TRANSCAROTID ARTERY REVASCULARIZATION: THE FUTURE OF CAROTID SURGERY

One of the most gratifying problems we help treat for patients is carotid artery disease.  The carotid arteries supply the brain with blood.  In patients with high blood pressure, high cholesterol, diabetes, and a history of smoking, the carotid arteries can become narrowed and form blood clots that then go into the brain and cause strokes.  Traditionally, vascular surgeons have fixed this carotid artery narrowing’s with a surgery called a carotid endarterectomy.  The carotid artery is dissected out and cut open.  The plaque is then removed, and the carotid artery is sewn back together.

Over the past five years, however, I have had the opportunity to perform a new technique involving carotid stenting called trans carotid artery revascularization or TCAR.  Stents are self-expanding metal tubes that we can use in the carotid artery to stop clots from forming in narrowed areas.  TCAR uses a suction machine to reverse flow in the carotid artery during the placement of a stent to minimize the risk of inadvertent stroke during the procedure itself.  After having performed over 20 of these procedures in the past two years, I can say with confidence that the flow reversal and stenting that TCAR provides is a highly safe and successful way to treat carotid artery disease.  Furthermore, the length of the incision, postoperative pain, and risk of nerve damage and bleeding are all much less with TCAR than with CEA.

I am so happy to be able to offer this revolutionary, safe, and effective therapy to all my patients at South Bay Vascular Center.  Should you or anyone you know have any problems with your carotid arteries or a stroke, please do not hesitate to call us today at 408-376-3626 to schedule a consultation.

https://youtu.be/O32nDoovMPY]

WHAT CAUSES VARICOSE VEINS; WHY DO MY LEGS SWELL WHEN I HAVE THEM AND WHAT CAN I DO ABOUT THEM?

Hello. Dr Lau here again. Today I wanted to share some information about Varicose Veins.  Almost daily, my patients ask me “Dr Lau, what causes varicose veins and associated swelling in the legs and what can I do about them?”

Although every patient I meet is different, varicose veins are one of the most common conditions that I treat as a vascular surgeon and relate to a disruption of structures within the veins called valves.

Normally, veins have valves that allow blood to go from the feet to the heart and prevent the blood from pooling in the legs. When these valves become damaged, patients can develop varicose veins because of the higher pressure in the veins within the legs. Damage to the valves can occur from standing for extended periods of time at work or otherwise which increases stress on the valves.

Deep vein thrombosis otherwise known as a blood clot can also damage the valves irreversibly. Some patients do not stand for extended periods of time and/or have blood clots but still develop varicose veins and swelling. In these patients, genetic factors may play a role.

Due to advancements in our understanding of how the veins work and, in the technology, we use to treat veinous disease, vascular surgeons have much to offer patients with varicose veins and swelling. We always try a period of compression stockings which are effective for reducing swelling and varicose veins in up to 50% of patients. If compression stockings do not work, we can perform a procedure that heat seals or glues the veins in the legs closed so they can no longer leak. Finally, we can also investigate obstructions in the connections between the heart and the legs in the abdomen with both ultrasound and specialized x-ray machines.

 

A SPECIAL WORD OF CAUTION: Not all Varicose Veins are Cosmetic Problems. In fact, varicose veins can sometimes be the sign of a much more complex vascular condition and as such Vascular Surgeons are uniquely qualified to diagnose and evaluate the underlying causes for the formation of varicose veins.  Clinics focusing exclusively on the treatment of varicose vein often time underdiagnose the underlying causes of these varicose veins and physicians advertising as “Vein Specialists or Vein Doctors” should be carefully evaluated before being allowed to treat your veins. Medicare as well as most commercial insurance carriers have identified strict guidelines for treating varicose veins and your treating physician must carefully follow these guidelines before treatments will be reimbursed. Many cosmetic varicose vein clinics will encourage patients to pay for cosmetic procedures in cash to avoid the guidelines established by Medicare and most major commercial insurance companies so patients must make informed decisions prior to simply paying cash to have a cosmetic procedure done.

As a vascular surgeon, I am well versed in the ways to diagnose and treat venous disease. Please do not hesitate to call to schedule an appointment if you have either varicose veins or swelling in your legs! If you or anyone you love is suffering from Varicose veins, please call our office to schedule an appointment at 408-376-3626.

