needed to realize the objectives of their heading. I considered it appropriate to outline the impact and throes of peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) worldwide, especially in low–middle-income countries (LMIC), including India. This subsists their title that such is needed in most countries. Most of the details in my editorial are extracted, and quoted, from the last chapter of Global Vascular Guidelines (GVG), titled “Global Perspectives of in CLTI,”[2] of which I was the main author.

”Vascular specialists managing CLTI across the globe serve the needs of diverse communities and cultures, working within a wide range of health-care environments. Most vascular specialists will strive to keep up to date with the published evidence base and are greatly facilitated in doing so through the use of modern information technology systems. However, the reality is that most publications on CLTI are written in English, and the data contained therein overwhelmingly derive from relatively few countries, mainly high-income countries (HICs) (Western Europe, North America, and Japan), that have mature, well-resourced health and social care systems as well as clinical research infrastructure. Most vascular specialists treating patients with CLTI do not, of course, work in such favorable environments. As such, they often have to adapt foreign “evidence-based recommendations” to their own particular situation to provide the best possible care to their patients with the resources available.”[1] Having quoted above, the best medical care is what we can provide our patients by adapting the guidelines to our own working environments.”[2]

”The data on the country-specific incidence of PAD and CLTI are sparse in these LMICs, unlike in HICs. There are no relevant epidemiologic data from large regions worldwide. Lacking firm epidemiologic data, recent estimates of CLTI prevalence have used extrapolations from demographic and other available disease prevalence data, yielding global estimates of between 20 and 40 million individuals afflicted [Table 1]. About two-thirds of these are projected to be in LMICs. Unfortunately, documented data to support this are difficult to find in any indexed, peer-reviewed journals.”[2]{Table 1}

Diabetic data from IDF, published in 2021, outlined the present status of diabetes worldwide – [Figure 1].{Figure 1}

”According to the survey of about 50 respondents to a GVG questionnaire, the risk factors for CLTI in their regions are large as expected, but diabetes mellitus (DM) is a predominant cause, more than in HICs. The prevalence reported by respondents varied from 40% to 90%. Interestingly, a cultural preference for walking barefoot or a lack of appropriate footwear is a significant problem in some countries. Approximately 60%80% of all the PAD patients seen by the respondents presented with CLTI. The average age was around 65 years, and about 70% were men. Most respondents reported that 70%–100% of CLTI patients presented with tissue loss; in three countries, it was <50%. Primary amputation was performed in 10%–40% of CLTI patients, this being mainly (25%–90%) due to delayed presentation or referral. Only two countries reported a primary amputation rate of <10%. Postprocedural amputation rates were reported at around 5%–10%, although two countries reported much higher rates (60%–70%) due to the late presentation or aggressive disease patterns encountered.”[2]

 Health Economics

CLTI has a serious adverse economic impact on patients, their families, and wider communities right worldwide but especially so in LMICs. Although these countries are often grouped together, the division between middle income and lower income is variable and imprecise. Furthermore, there is often considerable inequality within each LMIC, and respondents reported that most patients with CLTI (30%–90%) appear to come from poor socioeconomic backgrounds. The following data from the Indian National Sample Survey Office could represent the situation in many LMICs,[4] and likely apply to patients with vascular diseases:

Only 18% of urban population and 14% of rural population are covered by some form of health insuranceGovernmental health expenditure is <2% of the gross domestic product overallPeople in villages mainly depend on “household income or savings” (68%) and “borrowings” (25%) to fund hospitalization expensesAround 1% of the poor in rural areas have to sell their physical assets to meet health expenditures, and >5% seek help from friends and relatives. This is also in line with earlier studies showing that millions are pushed into poverty each year by medical expenditures and that such expenses are among the leading causes of indebtedness among the poorIn cities, people rely much more on their income or savings (75%) than on borrowings (18%) to fund their treatment. Previous studies have repeatedly shown that India has one of the most privatized health-care systems in the world, with out-of-pocket expenses accounting for the bulk of medical spending.

In India, the cost of an IP bypass is U.S. $1500 to $3000, and the costs of balloon angioplasty are similar. The use of a stent or DCB would add another U.S. $500 to $1000, and wound care adds at least U.S. $500. Such out-of-pocket expenses are probably unaffordable for most CLTI patients. Importantly, these costs depend on the recycling of single-use devices such as sheaths, angioplasty balloons, and guidewires. Without such practice, the cost would increase by at least 50%, and far fewer patients, especially poorer ones, would have access to treatment, resulting in much greater loss of life and limb. Recycling of single-use devices (not just vascular devices) is common in Asia, Africa, Latin America, and Eastern Europe, and proper regulation of the practice, including appropriate consent procedures, is important to mitigate patient harm.[5]

Summary of global perspectives: Based on the responses to the questionnaire and the limited published and unpublished data at times, we can draw the following conclusions.

