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Multidisciplinary approach to CLI care may confer fewer amputations
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SAN DIEGO — An effective treatment option for patients with critical limb ischemia may involve a multidisciplinary approach, according to a presentation at TCT 2018.
There have been several recent studies that focus on patient populations with CLI, including the LIBERTY 360° study.
As Cardiology Today’s Intervention previously reported, regardless of severity of a patient’s lower-extremity peripheral artery disease, interventions that included percutaneous transluminal angioplasty, atherectomy and stents were associated with positive 30-day outcomes. This continued to be beneficial to patients at 18 months.
“The great thing about this registry is that it included patients who classically would not be included in clinical trials, mainly Rutherford [category] 6 and patients with advanced tissue loss,” Michael R. Jaff, DO, FACC, FSCAI, professor of medicine at Harvard Medical School, president of Newton-Wellesley Hospital in Massachusetts and a Cardiology Today’s Intervention Editorial Board Member, said during the presentation.
Of the patients with CLI in this study, 20% who presented for therapy had a previous major limb amputation on the nontarget limb.
“These are seriously disadvantaged patients,” Jaff said. “If that doesn’t tell you that we need a comprehensive approach to their care, nothing will.”
Patients with CLI are at high risk for limb loss, including contralateral limb loss, in addition to morbidity and mortality, according to the presentation. They also require urgent revascularization and optimal adjuvant medical therapy such as diabetes management.
The utilization of interdisciplinary care teams to treat patients with lower extremity PAD is addressed in the 2016 American Heart Association/American College of Cardiology PAD guidelines.
“For the first time in published guidelines, there’s a call-out that this should be part of practice,” Jaff said.
In this guideline, it directs physicians that an interdisciplinary care team for patients with CLI should include those who are skilled in surgical revascularization, endovascular revascularization, medical evaluation and care, foot surgery and wound-healing therapies.
This approach is currently being assessed in real clinical practice in the BEST-CLI trial.
“One of the most innovative parts of this trial was the fact that it includes every specialty who manages patients with CLI,” Jaff said. “It clearly stated that for this trial to answer a clinical key question, everyone has to be involved.”
Teams involved in the BEST-CLI trial consists of specialists who treat patients with CLI while maximizing interdisciplinary collaboration within each site, according to the presentation.
“We have to think creatively and strategically about innovation on behalf of our CLI patients,” Jaff said. “That innovation is not only about what’s the coolest new technology to revascularize a patient, but it’s thinking differently about how to manage patients.” – by Darlene Dobkowski
Reference:
Jaff MR. Critical Limb Ischemia Deep Dive. Presented at: TCT Scientific Symposium; Sept. 21-25, 2018; San Diego.
Disclosure: Jaff reports he is a consultant for Abbott Vascular, AOPA, Boston Scientific, Cordis, Medtronic, Micell, Primacea, Silk Road Medical, Vactronix, Venarum and Volcano/Philips and holds equity in Embolitech, Gemini, Janacare, MC10, Northwind Medical, PQ Bypass, Primacea, Sano V and Vascular Therapies.