SOUTH BAY VASCULAR CENTER WELCOMES DR IGNATIUS H LAU

My name is Ignatius Lau, and I just joined South Bay Vascular Center as a vascular surgeon.  I grew up in Portland, Oregon, and then went to the University of Washington in Seattle, Washington, for college.  Afterwards, I went to Stony Brook University in Long Island, New York, for medical school and finished my training at the Icahn School of Medicine at the Mount Sanai Hospital in New York City.

Developing a passion for vascular surgery has been one of the most satisfying parts of my life.  I love the technical challenge of vascular surgery.  I love the ability to form long-term relationships with my patients and help lead them through challenging points in their journey to become stronger healthier people.

The scope of therapeutic options is growing so rapidly with advancements in technology in vascular surgery.  As such, I look forward to sharing these ways in which we as vascular surgeons can help patients on this blog!

WHY DON’T THE WOUNDS ON MY LEGS AND FEET HEAL ANYMORE?

Hi! Dr. Lau here again with South Bay Vascular. Today, I wanted to shed some light on one of the most common issues that we see in vascular surgery, non-healing wounds of the feet and toes. My hope is that after reading this blog you will have a better understanding of what causes leg wounds and ulcers; why sometimes they won’t heal on their own, and what we in vascular surgery can do to help them heal.

Ulcers, generally speaking, develop because of TWO main causes: nerve damage induced by diabetes and lack of blood flow. When patients have elevated levels of sugar in their blood with diabetes, the sugar forms toxic compounds that damage nerves in the foot. Consequently, the patient cannot feel injuries that would otherwise cause a normal patient to adjust position to stop the injury. With this loss of sensation ulcers form at the point of repeated injury that the patient cannot feel.

The second cause, a lack of blood flow, develops over decades in patients who smoke and who have high blood pressure and high cholesterol. These medical problems cause hardening and narrowing of the blood vessels, otherwise known as atherosclerosis.

In patients with diabetes, I coordinate carefully with my podiatrist colleagues who are experts in specialized footwear and surgical interventions that alleviate common areas of trauma. In patients with poor blood flow, I, as a vascular surgeon, can perform minimally invasive surgery to restore blood flow to the affected area. We use wires and specialized tubes to gain access to the blood vessels and then use balloons to break open the narrowing’s and self-expanding tubes called stents to keep the vessels open. Afterwards, we use a specialized x-ray machine called fluoroscopy to see that the narrowing’s have opened again to allow blood to flow back to the area. Patients usually leave to go home the same day with only a 2-millimeter puncture in their groin and are back to normal activity the day after surgery!

If you or anyone you know has a wound on their leg, foot or toe that hasn’t healed in more than two weeks, please call our office at 408 376 3626 to schedule an appointment.

ONE PATIENT, ONE DOCTOR, ONE NURSE; SOUTH BAY VASCULAR CENTER’S COMMITMENT TO PERSONALIZED CARE

Unlike so many big box medical centers (Kaiser, Sutter, PAMF, Stanford) where patients are often “overwhelmed” as soon as they get to the parking lot, South Bay Vascular Center and Vein Institute offers world class, cutting edge vascular surgical care in a kinder, gentler environment.  Individualized patient care, although talked about and marketed heavily by these corporate health systems, more often than not falls far short of patient expectations as higher order operational efficiencies and profitability concerns impact the kind of care patients actually experience in these larger health care systems.

ONE PATIENT; ONE DOCTOR; ONE NURSE. 

Putting patients at the center of everything that a physician does is a philosophy that sounds obvious…but is that always the case? At South Bay Vascular Center we are honored by the chance to earn your trust and to serve as your physicians; BUT, we also know that we must EARN the trust of every patient that we see.  That’s why our CREDENTIALS are NOT Enough…That’s why our REPUTATION is NOT enough. That’s why unmatched patient care is at the center of everything that we do. That’s why when patients come to our facility for a procedure each patient has their own nurse from start to finish to ensure the greatest patient care experience from start to finish. 

We know patients have options for their vascular care and that’s why we work hard to ensure that any patient referred to us by another doctor or that comes to us on their own has the confidence to know they’ve made the right choice of doctor to help them with their vascular related illnesses. ONE PATIENT; ONE DOCTOR; ONE NURSE is just one of the many ways that South Bay Vascular Center demonstrates our commitment to our patients in our efforts to provide the most advanced vascular care options offered anywhere in the world.

