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Vascular surgeon Xzabia Caliste discusses her article, “The silent disease causing 400 amputations daily.” She shares the heartbreaking personal story of witnessing both her aunt and uncle lose their limbs to peripheral artery disease (PAD), a preventable condition that causes over 400 amputations every day in the U.S. Xzabia explains how PAD restricts blood flow and why symptoms like leg pain or non-healing wounds are often dangerously dismissed as simple aging. The discussion addresses the critical “confidence gap” in primary care, where eighty percent of providers feel unprepared to diagnose vascular disease, and highlights the urgent need for early screening for those with risk factors like diabetes and smoking. Learn how to recognize the subtle warning signs of vascular disease and advocate for the specialized care that can save your mobility and independence.

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Transcript

Kevin Pho: Hi. Welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Xzabia Caliste. She is a vascular surgeon. Today’s KevinMD article is “The silent disease causing 400 amputations daily.” Xzabia, welcome to the show.

Xzabia Caliste: Thank you so much for having me, Kevin. This is a wonderful opportunity, and I am grateful.

Kevin Pho: All right. We will jump into your article in a bit, but just briefly share your story and journey.

Xzabia Caliste: I am a vascular surgeon in Albany, New York. I completed my training in 2016, so I have been practicing for about nine years. I am an associate professor of surgery currently, and I treat all aspects of vascular disease. I treat carotid artery disease, aneurysmal disease, peripheral arterial disease, and venous disease, to name a few. In that capacity, I treat things in both an endovascular or less invasive way with stents as well as open surgical interventions like leg bypasses or open abdominal aortic aneurysmal surgery.

I am an active member of the Society for Vascular Surgery. In that role, I have currently been elected to be an ambassador for the Highway to Health program, which allows me to highlight vascular disease and the work that vascular surgeons do so that we can increase awareness and help to affect outcomes for our patients.

Kevin Pho: All right. Your KevinMD article is titled “The silent disease causing 400 amputations daily.” For those who didn’t get a chance to read your article, tell us what it is about.

Xzabia Caliste: It is a really impactful article because it highlights things that I have been able to see professionally as well as my own personal experience. It is really about the 400 amputations that occur on a daily basis in the United States. As a kid, I grew up in the Bronx in a Caribbean family. As an immigrant family, we are all very big on social gatherings. I had the opportunity to spend a lot of time with my multiple family members, including my aunts and uncles, two of whom suffered from peripheral vascular disease that was undiagnosed at the time.

They had high blood pressure and diabetes. I saw them go through having one toe amputated, several toes amputated, and all toes amputated. One ultimately had a below-the-knee amputation, and the other ultimately had an above-the-knee amputation. Over time, I saw them go from being ambulatory, active people to people who were using canes, walkers, and ultimately wheelchairs. That is where they remained until they each passed away.

Getting to see the devastating effects of high blood pressure and diabetes and knowing that they never saw a vascular surgeon and their circulation was never assessed was extremely impactful for me. Years later, I am a vascular surgeon. The reality is that the personal impact of this is very instrumental in helping drive my passion to manage vascular disease today. Out of these 400 amputations that occur on a daily basis, some of these can be avoided. Some of this can be mitigated to be lesser forms of amputations and not major amputations if we deal with the circulation problems ahead of time and if we even know that they are present and evaluate them. That is why I am here today to talk about that and really make a push for it.

Kevin Pho: Peripheral vascular disease leads to amputations if untreated. Like you shared with us in your story, why does a disease with such severe consequences remain so silent and generally unknown to the public?

Xzabia Caliste: That is a great question. The problem is that the precursors to vascular disease are diabetes, hypertension, high cholesterol, and past or current nicotine use. These are often things that take a lot of time to develop. We have an aging American patient population. People over the age of 60 might think: “I have leg pain with walking, but I am over 60. Maybe that is just a normal part of aging.”

A lot of things go unrecognized because it is misunderstood. That is why I am here to bring awareness to the fact that if you are over 60, you are having leg pain, and you are a former smoker or might have diabetes or high blood pressure, you should feel empowered to ask your primary care physician for a circulation check. That is really important. If the patient doesn’t know that this isn’t “normal aging” or if the wound that they have on their foot is taking a long time to heal and this isn’t normal, then they are not going to make the inquiry. Oftentimes, my colleagues who are the gatekeepers—the primary care doctors, the family medicine doctors, the podiatrists, or the endocrinologists—might have a suspicion for vascular disease, but they might not be sure. Sometimes they tough it out and go it alone and try to manage it. But we are here to help. It is really important to emphasize that teamwork and collaboration is something that vascular surgeons are here to do. We want to work together so we can improve our patient outcomes.