CLTI is a significant and increasing global problem, especially in LMICs, where the incidence in women appears to be rising more quickly than in menDiabetes and unabated smoking are the major causes of CLTI globallyAlthough vascular specialists try to follow the published evidence base, economic, and social constraints mean that the approach to CLTI must to tailored to the working environmentCLTI and diabetic foot problems are associated with high amputation rates in LMICs due to delayed presentation and referral and limited access to affordable careEconomic constraints are an important limitation in the adoption of advanced vascular technologies, and practical issues such as recycling of single-use devices require oversight from a public health perspectiveFew countries maintain national registries or other CLTI data setsMost countries do not have a standardized approach to CLTI, with considerable locoregional variation in practiceMost countries do not have well-organized and supported vascular societies where best practices and research can be shared and disseminated.

I would just like to share few of my own thoughts about the points well outlined by Rajendran and Sekar in the editorial of this issue under different headings.

Why vascular awareness in India?

In this section, authors very appropriately point out that there are only 400 specialized and well-trained vascular surgeons across India. Although the number is woefully short to provide vascular care across the country, more glaring is the inequality of distribution of these specialists, who are mostly in South India and bigger cities and in small swaths of North India. The rest of the country does not have a qualified vascular surgeon within reaching distance. At our present number of training centers and trainees, it might take decades to populate most of India with our tribe. Hence, most vascular surgeons/centers must try to start training programs as soon as they can. However, with an increasing burden of DM, even at a younger age, nights keep thus hiatus unchanged. This hiatus will invite predatory surgeons and others to forage into these terrains. Is there a faster solution? Can vascular surgeons start outreach clinics in these barren areas? A daunting task indeed due to overwhelming variables!

Catch them young

But how? As pointed out by the authors is to incite, through VSI, most if not all the central institutions to start dedicated, vascular units headed by an authentic vascular surgeon independent of being tagged with other specialties like CTVS, which offer very little if any vascular exposure. Their curriculum contains only two lines and offers 10 cases in each of arterial and venous procedures to qualify as a vascular surgeon. My personal opinion – it is preposterous!

It would be prudent to offer vascular surgical rotation to 2nd year general surgical residents across India a 2–4 weeks to offer them exposure and awareness and encourage some of them to pursue further training in vascular surgery.

More impactful vascular training

A vascular trainee from any recognized vascular training program in India should be capable of handling most if not all vascular care – medical, surgical, and endovascular – independently. The programs should be structured to provide holistic training with simulators and surgical models apart from direct patient exposures. Rotations through several outstanding vascular departments in India, in teaching or nonteaching institutions, should be encouraged and facilitated by VSI

Educating medical professionals

Extremely important facet since, unfortunately, most doctors are not aware of the adverse impacts of vascular diseases, especially PAD. Some factors that should be stressed:

75%80% of all nontraumatic amputations are in diabetic patientsOperative mortality for BKA – 8%–12%; AKA – 12%–16% compared to cardiac surgery mortality of 1%–2%, vascular surgery mortality of 3%–6%Twenty-two percent require ipsilateral higher amputation30%–50% need contralateral amputation within 3 yearsForty percent mortality in 3 years in amputees.

Five-year relative mortality rates are depicted below:


American Cancer Society. Cancer Facts and Figures, 2000;† Criqui MH et al. N Engl J Med. 1992;326:381-6.

‡ Larssen, Apelqvist et al.: 1998 ∫ Moulik et al: 2003 § Van Baal et al. 2010; Belch et al: Arch Int Med 2003; 163:884-892.

Few facts that should be stressed:

The presence of PAD, symptomatic or not, is the leading indicator of systemic atherosclerotic burden and predictor of future cardiovascular eventsNeed aggressive medical therapy to prevent future systemic cardiovascular events such as MI, stroke, and limb loss since these patients are at high risk for the rest of their life.

The authors have outlined several other measures to promote the awareness of vascular and these should be approached on a war footing by VSI, the teaching departments, and all vascular surgeons.


1Rajendran S. Vascular awareness in India, what more needs to be done. IJVES 2022;9:277-80.
2Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. Eur J Vasc Endovasc Surg 2019;58:S1-109.e33.
3IDF Atlas 2021. Available from: [Last accessed on 2022 Oct 29].
4Health in India. Government of India. Available from: [Last accessed on 2018 Dec 07].
5Kapoor A, Vora A, Nataraj G, Mishra S, Kerkar P, Manjunath CN. Guidance on reuse of cardio-vascular catheters and devices in India: A consensus document. Indian Heart J 2017;69:357-63.