OUR TEAM

Together with her full time, highly skilled team of critical care and surgical nurses, radiological technicians, RVT certified Ultrasound Technologists and scrub assistants, Dr Kokinos provides unmatched peripheral vascular surgical care in her Nationally Accredited Surgical Facility. As diverse as Silicon Valley is, our staff reflects this same diversity as we have native speaking staff fluent in over 10 different languages. Be it Vietnamese, Mandarin, Korean, Russian, Tagalog, Hindi, Spanish, French, Greek or English, we have staff to make our patients comfortable in their native tongue.

OUR FACILITY

The South Bay Vascular Ambulatory Surgery facility is one dedicated entirely to the practice of Vascular Surgery and houses a specialized inventory of vascular medical devices and imaging equipment that surpasses the number of vascular medical devices and imaging equipment at Good Samaritan and O’Connor Hospitals combined. Together with her highly trained and specialized team, Dr Kokinos brings over 30 years of surgical experience and 7 years of specialized surgical experience operating in a specially built vascular surgery outpatient facility to her patients.  Other physicians may claim to have the kind of training and experience that Dr Kokinos has in the outpatient environment, but NO other Vascular Surgeon in Silicon Valley comes anywhere close to having the kind of experience and outcomes Dr Kokinos does when it comes to providing care to the patients who come to her for the treatments and care of their vascular disease.

Put another way, for 25 years Dr Kokinos and her team at South Bay Vascular Center and Vein Institute have provided unmatched, compassionate and individualized vascular surgical care to South Bay communities. It is why more independent physicians refer their vascular patients to Dr Kokinos than to all the other Silicon Valley vascular surgeons combined. When it comes to your health, we know that it’s not just our credentials and our experience that count.  It’s not about just having an accredited facility or a staff of travelling specialists to help when needed…   It’s about the RIGHT KIND OF EXPERIENCE EVERY TIME YOU NEED IT.

RESULTS matter when it comes to your health because sometimes you don’t get a second chance.

South Bay Vascular Center and Vein Institute: We Offer Hope When Others Say there Is None.

Call us at 408-376-3626. We Can Help

FOOT PAIN AT NIGHT: IT MIGHT BE MORE SERIOUS THAN YOU THINK

Many patients over the age of 65 who have a history of smoking, diabetes, high blood pressure, and/or high cholesterol wake up at night with pain in their foot or toes. Some believe this is arthritis or gout; others think it is the result of just spending too much time on their feet during the day.  Patients often self-adapt to this problem, as it usually develops slowly over time, but when questioned about their sleep habits, they will sometimes tell you that they sleep in a recliner or they sleep with their leg hanging over the side of the bed to make their pain go away.

It is very common for elderly patients to get up at night to go to the bathroom. Sometimes, however, it’s actually foot pain that wakes them up.  Once up, they get out of bed because that makes their feet feel better (again due to gravity) and after walking to the bathroom they can go back to sleep, pain -free for a couple of hours.  Even that small amount of walking helps to get their blood flowing again and makes it easier for them to go back to sleep.

Sometimes, foot pain at night is the sign of a more serious condition.

  • Foot pain at night may be related to having poor circulation in the foot. The name for this in medical terms is “rest pain”. This is not “pain at rest” but rather pain that happens because the circulation cannot support the tissues even when they are at rest.

Foot pain at night may be an early warning sign of critical limb ischemia.

  • Chronic Limb Ischemia is another term for lack of blood flow;  if you experience this rest pain at night and it goes away after hanging your foot over the side of the bed or chair you are sleeping in, immediately call and speak with your doctor to set up an appointment for them to evaluate your symptoms. Although it may come on slowly, the arteries in your feet may be so blocked that they cannot even deliver the minimal amount of oxygen the tissues in the foot and toes need to keep them nourished. Left untreated, this blockage can lead to a more serious problem, amputation or even death.

What’s important for the patient to realize is that chronic limb ischemia causes the foot and leg to get swollen, so the patient is often MIS-DIAGNOSED with a vein problem, not an arterial problem

If this sounds like something you or someone you love is experiencing, it is important to tell your primary care doctor OR schedule an appointment DIRECTLY with a vascular surgeon. These symptoms are a sign that your body is giving you that you may need immediate help. This truly is a sign that your foot is starving for oxygen and blood and that if left untreated, might lead to an unnecessary amputation. Help is possible, however and if treated early enough, those suffering from these symptoms can be helped significantly.

