Multidisciplinary Approach for a Successful CLI Management Program Craig M. Walker, MD, FACC, FACP Clinical Professor of Medicine Tulane University School of Medicine New Orleans, LA LSU School of Medicine Founder, President, and Medical Director Cardiovascular Institute of the South Houma, LA Clinical Editor Vascular Disease Management Global Vascular Digest

Disclosures Speaker’s Bureau: Abbott Bard Boehringer-ingelheim Bristol-Myers-Squibb/Sanofi Cardiva Cook Medical Cordis DSI/Lilly Gore ACHL/Merck Spectranetics PVD Training: Boston Scientific TriReme Medical Stockholder: CardioProlific Cardiva Spectranetics Vasamed Consultant/Medical/Scientific Boards: Abbott Boston Scientific Cook Medical CR Bard Lake Regional Medical Medtronic

There is an epidemic of PVD Mary Yost of the Sage Group estimates up to 20 million Americans have PVD. In 2006 between 1 million and 2.5 million people in the U.S. had CLI. (Estimated this will grow to 2.8 million by 2020). PAD is a marker for death with 1 year mortality or major CV event rates of 20%. The Majority of patients with PAD or either asymptomatic or ascribe their symptoms to etiologies other than PAD. THE OVERWHELMING MAJORITY OF PATIENTS WITH PAD ARE UNDIAGNOSED.

Patient Survival by Ankle-Brachial Index in Cardiovascular Health Study Newman et al ATVB 1999;19:538-545

CLI is not created Equal Rest Pain (Rutherford 4) Ischemic Ulceration (Rutherford 5) Gangrene (Rutherford 6) Severe Infection worsens prognosis Major tissue loss worsens prognosis Comorbid conditions worsen prognosis

It is not conservative treatment to amputate! Amputations Less than 20% get an angiogram Only 50% get an ABI Most of these patients do have limb salvage options It is not conservative treatment to amputate! David E Allie, MD, Craig M. Walker, MD: Critical Limb Ischemia: A Global Epidemic. A Critical Analysis of Current Treatment Unmasks the Clinical and Economic Costs of CLI. Eurointervention Journal, 2005, 1, 1, 75-84.

Amputation (Impact!!) 160,000 per year in the US 20%-25% (1/4) all diabetics-lifetime 30 Day perioperative mortality BKA - 5-8% AKA - 8-12% 18 - 24 month overall mortality - 40-50% Amputations are NOT benign! David E Allie, MD, Craig M. Walker, MD: Critical Limb Ischemia: A Global Epidemic. A Critical Analysis of Current Treatment Unmasks the Clinical and Economic Costs of CLI. Eurointervention Journal, 2005, 1, 1, 75-84.

“For some reason, it is considered conservative treatment to chop someone’s leg off and aggressive treatment to even do an angiogram”

Treating PVD Primary Treatment for severe PVD in the 1800’s

Treating PVD In some places Primary Treatment for severe PVD in 2017

Keys to avoiding amputation Earlier diagnosis Earlier appropriate medical therapy Earlier referral for revascularization Revascularization (straight line flow to foot) Infection control and nutritional support Wound care/Minor amputation in some cases Unloading and cushioning Hyperbaric therapy

We need Limb Salvage Teams No patient should have a major amputation without TEAM evaluation Components of TEAM Nurse Coordinator Interventionists Open Surgical Revascularization Infectious Disease Podiatry Diabetologists Wound Healing Experts Dialysis Smoking Cessation

Limb Salvage Teams (cont.) Perform continued medical education Routine Screening (the earlier the disease is diagnosed, the better the long-term prognosis) COMMUNICATION

Who is a candidate for limb salvage “There is no patient facing major amputation on whom I would not consider intervention except: Cases of true acute limb ischemia with totalloss of neurological function where reperfusion could result in severe complications including death with no benefit. or extensive deep infection that can’t be treated.”

Goals of the Interventionalist in Limb Salvage Establish straight line flow to the foot At least long enough to heal the ulcer Avoid further trauma Never take away a surgical option Never make things worse Limit iodinated contrast (CO2 is an option) Avoid stenting at surgical areas Avoid occlusive sheaths Avoid distal wire complications ( Spasm, dissection, perforation, etc.)

Case: 27 Year old Female Nurse, Single Mom Pre-Intervention

Actual Operative Report Date of Procedure: 08/24/09

Left Side

1 Month Post Intervention

Conclusion Amputations are not benign Amputations carry high morbidity/mortality rates and cost more than limb salvage. Earlier diagnosis and treatment improve outcomes Newer revascularization and wound healing techniques are yielding improved results No one should ever be subjected to amputation without access to CLI team