Kevin Pho: In your article, you wrote that 80 percent of primary care clinicians lacked confidence in diagnosing vascular disease. I am a primary care physician. If someone comes into my exam room with leg pain, tell me the types of questions I should be asking that patient to determine whether this is vascular in origin or not.

Xzabia Caliste: Great questions. I typically ask my patients: “What kind of pain are you having? Where is the pain located? Is it your calf, your thigh, or your buttock? When did this start? How long has this been going on? Has it gotten worse over time? If you are walking up an incline, is it worse?”

I also ask if they have had wounds on their legs or feet that have taken a long time to heal. One key question is: “If you are laying in bed with your feet up, do you have pain in your foot?” If a patient says they do have pain, then I ask what makes it better. If they say they dangle their foot off the side of the bed or they get up and walk around, that means they need gravity to bring blood flow to their foot. That is a huge indication that there is a big problem here.

Kevin Pho: How about answers to those questions, for instance, on exertion? What are some of the answers that would potentially signify a vascular etiology?

Xzabia Caliste: If a patient says: “I used to be able to walk a mile with my partner as we were walking up and down the road on our excursions together and talking, and now I can’t walk that far. My partner can continue to walk, and now I need to stop multiple times.” I am looking for pain that is making their leg feel tired or crampy. Answers like that indicate that there is a problem with the blood flow.

Oftentimes, it would be unilateral. One leg is a problem. Sometimes it might be both legs, but one leg is usually going to hurt the patient worse than the other. If they say things like: “I can’t go as far as I used to. I can’t walk my dog as far as I used to. I can’t go to the mailbox without having to stop a couple of times because of the pain in my leg,” those are all great indications that there is a vascular flow problem.

Kevin Pho: In terms of next steps, if I suspect a vascular problem, typically I order non-invasive tests like ankle-brachial index and pulse volume recording. Should I just refer suspicions to a vascular surgeon? Tell us the role of these non-invasive tests before we send these patients to vascular surgeons. What is your preferred diagnostic workup?

Xzabia Caliste: Those are all perfect. ABIs are wonderful and easy. Sometimes my primary care colleagues might not have PVR machines in their office, so you can do a quick ABI and get an assessment. A result of 0.9 and above is generally normal. However, if you have calcifications of your blood flow, that number can be falsely elevated.

Oftentimes, I will just say to refer them to a vascular surgeon. We have accredited labs here in which we can easily perform these tests. We have no problem bringing the patient in, assessing for their disease issues, doing the PVRs and ABIs, making an assessment, and then working together with you. If it is easier because you don’t necessarily have all of the tools available in my colleague’s office, send them here to us. We will do it and go from there.

Kevin Pho: If we send patients to you and they are diagnosed with some type of peripheral vascular disease, tell us what happens next. What are the options normally available to the patient?

Xzabia Caliste: First of all, we always want to manage their medical comorbidities and optimize them. If someone has an out-of-control hemoglobin A1c, they need to see an endocrinologist and get that taken care of. If their blood pressure is out of control, that needs to be taken care of. I typically place all of my patients on a baby aspirin because that is extremely important, as well as a statin medication to help stabilize plaque, as plaque rupture can lead to more catastrophic events.

The first front is certainly medication and medical optimization of their comorbidities. The second step would be placing patients on a walking program if that is appropriate for them. Thirdly, some patients absolutely need to have an intervention sooner rather than later. Those patients might be scheduled to get an angiogram. An angiogram can be both diagnostic and therapeutic. I can assess the blood flow, and if it is something that I can fix at the time, I can place a stent or a balloon to open up the blood flow. I will absolutely do that at the time. However, if that is not possible because there is multi-level disease, I will then bring the patient back and have a conversation about a surgical intervention like a leg bypass.

Kevin Pho: Regarding the decision point between surgical and medical treatment, what are some of the key factors that would sway you one way versus the other?

Xzabia Caliste: Certainly, if a patient presents with what we call critical limb-threatening ischemia, that is someone who is reporting what we call rest pain. That goes back to what I described earlier: If they are laying in bed, they are having pain in their foot, and they have to dangle that foot off the side of the bed or get up and walk, that is rest pain.

