Saving limbs: Interdisciplinary approach helps avert amputation for patients with CLI
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A novel, interdisciplinary limb salvage team reevaluating severe cases of critical limb ischemia avoided amputation for 75% of patients 180 days after revascularization, according to findings from a small study.
Despite the recommendations for an interdisciplinary approach in the care for complex patients with CLI, also known as chronic limb-threatening ischemia, clinical decisions of amputation are frequently made in isolation by an individual team, Mehdi H. Shishehbor, DO, PhD, MPH, president of University Hospitals (UH) Harrington Heart & Vascular Institute and the Angela and James Hambrick Chair in Innovation, and colleagues wrote in a research letter in Circulation: Cardiovascular Interventions. UH Harrington Heart & Vascular Institute created a systemwide interdisciplinary team, the Limb Salvage Advisory Council, to evaluate patients with CLI who were already scheduled for amputation. The study included 19 patients, most Rutherford class V and VI, who underwent evaluation from January to September 2019. Within the cohort, 16 patients were reconsidered for limb salvage and 15 had successful angiosome-directed revascularization.
Excluding patients who died or were lost to follow-up, only one-quarter of the patients formerly scheduled for a major amputation lost a limb at 180 days.
Healio spoke with Shishehbor about the benefits of expert collaboration for patients with CLI, learning from challenges and the importance of breaking down institutional silos.
Healio: You and your colleagues recently published a research letter detailing the impact of your interdisciplinary Limb Salvage Advisory Council. What is the take-home message for readers?
Shishehbor: The take-home message is we can save a considerable number of limbs for patients who are told there are no options and they need an amputation. To do this, we must bring together a group of experts in an interdisciplinary format. This is similar to the process that cancer hospitals have successfully established with tumor boards.
Healio: What is the typical clinical decision-making process for a patient with CLI involving amputation?
Shishehbor: Hospitals tend to treat vascular disease in a silo, through several different specialties. For example, in our institution, a CLI patient may start their journey with a vascular surgeon, interventional radiologist, or interventional cardiologist. Each of those specialists works with their own vascular experts who have knowledge of aortic aneurysm, carotid intervention and venous disease. Unfortunately, these specialists are not always limb salvage experts. These physicians do their best to treat patients, offering various options such as bypass, stent or a hybrid of the two. This usually happens in isolation with little interdisciplinary discussion or collaboration, other than perhaps a referral. Furthermore, patients are usually scheduled with a provider based on location or availability and are not connected immediately with a limb salvage expert, exacerbating the issue.
Healio: What is your team doing differently? Who makes up the team?
Shishehbor: At UH Harrington Heart & Vascular Institute, the LSAC team consists of four divisions: vascular surgery, vascular medicine, podiatry, and interventional cardiology. Traditionally, hospitals have difficulty bringing together vascular surgeons and interventional cardiologists for collaboration around limb salvage. We have found success in holding virtual meetings and we schedule a separate meeting to discuss each patient. Every one of these patients was scheduled to undergo a major amputation. These are people who have exhausted all options. The patient now gets to be seen by all the experts at our hospital.
Healio: What has this interdisciplinary program taught you and your colleagues?
Shishehbor: As physicians and organizations, we can work in an interdisciplinary team to address complex patient care issues. It’s important to foster a culture of mutual respect and trust within the team and among various specialties to avoid judgement and competition. These programs require continuous investments and support. We can always continue to improve, so we have added improvement initiatives to our process.
Healio: What are your goals for this program moving forward?
Shishehbor: The next step for us is creating a plan to catch these patients even earlier. We are proud of our team. We had to check egos and be humble, recognizing that others may have expertise that is more advanced than ours. Remember, in this study we were waiting until patients were scheduled for a major amputation. We want to get ahead of that and make their journey more patient-centric so those at elevated risk for amputation are identified sooner for more optimal outcomes. Future research should explore how to move the referral to the Limb Salvage Advisory Council further upstream to allow for early intervention.
For more information:
Mehdi H. Shishehbor, DO, PhD, MPH, can be reached at mehdi.shishehbor@uhhospitals.org; Twitter: @shishem.
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Shishehbor MH, et al. Circ Cardiovasc Interv. 2021;doi:10.1161/CIRCINTERVENTIONS.121.011306.
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