Avoiding amputations before they happen

Across the United Kingdom, too many people still lose a leg to peripheral artery disease (PAD). It is a life-changing event that often follows months of pain, slow-healing wounds, and repeated contact with healthcare services. The guidance is clear, and the National Institute for Health and Care Excellence (NICE) sets out what good PAD care should look like, yet outcomes remain uneven, and major amputation rates have not fallen as we would expect in a modern healthcare system^[1]. The uncomfortable truth is that timing matters as much as technique. We are diagnosing disease, but we are not always moving fast enough to treat it.

This is where leadership, not just clinical skill, makes the difference. If the National Health Service (NHS) wants fewer avoidable amputations, it needs to bring assessment and treatment forward – closer to the first sign of trouble, not the last. That means spotting risk earlier in the community, moving patients more quickly through imaging and decision-making, and making minimally invasive treatment the default when it can save a limb.

Why patients still arrive too late

Ask any vascular team, and you hear the same story. People arrive with rest pain, deep ulcers, or infection – classic signs of chronic limb-threatening ischaemia (CLTI). By the time they are seen, the odds have shifted against them. NICE guidance recommends ankle-brachial pressure index (ABPI) testing in primary care and rapid referral when CLTI is suspected, followed by timely duplex ultrasound or computed tomography angiography. In reality, ABPI is not used consistently, community Doppler provision varies, and access to definitive imaging can be slow^[2].

The National Vascular Registry’s (NVR) latest State of the Nation report turns that experience into numbers. In 2023, only half of non-elective admissions with CLTI received revascularisation within five days, with a median wait of six days from admission to treatment^[3]. Those lost days are not just statistics. They are the difference between a wound that heals and one that advances – the difference between salvage and loss. The longer a limb remains starved of blood, the narrower the window for success.

The case for moving earlier

There is strong consensus on what good looks like. The Vascular Society’s Peripheral Arterial Disease Quality Improvement Framework (PAD-QIF) sets a clear five-day standard from urgent referral to revascularisation for people with CLTI, turning urgency into a practical, time-bound goal for services to organise around^[4]. Nationally, the Commissioning for Quality and Innovation (CQUIN) financial incentive – which once measured five-day performance – has been paused since 2024/25, but many systems still track the metric locally and through NVR reporting because it reflects real-world outcomes that matter to patients^[5].

What changes when systems lean into those standards is simple but powerful. Rapid-access clinics triage people with new ulcers or rest pain within days, not weeks. Imaging is fast-tracked so that duplex ultrasound and cross-sectional angiography answer the key question: “Can we revascularise now without a string of separate appointments?” Decision making moves out of silos and into joint sessions where vascular surgeons, diabetes specialists, podiatrists, and interventional radiology (IR) agree, on the day, what happens next.

Interventional radiology at the heart of limb salvage

Interventional radiology, the specialty that treats through tiny incisions using imaging guidance, is built for this moment. Endovascular procedures such as angioplasty and stenting can restore blood flow with fewer complications and shorter hospital stays for many patients, often as day-case care. When IR is embedded inside the pathway, patients move from assessment to treatment quickly enough for it to matter. The alternative is a long referral chain that closes the window for salvage before the patient reaches the right room.

The case for speed is not just intuitive; it is increasingly evidence-based. Recent research associates longer waits from admission to revascularisation with worse outcomes after treatment for CLTI, strengthening the argument for services designed around days, not weeks^[6].

Turning guidance into action

This is not about inventing a new model of care; it is about making the proven model the norm. NICE provides the clinical foundations for PAD assessment and referral^[7]. The PAD-QIF shows what an end-to-end pathway should look like and where delays commonly hide^[8]. NVR puts transparency around delivery, reporting the five-day metric and average waits so systems can see their performance against peers and against their own potential^[9]. The task for leaders is to make these frameworks live in their services.

That starts in primary care and community teams, where confidence to use ABPI and refer CLTI quickly must be matched by capacity in vascular centres to receive and act. It continues in imaging, where urgent vascular slots are ring-fenced, so they are not crowded out by elective demand. Then it lands in the clinic, where teams track their own time from referral to revascularisation week by week and remove the friction points they find. None of this is glamorous, but all of it saves limbs.

From late rescue to early prevention

Amputation reshapes a life. It changes a person’s independence, work, and family roles, and the demands on social care. Many amputations are preventable if we move upstream. We have the tools: ABPI in the community, rapid-access vascular clinics, fast-track imaging, and minimally invasive treatment delivered by integrated teams. We have the frameworks to guide us and the data to show where we are falling short.

The next step is intent. Every Integrated Care System should treat avoidable amputation as a core measure of quality and inequality. Every vascular network should publish its time-to-revascularisation performance for CLTI alongside its amputation rates and act on what the data reveal. Every provider should put Interventional Radiology at the centre of its limb-salvage pathway, not at the edge.

When we meet PAD earlier and act faster, fewer people will face the hardest conversation in vascular medicine. That is a prize worth organising for.

References

[1] https://www.vsqip.org.uk/wp-content/uploads/2024/11/NVR-2024-State-of-the-Nation-Report.pdf

[2] https://www.nice.org.uk/guidance/cg147/chapter/Recommendations#diagnosis

[3] https://www.vsqip.org.uk/wp-content/uploads/2024/11/NVR-2024-State-of-the-Nation-Report.pdf

[4] https://www.vsqip.org.uk/wp-content/uploads/2024/04/PAD-QIF-2022-Update.pdf

[5] https://www.england.nhs.uk/long-read/25-26-nhsps-nhs-provider-payment-mechanisms/v

[6] https://pubmed.ncbi.nlm.nih.gov/39725308/

[7] https://www.nice.org.uk/guidance/cg147/chapter/Recommendations

[8] https://www.vsqip.org.uk/wp-content/uploads/2024/04/PAD-QIF-2022-Update.pdf

[9] https://www.vsqip.org.uk/wp-content/uploads/2024/11/NVR-2024-State-of-the-Nation-Report.pdf

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