November 2012

How to Build a Busy PAD Practice — Interventional Radiologists Share Their Experiences
By Beth W. Orenstein
Radiology Today
Vol. 13 No. 11 P. 24

Obesity and diabetes are on the rise in America, which explains, in part, why physicians are seeing more cases of peripheral artery disease (PAD). Also, the population is aging, and while PAD can occur at any age, clogged or narrowed arteries in the extremities are most common in people over the age of 50. According to the Society of Interventional Radiology (SIR), PAD affects 12% to 20% of Americans older than 65.

PAD is often asymptomatic and is therefore underrecognized. Sometimes, patients attribute the pain they experience in their legs when walking or exercising or the numbness in their legs and feet to aging and don’t seek medical attention. However, PAD increases the risk of dying from heart disease and stroke and should be treated before it progresses.

PAD may be treated with lifestyle changes such as weight loss, smoking cessation, and exercise but may require angioplasty or stenting.

Growing Opportunity
This scenario sets up “an excellent opportunity for interventional radiologists who are interested in treating PAD to build volume,” says James F. Benenati, MD, FSIR, medical director of the peripheral vascular laboratory at Baptist Cardiac & Vascular Institute in Miami.

“With the obesity epidemic and the aging population, the numbers of patients diagnosed with PAD will likely increase significantly, and interventional radiologists can be at the frontlines of diagnosing and triaging patients with PAD,” adds Robert Lookstein, MD, FSIR, division chief of interventional radiology at Mount Sinai Medical Center in New York.

However, Benenati and Lookstein warn that interventional radiologists can’t hang a sign announcing they treat PAD and expect patients to fill their waiting rooms. Interventional radiologists who want to build a busy PAD practice must take several steps, including actively marketing their skills to referring physicians and accepting the clinical responsibility for patients before and after their procedures.

Interventional radiologists who want to build endovascular practices have to “go after” patients, says Mahmood K. Razavi, MD, director of the department of clinic trials at Vascular and Interventional Specialists of Orange County, California. In the past, many interventional radiologists could rely on their hospital to generate business for them but not anymore. “You need to go and develop a patient base and mold your practice the way you want it,” he explains.

Marketing includes identifying and establishing a rapport with the physicians who are most likely to identify patients with PAD. These include general practitioners, family practice physicians, internal medicine specialists, endocrinologists, cardiologists, and podiatrists. “They may be used to sending their PAD patients to cardiologists or vascular surgeons for treatment,” Benenati says. “But you can, with work, build a rapport with these physicians and have them think of you first.”

Benenati believes taking the physicians to lunch or inviting them to PAD seminars is more beneficial than targeting their patients directly. “You can hold screenings. You can go to churches and to retirement homes and American Legion posts and do lectures,” he says. “But even if you have a good response, only a small number of patients will have the disease. If I screen a hundred patients, maybe three will be positive. It helps to get people to know your name, but you’re not going to build volume directly from screening.”

Emphasize Imaging
The key in marketing to colleagues is emphasizing the imaging skills that an interventional radiologist brings to PAD treatment that a cardiologist or vascular surgeon does not, Lookstein says. Ultrasound, CT, and MRI are at the frontline of diagnosing PAD. “Ultrasound, CT, and MRI are within the practice of radiology, so the radiologist is uniquely positioned to interpret studies and help to diagnose PAD,” he says.

At his busy vascular practice, Lookstein says physicians perform more than 150 vascular diagnostic studies per week—6,000 to 7,000 diagnostic studies per year. “Our interventional radiologists interpret all of these diagnostic vascular studies and act as consultants in the interpretation of these studies for referring physicians. That puts us at the frontlines of diagnosing and triaging patients with asymptomatic and symptomatic PAD,” he says.

Vascular surgeons and cardiologists who treat patients with PAD often don’t see the value of cross-sectional imaging and downplay it because it’s not within their scope of practice, Lookstein says. “But studies show cross-sectional imaging shortens the procedure time and reduces the complication rate if the studies are done before treatment, and interventional radiologists need to emphasize to their colleagues that by referring to them, they’re improving patient care and making the treatment of this disease safer,” he says.

Lookstein says virtually all his PAD patients undergo CT or MR angiography prior to their therapeutic procedures.

Razavi’s practice, which he says performs a heavy caseload of PAD procedures and consists of three vascular surgeons and three interventional radiologists. Many might think sharing office space with vascular surgeons would make it easier to get referrals for PAD angioplasty and stenting. In reality, he says, the opposite is true. “Having vascular surgeons as part of your practice makes it a little harder. Because we’re all part of the same practice and share the same financial pie, we don’t want to compete with each other for the same patients. We have to go outside of their referrals to attract patients and get our own.”