Or if someone has gangrene or an open wound, that places them in a higher category. That category means we have to move immediately because you are at risk of toe loss, limb loss, or minor or major amputation. Those are the patients that we move on immediately. They get an angiogram, a leg bypass, or whatever the appropriate surgical intervention is.

If patients just present with claudication, which is pain in their legs with ambulation, some of those patients can be managed with just medical optimization. Some of them have disabling claudication, which is really affecting their lives, and they cannot go about their daily routine. I remember a patient who was a mailman. He could not walk, he could not work, and he could not perform his job, so he had disabling claudication. I took that patient for an angiogram and then intervened. So for patients who are critical limb-threatening ischemia, immediate action is needed. For patients who have disabling claudication, more immediate action is needed as well.

Kevin Pho: A lot of patients fear that whenever I send patients to a vascular surgeon like yourself, it means some type of major vascular surgery, like bypass surgery. Talk more about some of the minimally interventional options as well. You mentioned things like a stent.

Xzabia Caliste: Yes. I like to tell my patients that the same things that you can do in the heart blood vessels, you can do in the leg blood vessels, just bigger. Some patients have just a narrowing of their blood vessels. You can go in, and there are lots of different techniques where you can use drug-coated balloons to open up that blood flow or just a regular balloon. You can use particular devices to shave down some of that plaque to minimize it and increase the blood flow. Then you can, of course, place stents. There are lots of different minimally invasive techniques out there now, like shockwave, to help break up some of that plaque that is present so you can have longer-lasting effects of improvement of the blood flow.

Kevin Pho: Let’s talk about screening. Obviously, we screen for patients to make sure they are not smoking and check things like cholesterol specifically for peripheral vascular disease. Where are we in terms of potential screening options?

Xzabia Caliste: Screening options really involve those medical comorbidities that you mentioned. Those are all precursors to vascular disease. We have to screen patients for prediabetes and diabetic issues ahead of time. That is where our gatekeepers come in. That is where physicians like yourself come in. You are catching it ahead of time before we necessarily get to vascular disease.

Screening for diabetes, managing hemoglobin A1c, looking at patients’ hypertension and making sure that it is really well controlled, and making sure patients who have hyperlipidemia are on statin medications are all vital. For smokers, it is really important to have conversations about smoking cessation and mitigation. That is extremely important. For all of those four entities that I mentioned, that is where the screening comes in and what leads to peripheral vascular disease.

Kevin Pho: In your article, you also talk about high-profile figures like Deion Sanders, coach of the University of Colorado football team and former NFL player, bringing more attention to vascular disease. What more needs to be done to bring this to the forefront?

Xzabia Caliste: This is a wonderful opportunity, and I really want to thank you for giving me the opportunity to speak here. Social media and having this platform is just fantastic because the reality is that eight out of 10 Americans don’t even know what a vascular surgeon does. Upwards of a third of Americans don’t know the disease processes that are actually treated by a vascular surgeon. They don’t know about carotid disease, and they don’t know about aneurysmal or peripheral arterial disease.

Having platforms like this where someone like me can come on and just speak about it helps to empower patients because you are your own best advocate. If you have a concern, you can say to your gatekeeper, your family medicine physician, or your internal medicine physician: “Hey, can I get my circulation checked because I am concerned about this?” But that comes with first having the knowledge that this is something to be concerned about.

Kevin Pho: We are talking to Xzabia Caliste. She is a vascular surgeon. Today’s KevinMD article is “The silent disease causing 400 amputations daily.” Xzabia, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Xzabia Caliste: Thank you. I do have three take-home messages. The first is to the patients. We are all patients in some capacity. We have all had family members that are patients. It is really important for all patients to feel empowered. You are an advocate for yourself, so you can request a circulation check this month by your physician. You can have a conversation and say: “Hey, is a vascular surgeon the appropriate person for me to see as a next step?” So first, it is really about empowerment of patients.

Secondly, I want to empower my colleagues who are the gatekeepers. You guys have such a gargantuan job managing all of the medical comorbidities of this aging American population. I just want to say that we as vascular surgeons, and I myself, are here to collaborate with you and help you with the heavy load of managing this disease process. We are here for you to refer your patients to us, and we will work together as a team to manage this.

Thirdly, just follow me on social media, LinkedIn, and X, because I do post regularly about vascular-related issues and vascular disease. I also want to direct patients to YourVascularHealth.org, where you can get a much deeper dive on vascular issues. This is for both my colleagues in other specialties as well as for patients.

Kevin Pho: Xzabia, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Xzabia Caliste: Thank you, Kevin. I appreciate it.