Team Approach to CLI: Who, How and Why Alex Powell, M.D., FSIR Miami Cardiac and Vascular Institute
NONE DISCLOSURES
WHY? Better outcomes Amputation free survival Mortality Cost savings Shorter length of stay Avoid admission altogether
JVS 2010 2005: 1.6 million people in the US living with amputation 2050: Number is expected to double One half of all patients with an amputation will develop limb threatening ischemia in the contralateral limb Medicare spends 34 billion dollars a year on lower extremity care Preventing ulcerations and amputations is critical JVS 2010;51:1504-6
Numerous centers around the world have reported significant reductions in amputations and ulcer recurrence with multi-disciplinary teams The presence of multiple practitioners caring for the same patient increases the opportunity for lifelong follow up for surveillance of vascular and podiatric disease A coordinated team can more rapidly assess a patient (that frequently has multiple major comorbidities) and provide care using established evidence based algorithms JVS 2010;51:1504-6
Optimal Medical Therapy Predicts Amputation Survival in Chronic CLI Despite guidelines regarding optimization of risk factors, less than 1/3 of patients presenting with CLI present with risk factors that are optimally managed Patients who are medically under treated have and eight fold increased risk of major amputation and death Chung et al JVS 2013;58:972-80
Case Example 45 year old female with HTN and type II DM Developed blister on left 4 th toe to 2 weeks prior to admission Started on trial of antibiotics Outside podiatrist sent her to the emergency room after toe became necrotic HbA1c on admission: 12.7 (12.0 18 months prior to this admission) Admission meds No statin No antiplatelet Captopril Metformin Levemir
Hospital Course 4 th toe deemed non viable Attempts made to limit level of amputation Endovascular revascularization (PTA of tibio-peroneal trunk) performed day 3 In spite of revascularization wound progressed to wet gangrene Amputation of toe day 8 (amputation did heal) Discharge on day 8
Same Patient-3 months later Seen in office with new wound to right 2 nd toe Treated as outpatient with anterior tibial (via pedal access) and peroneal artery PTA Discharged after overnight outpatient stay Wound completely healed-no amputation
Same Patient-3 months later Seen in office with new wound to right 2 nd toe Treated as outpatient with anterior tibial (via pedal access) and peroneal artery PTA Discharged after overnight outpatient stay Wound completely healed-no amputation Meds now include: Clopidogrel, ASA and Rosuvastatin HbA1c: 7.9
WHO?
Components of a CLI Team Preventative foot care Wound management Pre and post procedure Revascularization specialists Endovascular Open surgery Hybrid Risk factor and co-morbidity management Vascular medicine Nephrology Cardiology Communication, coordinator and follow up specialist (The How ) Improved communication Between specialists With wound care center With referring doctors With home care With patient Get patient back for follow up exam
Barriers Not all specialties work in same location Potential competing economic incentives Testing locations Time away from main office Insurance coverage Limited contracts for many groups Poor communication Poor understanding of what other specialties have to offer
Conclusions CLI teams have been proven to lower amputation rates Rapid assessment and improved communication are keys Multispecialty revascularization can improve outcomes Risk factor modification is not to be ignored and is one of the greatest variables that a coordinated team can control
Thank You!
Issues in CLI Care Poor communication between all specialists Patients are sick with multiple co-morbidities Co-morbidities are frequently undertreated Lack of coordinated care leads to hospitalization Lack of coordinated care leads to prolonged hospitalization Poor long term follow up Treatment options can be quite complex and require multiple specialties