If you suffer from painful feet in the middle of the night, WE CAN HELP

contact us today  at 408-376-3626 to learn more about PAD and how Dr. Kokinos can help, click here.

South Bay Vascular Center and Vein Institute: We Offer Hope When Others Say There Is None.

 

 

COMMITTED TO YOUR HEALTH: SOUTH BAY VASCULAR CENTER CELEBRATES ITS 25TH YEAR IN PRIVATE PRACTICE

Having dedicated her career to providing cutting edge care to patients suffering from vascular disease, Dr Kokinos has earned her reputation as being San Jose and the South Bay’s most trusted Vascular Surgeon. As we begin our 25th year in private practice we are deeply honored to have had this opportunity to meet and to care for so many patients in our community and remain committed to offering the most advanced vascular surgical and clinical care found anywhere in the world.

Over the past 25 years Dr Kokinos has performed over 20,000 varicose vein procedures, thousands of peripheral revascularizations and has pioneered the use of IVUS (intravascular ultrasound) to assist in the diagnosis and treatment of chronic leg swelling. Benefitting from her expertise, vascular surgeons from throughout the region have trained in her outpatient lab on how to both identify and to treat May Thurners disease much of which had previously gone undiagnosed and untreated. By giving back in this way, Dr Kokinos expands on her reputation as the valleys pre-eminent vascular surgeon and continues to set the standard of care in the diagnosis and treatment of patients suffering from complex vascular disease.  (Visit our website www.southbayvascular.com to read over 150 reviews from patients treated by Dr Kokinos and her staff)

In response to the overwhelming growth of our practice during the past year we continue to expand our care throughout the South Bay.  Having expanded our services to Gilroy 8 years ago, we are now proud to announce the expansion of our vascular ultrasound services to our newest location in Hollister.  Growing ever closer to our patients, our newest office offers vascular ultrasound services to an underserved community and now gives patients suffering from complex vascular disease a gateway to the most advanced vascular surgical care found anywhere in the world.

Offering Hope When Others Say There Is None is at the core of what we do. If you or anyone you know is suffering from a circulation related illness, un-matched world class Vascular Surgical care is available at South Bay Vascular Center and Vein Instute.

Call us today to schedule an appointment at 408-376-3626.

South Bay Vascular Center and Vein Institute. Un-Matched Vascular Surgical Care

www.southbayvascular.com

 

 

 

 

 

 

SANTA CLARA COUNTY’S LEADING VASCULAR SURGERY PRACTICE

South Bay Vascular Center and Vein Institute

 

Our Passion for Innovation and World-Class Performance speaks for itself:

 

  • Top Ranked in Physician Referrals for Vascular Disease in Santa Clara County.
  • First fully accredited out-patient ambulatory Surgery Facility dedicated entirely to the treatment of Vascular Disease in Santa Clara County.
  • First and only ICAVL accredited Vascular Ultrasound Lab in Santa Clara County dedicated entirely to the evaluation of vascular disease.
  • First out-patient facility to utilize IVUS technology to diagnose and treat Iliac Vein Compression (May-Thurners Disease) in the out-patient setting in Santa Clara County.
  • First fully integrated Vascular Medical Clinic, Vascular Ultrasound Laboratory and Ambulatory Surgery Facility in Santa Clara County.
  • First private practice Medical Gap Year Internship program dedicated to training and preparing pre-med students for Medical School… To date 8 of our medical interns have matriculated to accredited US Medical School.
  • Over 20,000 Successful Varicose Vein Procedures.
  • The Bay Area’s leading limb salvage, amputation prevention and dialysis access treatment center.
  • The South Bay’s most trusted Vascular Surgeon; Serving South Bay Communities for 25 years as a private practice physician.

 

“We offer hope when others say there is none”

 

www.southbayvascular.com

SOUTH BAY VASCULAR SHINES SPOTLIGHT ON CRITICAL LIFE AND LIMB SAVING SOLUTIONS DURING PAD AWARENESS MONTH

September is Peripheral Artery Disease (PAD) Awareness Month

 

September is Peripheral Artery Disease (PAD) Awareness Month and Dr. Polly Kokinos at South Bay Vascular Center & Vein Institute is sharing critical limb- and life-saving information about this chronic vascular disease.

