What are best

practices

for limb salvage?

An open letter to physicians:

A patient presented to The Way To My Heart with ischemic toes. Her physician had told her that the next step was amputation because her below-the-knee vessels were unsalvageable. We found a physician with advanced training near her who offered a second set of eyes and hands to see if he could help save her right leg. After yesterday’s procedure, he called me in horror as to what he saw during the angiogram. More than a dozen small bare metal scaffoldings from the distal SFA halfway down the anterior tibial vessel. Even worse is he informed me that the scaffoldings were not sized properly for the vessel diameter. They were too large which he explained induced more trauma to the vessels and therefore more intimal hyperplasia. In basic terms, it was causing her vessels to block back up quickly.

This particular scaffolding is designed merely to fix small tears in the vessel if, for example, the physician didn’t eye the sizing of the vessel properly without using intravascular ultrasound, and the balloon was too large and too much barometric pressure was too high. They’re not designed to blanket large treatment areas. I sat through an entire session on the proper use of this device at a conference last summer and even had the opportunity to deploy one at the company’s booth alongside several Fellows who were also learning. It’s a valuable tool to repair tears in the vessel, especially below-the-knee without sentencing a patient to a full metal jacket, which is not preferable in the small vessels.

That’s when used as designed.

This physician indicated to me that in this case the tool was not used as designed.

The good news is that this physician was able to restore blood flow to this patient’s foot.

The bad news is that because of the misuse of the tool, this patient will likely need to be closely watched and will need to be unblocked again…and again.

Devices can be limb-saving if used as designed in medically appropriate situations.

Companies provide clinical specialists to work alongside physicians in the lab to learn the indications for use and proper deployment.

But it's important to see how other highly respected physicians are using these tools effectively and learn agreed upon "best practices" for their use by your peers.

At conferences such as the upcoming CLI-C in Venice, Italy, physicians from around the world are sharing the most advanced tools and techniques.

What I love about this conference is that they chose physicians specifically for their diverse opinions on how to approach treatment for Peripheral Artery Disease.

Everyone agrees that there are two types of PAD patients: Claudicants and CLI, and that frontline treatment for claudicants in walking and medical therapy. They also agree that with claudicants, it’s best not to offer intervention or surgical treatments too soon as it starts the clock for the next procedure.

For CLI, this is where approaches vary, especially for complex cases.

Different physicians have different philosophies, tools, and techniques for approaching each case.

There’s no one-size-fits-all, although there are agreed upon ‘best practices.’

But how do you learn what options are available if you don’t attend educational events such as CLI-C where they have a broad spectrum of perspectives offered for each case?

Physicians need to connect with other physicians to continue to advance ‘best practices’ in limb salvage.

I was in a case in Nancy, France where I was observing a physician presented with a ‘no stump sfa’ he felt was not possible to cross safely from an antegrade approach. So, he said, “amputation.” A visiting physician stepped in and suggested giving a retrograde approach a try first. The physician had never tried that before. So, the visitor walked the physician through it. Success! If that visiting physician wasn’t in the lab at the time, the patient’s fate would’ve been sealed with an amputation. Now, this physician has another limb salvage technique to use with other patients, which ultimately will reduce the number of amputees on his watch.

Having other visiting physicians with varying experience is rare in most cath labs. That’s why it’s important for physicians to attend educational seminars where they can focus on sharing ‘best practices’ and learning without interruption.

Conferences such as CLI-C, broadcast LIVE cases during the educational events, which bring attendees alongside them during the case to walk them through their approach step-by-step. What’s more is they include a panel of other physicians from around the world who also share their opinions as to how they would approach the same case differently.

Dr. Marco Manzi and Dr. Mariano Palena are pioneers in endovascular treatment of PAD. If amputation is on the line, they will do everything in their power to try to save that limb. At this conference, physicians who may have been skeptical about the possibility of treating the smaller vessels below the knee, will see that it is possible with the right tools and techniques. I still hear regularly from patients in my network whose physicians have told them "amputation" simply because they don't know how to treat below-the-knee and never learned because they once read in a study that it may increase the risk of amputation.

Mandy was presenting with lifestyle limiting claudication which limited her walking distance from her door to the curb, less than 100 feet. The cramping was so severe by the time she would get to the curb, that it would make her dizzy and vomit. She would bring a small bag with her each time she forced herself to take her daily steps. A The Way To My Heart P.A.D. Navigator attended Mandy’s next vascular appointment to find out options. The vascular specialist, who was head of the hospital’s vascular department, said her only option was amputation because "why delay the inevitable." When the Navigator asked why he wouldn't simply try to "kiss" the few areas of narrowing with a balloon to give her a little more flow. He replied, "Treating below the knee is ineffective." The patient asked for a referral for a second opinion at a different hospital in the same system. He refused saying he was confident in his assessment and would not approve sending her to someone who would touch her BTK vessels. We had to go back to the patient’s primary care physician and got the referral. The new vascular specialist successfully revascularized several areas of stenosis below-the-knee. She now walks up to half a mile multiple times a day without pain and she continues to increase her walking distance six months later.

If a case screams next step as amputation anyway, then why not try, right?

Patients deserve every opportunity to keep their limb. Dr. Manzi has told me personally that it’s his commitment to not only the patient but also the community to help every patient to the best of his ability to stand on their own two feet. Not only is it of benefit to the individual patient and their family, but also people are less of a burden on society when they are able versus disable. He believes it’s his moral and civic duty to save limbs.

What’s your moral and civic duty?

If you’ve become a physician, you care about life and limb.

Take that next step and go beyond your cath lab to learn what’s new and what’s next in a forum where not just those who align with your current practices present, but those who offer multiple philosophies and approaches share how complex cases can be addressed.

I’m headed to CLI-C in Venice later this month. I hope to see you there! This year they’re not offering virtual attendance.

The value is being there and engaging with peers to share and to learn.

They have specific sessions dedicated to the most advanced techniques for limb salvage including when and how to use alternative arterial access, strategies for crossing chronic total occlusions (CTO) in CLI patients, weighing the pros and cons of a subintimal approach, understanding when it's feasible and helpful to treat below-the-ankle, the role of pharmacological support in CLI patients, and more.

I know it’s tough to take time off from the frontlines. But a few days away, immersed in some of the most extreme CLI cases and learning what works and what doesn’t will position you as a true CLI Fighter, willing and able to exhaust all efforts to save life and limb.

So join me in Venice this month. Here's the link: Register here.

I'm going to be sharing what I learn with patients. Don't get left behind.