Besides marketing their skills to referring physicians, interventional radiologists who want to attract more PAD patients must provide a full range of services. “You have to be willing to see the patients in your office and manage them clinically for their peripheral arterial disease from start to finish,” Benenati says.

He says although it’s different than what many interventional radiologists are used to, they need to have an office where they see patients and can establish a rapport with them. “Once you see a patient in the office and establish a rapport with them, make them feel like you’re their physician. Explain to them the risks and benefits of the procedure and what the outcomes and expectations are. Once you establish that kind of rapport with them, the patients will consider you their doctor and not only come to you for their procedure but also come back to you for all their follow-ups,” he explains.

Benenati says it would be a terrible mistake to send patients back to their referring physicians for their post-op care. “That model is an absolute loser,” he says. Referring physicians want the physician who performs the procedure to manage all the issues that may come up afterward. “Other specialists keep the patient and manage everything. Radiologists who don’t do that can never compete with them,” he adds.

Follow-Up Care
“Treating PAD patients must include some responsibility for their clinical care,” Razavi says. “The days where you’d do the high-end part, which is the procedure, and get paid a lot, and let the low-end part, which is seeing the patient for follow-up are numbered. You need to provide clinical care for these patients. No one is asking you to treat anyone for diabetes or hypertension or heart failure. There are other specialists for that. But if someone comes to you for treatment of claudification, you need to not only address their anatomic problem but also be able to prescribe an exercise regime and medications if needed. If they develop complications postprocedure, you need to take care of that as well.”

Opportunities abound to learn the necessary clinical skills, Razavi says. The Society of Interventional Radiology and other societies provide workshops at their yearly meetings, he says. Lookstein notes that clinical training has been and will continue to be one of the foundations of interventional radiology training and that practitioners should have nothing to fear.

Another way to establish identity with patients and referring physicians is to offer noninvasive vascular testing, Benenati says. “Most patients who have any type of peripheral arterial intervention have some testing done beforehand. If you can provide that testing before and after a procedure, it’s another way you can establish identity with the patient and hold onto that patient. It’s also a great source to find patients,” he says.

PAD can be easily and accurately diagnosed with the ankle-brachial index, which compares blood pressure readings in the arms and ankles.

Another way to build a PAD practice, and what works for Razavi’s group, is to be actively involved in clinical trials, he says. “We all take advantage of various clinical trials when they come down the pike,” he says. “Clinical trials are important to establishing yourself as the guy to go to for the latest treatment when it becomes available.”

None of the strategies for building a PAD practice will work by themselves, Razavi says, “but if you put them all together, you will be successful.”

 Benenati cautions that it takes time to build a PAD practice. “We are on the mature side of that. Our group of nine does thousands of arterial interventions each year, but others who decide they want to do PAD interventions should not expect that tomorrow they will have a robust practice. It takes time to build it. Like any other effort, they have to stick with it to succeed.”

Interventional radiologists also must have the data to show that their procedures are helping patients, according to Benenati.

“As the population ages, you’ll see more demand for PAD interventions,” he says. “There’s going to be higher demand for interventional procedures because they’re less expensive and the recovery is shorter with fewer complications than surgical options. But we’re also under much more government and payer scrutiny. We need to have good data and good research that shows our interventional procedures for PAD are helping patients. It’s one thing to be able to do things and it’s another to show in the long term it works. And with PAD, it does.”

— Beth W. Orenstein of Northampton, Pennsylvania, is a freelance writer and regular contributor to Radiology Today.


Legs for Life
Approximately 8 to 10 million Americans are affected by peripheral artery disease (PAD), which can lead to stroke, heart attack, and loss of limbs. Yet awareness of diagnosis, treatment, and prevention of the disease among the general public and primary care physicians is low.

To increase awareness, the Society of Interventional Radiology started a public education and wellness campaign, Legs For Life, in collaboration with the American Diabetes Association, the American Radiological Nurses Association, the Council on Cardiovascular Radiology and Intervention of the American Heart Association, and the Society for Vascular Nursing.

 A national screening month is held in September, but one- to two-day screenings can be held anytime. The screening uses a questionnaire and ankle-brachial index to identify patients who may have PAD. Patients who are identified as being at risk are referred to their primary care physicians for additional diagnosis and treatment.

 For more information about Legs for Life and to learn how to participate, visit