Peripheral Arterial Disease (PAD) is a common circulatory problem in which narrowed arteries reduce blood flow to the limbs. According to the CardioVascular Coalition, https://cardiovascularcoalition.com/ PAD affects nearly 20 million Americans, and an estimated 200,000 of them – disproportionately from minority communities – suffer avoidable amputations every year.

Although estimates suggest that anywhere from 12 to 20 percent of individuals over the age of 60 are living with PAD, many Americans have not even heard of the disease. Symptoms include leg pain while walking, numbness in the toes, wounds on the toes or feet, and gangrene. Individuals with high cholesterol, high blood pressure, diabetes, or a history of smoking are at tremendous risk for PAD.

Experience Counts When It Comes To Your Health

 

Dr. Polyxene (Polly) Kokinos, a board-certified Vascular and General Surgeon with over 25 years of experience, is recognized as one of the region’s foremost authorities in the diagnosis and treatment of PAD. Dr. Kokinos has dedicated her entire career to serving the South Bay community as an independent physician. She founded the nationally accredited South Bay Vascular Center & Vein Institute and specifically designed the state-of-the-art facility in Campbell, California as a PAD intervention and treatment center…Dr Kokinos has performed more peripheral arterial revascularization procedures than any other physician in Northern Californina…and that’s why more independent primary care physicians and Nephrologists refer their patients with Vascular Disease to Dr Kokinos than to any other Vascular Surgeon in the South Bay: We Offer Hope When Others Say There Is None!

We Can Help!

 

Early detection is important to controlling PAD and allowing patients a full selection of treatment options. Dr. Kokinos has conducted extensive outreach to primary care physicians, internists, podiatrists, and orthopedic surgeons about the management of lower extremity arterial and venous disease and the signs and symptoms to look for.

“Early diagnosis and treatment are critical—because amputation is not the only answer,” explains Dr. Kokinos. “Over the past 15 years, the interventional treatment of peripheral arterial disease (PAD) has changed significantly. Minimally invasive endovascular procedures and pedal access techniques have replaced many traditional surgical procedures. By combining advanced medical technology with our years of experience and expertise, we can offer hope—even when others say there is none.”

For more information about Peripheral Arterial Disease and South Bay Vascular Center & Vein Institute, go to southbayvascular.com.

 

 

SOUTH BAY VASCULAR SPECIALIZES IN TREATING PERIPHERAL ARTERIAL DISEASE (PAD)

THE FOLLOWING POINTS ARE SHARED FROM THE

“TAKE A STAND AGAINST AMPUTATION WEBSITE”

Cardio-Vascular Systems Inc (CSI). To learn more, click on the link below.

 

https://standagainstamputation.com/peripheral-artery-disease/

 

 

Recognized for her expertise in treating patients suffering from Peripheral Arterial Disease, Dr Kokinos has been chosen by Cardio Vascular Systems Inc. (CSI) as one of Silicon Valley’s leading experts in the diagnosis and treatment of PAD. In recognition of this expertise Dr Kokinos and South Bay Vascular Center have been honored on CSI’s website in their Physician Locator Section as one of  Silicon Valley’s leading Peripheral Arterial Disease experts. https://csi360.com/covid_pad_locator/

 

What is Peripheral Arterial Disease? (PAD).

When you have PAD, your arteries are narrowed, restricting the blood flow to your legs, feet and/or toes. Symptoms include aches, numbness and burning sensations. If left untreated, things can get rapidly worse, including the possibility that his disease could lead to having one’s leg amputated.9 PAD is the biggest disease that most people have never heard about. It affects more than 18 million people – more than cancer, stroke and congestive heart failure.

 

Are You At Risk for Peripheral Arterial Disease? (PAD)

Smoking: Of all the risk factors for peripheral artery disease (PAD), smoking is considered the most powerful predictor of PAD.

Diabetes: Diabetes is a powerful risk factor of peripheral artery disease (PAD). One in three people over the age of 50 with diabetes is likely to have PAD.40 People with diabetes and PAD have a 10 times greater risk of amputation than patients without diabetes.12

Chronic Kidney Disease: Individuals with Chronic Kidney Disease (CKD) are at a greater risk of developing peripheral artery disease (PAD).

