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The Critical Limb Ischemia Team: Does it Improve

Outcomes or Streamline Care?

Ehrin J. Armstrong, MD MSc MASDirector, Interventional Cardiology

Director, Vascular LaboratoryVA Eastern Colorado Healthcare System

Associate Professor Of MedicineUniversity of Colorado

Disclosures

• Advisory board member/consultant for Abbott Vascular, Boston Scientific, Cardiovascular Systems, Medtronic, Philips

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There is No Shortage of CLI!

• Average life expectancy approaching 80 years (Number >65 years will double by 2050). Prevalence of PAD and CLI will continue to

rise.

• CLI is undertreated, with significant variation in care.

• The real challenge: Who to treat, what to treat, best management

Goodney, J Vasc Surg 2013

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Wide Variation in Revascularization Rates

Goodney, J Vasc Surg 2013

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Reasons for a Critical Limb Ischemia Team

• Patients with CLI are complicated.

• No single physician can treat all aspects of a patient with CLI. Revascularization Wound Care Optimal level of amputation Optimal Medical Care Infection control Diabetes Management Foot offloading

• Focusing on only one area is a recipe for poor outcomes.

How a CLI Center and Team Needs to Work

• Comprehensive care. Full, state of the art management of CLI

• Dedicated team Core nucleus, availability of multispecialty consulting

services• High Volume

Hundreds of cases a year• Availability

Urgent consultations, inpatient care• Patient education and Community outreach

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Core Team, Consulting Services

• Core Team Medical

coordinator Vascular

specialists Podiatrists Endocrinologists Wound specialists

• Consulting Services Dietician Infectious disease Nephology Physical therapy Social worker

Toe and Flow Model

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Who Should RevascularizePatients with CLI?

• Significant cognitive and technical overlap among interventional radiology, vascular surgery, and interventional cardiology.

• Specialty is less important than dedication to the treatment of patients with CLI.

Multidisciplinary Teams are Patient-Centered

• Collaboration may be achieved without sacrificing tribal identities

• Diversity in skills/paradigms can be synergistic to clinical partners Breeding ground for innovation

• Innovation can lead to alternatives that ultimately benefit the patient

• Diversity is an integral component of “Knowledge Management”

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2-D Diversity: Harvard Business Rev.• Inherent diversity: traits you’re born with• Acquired diversity: traits gained from

experience• Companies with 2-D Diversity out-innovate

and out-perform others• Six behaviors are catalysts of innovation:

Hear everyone (create a “speak up” culture) Create a haven for new ideas Delegate decision making authority Share credit for success Give actionable feedback Implement feedback from team

Hewlett S, Marshal M, Serbin L. How Diversity Can Drive Innovation. Harvard Business Review Dec 2013

Common Goals

• Three specialties perform image guided therapies for PAD at most institutions

• Internal competition in theory leads to efficiency but in practice leads to silos with duplication of services and missed opportunities for collaboration

• Multispecialty collaborative approach leads to safe and efficient (one standard) care

• Long term goal is to take competition externally--based on favorable institution-wide quality metrics and regionally competitive costs

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Common Goals

• Multidisciplinary CLI teams need the vascular specialists to lead the way and set up a tone of collaboration

• Once the core team of vascular specialists/proceduralists is formed, it is easier to attract talent and form the remainder of the multidisciplinary CLI team

• Everyone treating CLI patients should be all about the team and for the patient

How Can a CLI Team Be Implemented?

• Shared consultation/call. Across specialties?

• Multidisciplinary conferences Weekly wound care conference. Shared education. Group decision making.

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• Single center cohort.

• Standard care consisted of inconsistent mix of providers.

• Multidisciplinary care consisted of vascular surgeons, podiatric surgeons, and plastic surgeons working as a team.

Chung et al, J Vasc Surg 2015;61:162-169

• Outcomes driven by reduced rates of major amputation with multidisciplinary care.

Chung et al, J Vasc Surg 2015;61:162-169

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• Consecutive patients at a single center. 61 conventional, 11 multidisciplinary

Hioki et al, Angiology 2015;66:187-194.

Improved Amputation-Free Survival

Hioki et al, Angiology 2015;66:187-194.

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• 126 consecutive patients undergoing infrainguinal bypass for tissue loss.

• Aggressive wound care included beside surgical debridement, active skin grafting.

Mii et al, Ann Vasc Surg 2017;41:196-204

Improved Wound Healing Rates

Mii et al, Ann Vasc Surg 2017;41:196-204

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Summary and Conclusions• A Multidisciplinary CLI team is patient-centered and

focuses on all aspects of CLI care.

• Opportunity to collaborate and create a center of excellence. Improved outcomes, recognition

• Diversity promotes innovation.

• Data suggest that CLI teams improve the limb-related outcomes of patients with CLI.

Thank You

Ehrin J. Armstrong, MD MSc MASDirector, Interventional CardiologyCo-Director, Vascular Laboratory

VA Eastern Colorado Healthcare SystemAssociate Professor Of Medicine

University of Colorado