On a bright September morning, Carrington Sandidge is on his way out the door to mow the expansive lawn surrounding his Temple Hills, Md. home, 10 miles outside of Washington, D.C. It’s his 81st birthday, and he’s just as dedicated to home improvement as he was the day he bought his three-story Colonial a decade ago. “I did the kitchen, I did the powder room,” he catalogs his renovation projects. “I even put in all the fans.”
Nine months earlier, however, home remodeling was the last thing on Sandidge’s mind. He was having difficulty walking at all, let alone working on his home. Pain in his right leg that had been misdiagnosed as gout had worsened over the months, causing his toes to darken and hindering his mobility. “It was excruciating,” he recalls. “My toes were getting darker and darker, and it hurt all the time.”
Sandidge was eventually referred to the George Washington University Hospital’s Wound Healing and Limb Preservation Center, led by Richard Neville, M.D., chief of the division of vascular surgery and professor of surgery at GW’s School of Medicine and Health Sciences (SMHS). There, he was diagnosed with severe peripheral arterial disease. After amputating two and a half unsalvageable toes, Neville performed vascular surgery to bypass the left femoral-posterior tibial. Neville also performed a bypass on Sandidge’s right external iliac-peroneal artery. Without surgical intervention to restore blood flow, it would only have been a matter of time before Sandidge lost his entire lower leg.
Creating Teams to Avoid Amputations
When Neville came to Washington, D.C. as a junior faculty member at Georgetown University in 1990, he noticed that he was seeing a lot of patients with hypertension, high cholesterol, and renal failure — and even more with gangrene due to diabetes. “Rates of diabetes are through the roof in D.C.,” says Neville of the disease that affects more than 14 percent of the city’s African-American population. Diabetics often experience impaired circulation, developing blockages in the arteries of the small vessels below the knee. Limb amputation is a common treatment for such patients, but Neville saw that this drastic measure was often preventable.
Working in concert with a colleague in plastic surgery, Neville put together a multidisciplinary team of vascular surgeons, plastic surgeons, podiatrists, orthopedists, infectious disease specialists, and wound care experts to provide the range of services necessary to heal wounds, treat vascular disorders, and prevent amputations. In 2011, the team moved to SMHS and the George Washington Medical Faculty Associates, and the doors of the GW Wound Healing and Limb Preservation Center opened in August.
“Amputation is not a small thing,” Neville stresses. Although critical for patient survival, it is not without its costs. In addition to the steep medical bills and high mortality rates associated with amputation, the procedure often strips patients of their independence, placing an additional burden on family members. “I tell patients that we’re not just saving your leg, we’re saving your life,” Neville says.
Maintenance of his quality of life was especially important to Sandidge, who has lived alone since the death of his second wife in 2012. After four months of physical therapy — “I was the clown in the class, always making everyone laugh,” he says — Sandidge is back to his daily walks to Mt. Calvary Missionary Baptist Church, where he has served as a Deacon for more than a decade. “I’m cutting grass, I’m going up and down the steps, I’m doing everything,” he reports, cheerfully.
The presence of a limb preservation center in the community benefits not only the individual patients, but also other physicians who now have a place to refer complex cases for multidisciplinary treatment. “Our goal is to streamline care,” says Neville, who recognizes that getting to and from the doctor’s office is a hassle for anyone, but presents a particular challenge for his patients who are already having difficulty with mobility. Standard of care for the average patient requires eight-to-10 hospital visits; a burden that can hinder a patient’s willingness and ability to attend follow-up appointments — a crucial part of the process. The centralization of the Wound Healing and Limb Preservation Center allows various procedures, such as arteriograms, medical clearances, clinical evaluations, and revascularization, to be combined into just a few visits.
Neville is a well-traveled lecturer, regularly delivering talks on the Distal Vein Patch, a bypass procedure he invented that uses a prosthetic graft sutured to the small blood vessels of the lower leg. But recently, his audiences have been most interested in learning about how to set up a limb preservation and wound healing center in their own hospitals. “There aren’t too many places that are doing clinical work, basic science in wound healing research, and are involved in academic education,” Neville says. Physicians from across Asia in particular are anxious to replicate the initiative in their home countries, many of which are also experiencing a dramatic increase in rates of diabetes.
“It’s rather difficult to optimize limb preservation results by dealing with it in a haphazard way,” says Anton Sidawy, M.D., M.P.H. ’99, Lewis B. Saltz Chair of Surgery, and professor of surgery at SMHS, who spearheaded the center’s launch at GW. “It’s crucial to have an organized limb preservation program where wound healing people, vascular surgeons, infectious disease people, and podiatrists are involved,” he says. “A limb preservation center like the one we’ve created brings the knowledge, research, clinical care, and education necessary to optimize care of a patient with wound problems in the foot.”
Research and Outreach
“I’m very proud of this effort,” says Neville, who is grateful to GW for its support of not only his clinical vision, but also the research component that is crucial to the center’s progress. SMHS recently recruited Victoria Shanmugam, M.D., whose experience in wound healing brings cutting-edge immunology and genomics research to the patient’s bedside, to serve as the director of the division of rheumatology in the department of medicine. Bao-Ngoc Nguyen, M.D., assistant professor of surgery at SMHS, also conducts basic science research in wound healing, focusing on the molecular biology of wounds and why they sometimes don’t heal.
Neville himself continues his research into avoiding hyperplasia, the body’s natural response to arterial manipulations, and sits on the scientific advisory board of a Chicago company that is developing a stem cell product for use in revascularization. “It needs a lot of work, but in the future we might be able to implant something in the leg that will transform into an artery,” he says.
The future looks particularly bright for the GW Wound Healing and Limb Preservation Center as well, which plans to establish outreach clinics in neighborhoods around D.C., especially those with the highest prevalence of diabetes and other diseases that limit circulation. “The big procedures would still be done at GW,” Neville says, “but outreach and follow-up services will be accessible to people closer to home.”
The center is also in the process of formalizing and expanding its fellowship program, which currently includes three vascular residents. Physician education remains a primary goal, as evidenced by the organization of the second annual Cherry Blossom Vascular Symposium in 2014, a multi-day event that brings together nationally recognized vascular specialists and surgeons to share insights and network with their peers. “Physician awareness of the potential for limb preservation is a very important part of our efforts,” Neville says.
Patient awareness is an important component as well. “We want people to know that there’s something they can do. They don’t have to resign themselves to being in pain or having an amputation,” Neville stresses. Case in point, Sandidge is as pain-free and mobile today as he was before the blockage developed in his right leg, if not more so. “Believe it or not, I walk better on that leg than I do on my left leg now,” he boasts. “It’s really an amazing thing.”