  • Researchers estimate that 24% to 37% of patients with CKD also have PAD.44
  • 26 million American adults have Chronic Kidney Disease (CKD) and millions of others are at increased risk of the disease.45
  • PAD is an often overlooked and under-diagnosed condition in patients with CKD.44,46

Why it is important to diagnose and treat the early symptoms of Peripheral Arterial Disease? (PAD)

Left untreated, peripheral arterial disease can lead to amputation. In fact, studies have shown that among patients with critical limb ischemia (CLI), the worst form of PAD, AMPUTATION IS ESTIMATED TO BE ~25%.5 

 

Symptoms that may be signs you have PAD.

  • The presence of an ulcer or gangrene is often a sign of  Chronic Limb Ischemia (CLI)

This is the most advanced form of PAD. Leg pain while walking and leg pain that is frequently intolerable also can be common with CLI. Intense discomfort from CLI can last from minutes to hours, and often happens at night. The leg pain from CLI can interrupt your sleep, and you might hang your foot off the edge of the bed in an attempt to get relief. Or you might only be able to get rest when you sleep upright in a chair.20

Critical Limb Ischemia

  • Is it painful to walk?

Have you noticed pain in your leg when you walk? Is it more than just feeling tired when walking?  Peripheral artery disease (PAD) can cause leg pain while walking. Aches and pains from PAD are the result of narrowed, hardened arteries in the legs, limiting blood flow to your legs and feet. When there isn’t enough blood in your muscles and you try to move them, the pain in your leg can be severe. The discomfort can cause you to favor one of your legs while walking to avoid the pain.19 The pain can worsen when you’re active and decrease when you’re at rest.23 But you know it can come back.

    • Does leg pain frequently interrupt your sleep?

    Are you in the habit of hanging your foot off the edge of the bed to relieve the discomfort? Is sleeping upright in a chair the only way you can get rest? These might be more than normal effects of getting older. Pain in your legs and feet at night, or when you’re trying to sleep, is a symptom of peripheral artery disease (PAD). And nighttime leg pain could mean you have the worst form of PAD – critical limb ischemia (CLI). Are you in the habit of hanging your foot off the edge of the bed to relieve the discomfort? Is sleeping upright in a chair the only way you can get rest? These might be more than normal effects of getting older. Pain in your legs and feet at night, or when you’re trying to sleep, is a symptom of peripheral artery disease (PAD). And nighttime leg pain could mean you have the worst form of PAD – critical limb ischemia (CLI).

    Good circulation is important and it isn’t something you should ignore. Your blood helps regulate many things in your body. If blood is not easily reaching your toes and feet, those areas will experience a drop in temperature. If you have PAD, the arteries in your legs have narrowed and hardened. This limits blood flow to your legs and feet and can make them feel cold.

    Changes due to PAD can include thicker toenails and loss of hair on your leg, feet or toes. As you get older, you might notice changes to the look and feel of your skin and think these changes are a normal part of the aging process. But these changes could be a symptom of peripheral artery disease (PAD)

    • Painful Heavy Legs

    Unexplained pain or a feeling of heaviness in your legs could be caused by narrowed, hardened arteries from PAD. It may mean you have limited blood flow to your legs and feet. In the worst form of PAD, called critical limb ischemia (CLI), the obstructed blood flow is so considerable and widespread that the pain can be intolerable

    • Numbness or Burning in Your Legs

    If you notice a strange tingling in your foot, or you feel like your entire leg is on fire, pay attention to what your body is telling you and see a health care professional. Don’t ignore these kinds of unusual sensations, especially if they get progressively worse or more painful – they could be signs of a larger issue that requires a doctor’s attention. Peripheral artery disease (PAD) can cause uncomfortable numbness or burning sensations in your feet and legs. The restricted blood flow brought on by PAD can harm your body in a variety of ways, including damaging your nerves, which transmit messages between your brain and the rest of your body.

     

    IF YOU OR ANYONE YOU KNOW SUFFERS FROM ANY OF THE SYMPTOMS ABOVE, CALL OUR OFFICE AT 408-376-3626 TODAY TO SCHEDULE AN APPOINTMENT WITH ONE OF OUR PHYSICIANS.

    TAKE A STAND AGAINST AMPUTATION!