1. 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

2. 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

3. 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.

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

5. 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

6. 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,

7. Amputation (Impact!!) 160,000 per year in the US
20%-25% (1/4) all diabetics-lifetime
30 Day perioperative mortality
BKA - 5-8%
AKA %
month overall mortality %
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,

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

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

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

11. 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

12. 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

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

14. 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.”

15. 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.)

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

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

23. Left Side

28. 1 Month Post Intervention

34. 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