Management of CLI Requires Comprehensive Program, Multidisciplinary Team

Issue: November/December 2015

Critical limb ischemia is a complex disease that requires complex management. In recent years, it has become more apparent that the challenges presented by the disease cross over to multiple specialties, and patients can benefit from multidisciplinary team management.

“There has been a persistent desire for specialties to lord over this space to the exclusion of others, and that’s a mistake,” Sahil A. Parikh, MD, FSCAI, FACC, assistant professor of medicine at Case Western Reserve School of Medicine, Cleveland, said in an interview. “CV morbidity and mortality is the No. 1 overarching problem with these patients, and without cardiologists involved, these patients have a high mortality. Similarly, we need surgeons involved for surgical therapy and appropriate amputation, and we need wound specialists, be they in vascular medicine, podiatry or other specialties because many [interventional cardiologists] don’t have that expertise. We need a multidisciplinary team to be successful, and that’s the only way we’re going to be able to solve this problem.”

To that end, the American College of Cardiology published on its website a paper by Fadi Saab, MD, FACC, and colleagues with tips on how to build a critical limb ischemia (CLI) program.

According to the authors, the CLI team should include: a revascularization specialist; a noninvasive specialist; nurses and nurse assistants; a podiatry specialist; nephrology and infectious disease specialists; a wound care specialist; staff to handle scheduling and phone triage; lab and vascular technicians; and researchers.

“The creation of a CLI program requires the identification of all the team members (who share the same passion) across the different specialties that need to be involved,” according to Saab and colleagues.

Good indicators of success include institutional volume of 100 CLI procedures and 400 peripheral vascular procedures per year, operator volume of at least 75 CLI procedures per year, establishment of a CLI revascularization team with at least two operators performing 24-hour coverage, establishment of an outpatient team to monitor patient flow and progress, and a proctorship program, according to the paper.

At the center of the program should be a “physician champion” who is “almost exclusively dedicated to treating these patients” and is connected to the revascularization team, inpatient management, outpatient management, a peripheral vascular coordinator, a quality and safety committee, administrative support and community need, Saab and colleagues wrote.

“The best approach is, in general, a multidisciplinary one where we collaborate across specialties and utilize what we consider the best practice for that individual patient,” Parikh said. – by Erik Swain

Reference:
Saab F, et al. The nuts and bolts of building a critical limb ischemia program. American College of Cardiology. Sept. 8, 2015. Available at: www.acc.org/latest-in-cardiology/articles/2015/09/02/13/22/the-nuts-and-bolts-of-building-a-critical-limb-ischemia-program. Accessed Sept. 24, 2015.